Partnership working: How Alliance for Better Care used the learnings from its extensive vaccination outreach programme to adapt its new health check provision and ensure equity for underserved communities?

Aim and Introduction

In 2022 GP Federation, Alliance for Better Care (ABC), was asked by Surrey County Council Public Health to provide NHS health checks across East Surrey to priority populations.

The national programme offers an opportunity to engage with people aged 40-75 and identify those most at risk of cardiovascular disease (CVD), type 2 diabetes and dementia. ABC used this opportunity to build on their comprehensive work with vulnerable cohorts within East Surrey and ensure they had equal access to an NHS health check.

ABC’s Equity Programme works extensively with more than 30 partners in the area including local authorities, councils, link workers, food banks, housing organisations and charities to target and engage with communities. During the pandemic, it initially targeted those less likely to access vaccination services and who, in many cases, had no existing relationship with primary care. Groups identified during their work were the homeless, refugees and asylum seekers, and GRT community. Many hours were spent not just vaccinating these cohorts but also listening to their needs and understanding their concerns and long-term health needs.

Having forged relationships and earned their trust, ABC wished to invite these cohorts for an NHS health check.

Methods

Integral to this programme has been ABC’s willingness to meet these patients in their own settings - where they feel most comfortable. The team therefore invested in new portable health check equipment and began visiting local faith settings, community centres, GRT sites, homeless shelters and refuges. To ensure that ‘every contact counted’ the team offered access to vaccinations alongside checks at each site too.

As the Equity team began to roll out the NHS Health Check programme, it soon became obvious that the nationally set age criteria of 40-75 was restricting access to younger patients who were at risk of cardiovascular disease (CVD), facing vast health inequalities. Additional funding was successfully secured by Kent, Surrey and Sussex Academic Health Science Network to pilot expanding the scope of the health check programme to a younger cohort.

Clinics are always tailored to meet the specific needs of these communities, for example, some offer food to encourage a relaxed atmosphere and – it seems – a pizza can sometimes go a long way. A homeless charity donation has also funded food vouchers for those in need too.

We now have over 30 partners that we work with consistently – ranging from local councils to health inclusion teams, local charities, homeless shelters, women’s refuges, baby banks, food and clothing banks, community transport teams and outreach groups.

Results

As this pilot is ongoing, ABC is still processing the data available. However, by lowering the programme age range the team have had a significant impact on these cohorts. To date, around 50% of health checks have been accessed by those under 40 and 60% of these have led to direct referrals to follow-up services including bespoke support with the health advocate calling and completing the call with next steps and booked appointments. The team have also called emergency services and accompanied people in emergencies. In every contact, there is the time given to those individuals, rather than just acting in a signposting capacity.

Community settings include: homeless shelters, GRT sites, food clubs, health hubs and women’s refuges

Initial results show:

• 261 clinics in community settings i
• 850 people were vaccinated in these settings, including those who agreed to having either a first or second Covid-19 dose as recent as March / April 2023
• an increasing number of directly supported referrals by the health advocate includes:
• drug addiction counselling
• local A&E at hospital
• PALS
• Social prescribing
• Local baby banks
• Local food and clothing banks
• Dentist
• Health inclusion team
• GP registration and appointment setting on behalf of the patient
• Cancer support

Health data shows:

• 28% of patients had an abnormal BP readings
• 50% had abnormal BMI scores
• 27% had concerning cholesterol results
• 30% had diabetes concerns

Patient feedback

“You have listened to me and treated me like a human being.”
Homeless patient

“You have saved my life and given me a second chance."
Patient with substance misuse issues currently living in residential rehab

“We are so glad there is such a service, since you provided these checks some of the users come back and have since had their GP call them. It is so good to see this go the full circle. You have given them hope.”
Homeless shelter manager

Conclusions

Initial outcomes have reinforced the importance of the relationships ABC had built during the pandemic with vulnerable cohorts. Their local, mobile approach has fostered trust within the community and made people feel welcome and comfortable in their company.

When taking into consideration the lower life expectancy of many of these vulnerable cohorts (approx. 65 compared to national average of 80+), preventative measures need to take place at an earlier age in order to address and reduce health inequalities.

The learning of this pilot is hoped to inform a county-wide roll out across Surrey Heartlands.

Key learnings

By better understanding its target cohorts, ABC has been able to tailor its health check programme to meet patients’ specific needs – this has meant removing all age restrictions, creating a roving model, providing access to food or just giving people time to talk. The Equity Team’s work during the pandemic has allowed them to appreciate the disproportionate affect that Covid has had on these communities and makes it easier to design a response with a fluidity and flexibility that may not have otherwise been possible.

The strategy is informed by the data provided by the ICB and results feedback to the patients practice, demonstrating the clear benefits of a joined-up, holistic approach.

For more information, visit:
Alliance for Better Care - Equity Programme