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Tackling health inequalities

Home visits can offer GPs the most useful insights into people’s lives outside the consulting room.

For me, being immersed in someone else’s environment - and gathering information through all my senses - can be a stark reminder of the wider determinants of health. Issuing a prescription can feel like a drop in the ocean, when a person is battling a storm of underlying health inequalities.

Social prescribers were introduced to general practice to help support people facing wider socio-economic challenges impacting on their health and with the recent rise in the cost of living, their role has become even more important. However, linking social prescribers to the people who are most in need can be challenging - how do we identify them, since we don’t usually code data on many of the wider determinants of health, such as financial struggles and loneliness?

Dr Kumar, a GP based in Slough, with the support of the Slough practices and place team, has led an innovative project to gain a deeper understanding of the socio-economic needs of her patient population and empower them to make positive changes to improve their overall health and wellbeing.

Using the Connected Care population health intelligence platform, local social prescribers identified residents from deprived areas with multiple long-term conditions, deemed most likely to benefit from support. After preparatory training, the social prescribers then met with these residents to complete the DiPCare Questionnaire; a quick, reliable and validated tool used to measure deprivation in primary care. With the needs of individual residents identified, they were then directed onto different community services for support to address their problems.

As of January 2023, over 3000 questionnaires had been completed and coded. Approximately 35% of residents received an intervention, including fuel vouchers, digital and housing support, mental health reviews and referrals onto various food banks.

Hypertensive/diabetic residents who completed the questionnaire engaged more with their primary care health check-ups, with a reduction in A&E attendances (9%), NHS 111 calls (59%), 999 calls (3%) and inpatient admissions (15%) in the same cohort. It is hoped that over time, by building trust with these communities, care will move from being reactive to more proactive, with the core needs of residents being at the forefront of the solution.

Dr Kumar’s work demonstrates some of the core skills WiseGP aims to support and celebrate, including use of the 3E’s (Explore, Explain, Evaluate) principle that can help you systematically describe, understand and so address your problem. Dr Kumar recognised a need in her community, particularly after the onset of the cost-of-living crisis, that was impacting on the health of her patients and responded to this by exploring how her team could help. With her team at Slough Place, she explained how a new system utilising digital technology could help to target those most in need and has since evaluated the impact. Implementation was supported by training and group sessions that helped to link services together.

Looking at data drawn from the questionnaires and actions taken in response to them has facilitated insights into the needs of Slough residents at a personal and population level, to help inform future service development.

Our everyday work can at times feel overwhelming, so a project like this may feel outside the scope of what you can achieve. At WiseGP we recently led a project named Lazarus(1), which explored the idea of giving mid-career GPs facilitated, funded time out-of-practice, where they would have the headspace to develop and implement meaningful changes in their everyday practice - ideas like Dr Kumar’s. It’s easy to see how these grass root initiatives targeting the needs of local populations could benefit the wider health system if properly supported - this is the culture shift called for by Fuller(2).

Hopefully initiatives like Lazarus will gain support, so more GPs can have the time and headspace to apply their expert generalist skills beyond the consulting room. In the meantime, there are still small impactful changes you could make - for instance, just considering how you explore and code the wider determinants of health in your consultations could facilitate a better understanding of, and support for, the needs of your local population.

If you’ve been inspired by Dr Kumar’s project, you can read more about her great work in her blog:

You can follow Dr Kumar on twitter: @PKGP07

If you’d like to find out more about Lazarus, here’s a link to a blog on this WiseGP project:

  1. Machin A, Bennett J, Reeve J. Lazarus: working together to reclaim general practice. BJGP. 2023;75 (734): 410-411. DOI: 10.3399/bjgp23X734817

  2. Fuller C. Next steps for integrating primary care: Fuller stocktake report. 2022. (accessed 31 Aug 2023).


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