Agenda item

The Digital and Transformation Lead for Leicester City South PCN submits a report on a population health management approach to addressing health inequalities using social prescribing:

• 3 Conversations
• Multimorbidity population support with understanding their medication
• Overview of project and its impact

The Digital and Transformation Lead for Primary Care presented the report, it was noted that:

·       There was two key projects underway, the first being "3 Conversations" part of the approach to population health management was working with ICB, Midlands and Lancs partners, and clinicians within the organisation to get their insights in to the people in the area and develop a model.

·       A lot of data was used to support and identify different themes across the Primary Care Network (PCN) and some tailored interventions were developed to address the at risk population in the area.

·       A cohort of patients were identified that were not engaging with the general practice services for health needs and were often presenting in crisis at out of hours services.

·       The process of contacting a patient was reviewed and a particular theme was identified where 2 forms of contact were made to try and engage a patient and get them back on track. Due to pressures and resources in PCN these patients were not followed up with after the second form of contact was attempted.

·       Reports from the emergency department and Police Protection Notifications (PPNs) were used to identify high-contact individuals not accessing support and showed significant health concerns, this led to the clinical directors to assess this across the whole primary care network and review who they were trying to engage.

·        When the 3 Conversations training was delivered, this cohort of patients were looked at to be supported and engage with their health needs.

·       The population chosen for the project were registered across 3 practices based in Saffron and Eyres Monsell, individuals over 18 years old and had received a PPN with mental health issues raised in the last 6 months.

The "3 Conversations" Approach:

­   Conversation 1: Understanding what matters to the individual and connecting them to local resources to live independently.

­   Conversation 2: Supporting people in crisis.

­   Conversation 3: Helping individuals build a good life and take responsibility for their health and wellbeing.

­   Conversations were made with individuals from SystmOne via GP Surgeries and recording all notes on the progress and type of contact made.

­   Due to the number of non-engagements an initial letter was produced. It was found that the reading age in the area meant that sometimes the letters were not understood. So it was broken down into tailored engagement methods included letters adapted for local reading age, with short sentences, limited information visuals and the key message being to get in touch.

­   No timescale was decided for how long they would try to contact the patient, rather as much time that the patient needed to get on their journey.

­   Contact was recorded on a templated entry, to capture the different support that was being provided.

­   Check ins were taking place with Leicester City Councils Adult Social Care and usage of their Liquid Logic System to assess notes and understand what other workers were involved in their care to avoid duplication and manage timely communication between organisations.

­   Local team huddle meetings were held once per week to discuss strength and progress updates, risks and ending involvement with patients.

­   Local teams also met on the ground regularly with VCSEs to explain what the service provision was in case they identified patients that could be suitable for support.

­   Increased support was offered during a period of crisis and there were instances of this. Rather than connecting with the crisis team, it was decided to work with them and try and support them to avoid getting to conversation 2.

­   The overall aim of working in this method was to prevent people requiring conversation 3 and to avoid them needing the longer term commissioning services.

­   Average of 6 community engagements needed to establish connection.

­   Templated data entry introduced to capture support offered and improve consistency.

­   12.43

­   Over 7 months, project contacted individuals across a 12-month cycle.

­   23% engaged but did not take up the offer.

­   9% attempted engagement but dropped off.

­   15 individuals not suitable, 9 declined, 1 deceased.

­   Only 1% moved into Primary Care Networks.

­   Weekly drop-in held at Pork Pie Library to offer a safe space for community discussions.

­   Common themes: debt (23%), substance misuse (5%), social isolation (23%), therapy needs (29%), employment/education support (15%).

­   Challenges were present and they included:

­   The time between a patient receiving a PPN and the information being shared by the police to the practices varied due to resources. It was never managed to address the governance issue with police.

­   Record keeping on multiple systems. Using the patient record and governance and safeguarding involved in what was shared on the patient record. Moved to sharing patient information on record.

­   Practice engagement practices did not have the time to process and refer the correct patients to the team. This was addressed by providing additional support through a flow chart and MDT

­   Patient lack of engagement: 2 letters were created, door knocking and hand delivering them in attempt to make contact. On average it took 6 attempts to engage with the patients.

·       A team from Public Health led a project focused on patients aged 18–64 with five or more comorbidities, living within a Primary Care Network (PCN).

·       The project aimed to understand the challenges faced by this group and explore how to improve access to services, uptake of support, and self-management to enhance quality of life and life expectancy.

·       The approach began with contacting 60 patients, which was later expanded based on interest and engagement.

·       Focus groups and one-to-one discussions were held to explore lived experience, barriers to access, and existing service gaps.

·       Patients co-produced interventions and provided insight into barriers related to physical health, daily living, social isolation, special educational needs, technology use, personal resilience, routines, and stigma.

·       Voluntary and community sector organisations (VCSE) were involved to help shape the questions used in discussions and to observe and understand patient needs in greater depth.

·       It was found that many patients were unaware of the available support, including care navigators, GP practice services, health and wellbeing coaches, and social prescribing options.

·       Signposting patients to appropriate activities for working-age adults proved challenging in some local areas due to limited options.

·       Medication use emerged as a key theme, particularly regarding non-medical alternatives, side effect monitoring, and understanding how to use medication properly.

·       A notable example of good practice was identified at Saffron Health, where a dedicated phone access system was in place for digitally excluded patients to request prescriptions, fit notes, smear tests, health checks and other requirements.

·       The system supported patients in identifying whether their issue was urgent, whether they could see a pharmacist or social prescriber instead of a GP, and helped navigate available options.

·       Social prescribing was being used to support this cohort, including the development of a revised leaflet explaining Structured Medication Reviews (SMRs) in more accessible language.

·       Patients were also signposted to videos and websites via QR codes, with support from social prescribers to assist those with limited digital literacy.

·       Community pharmacists played a key role in continuing support, and group sessions remained part of the broader health inequalities strategy.

In discussions with Members, the following was noted:

·       Members highlighted that a number of pilot schemes had been trialled prior to wider rollout, and all PCNs had been offered support and training. It was noted that while over 1,300 VCSE organisations were listed in the database, more referrals could be made. Due to oversubscription, decisions had to be made to reallocate resources.

·       It was suggested that conversations about service access and navigation were wide-ranging, and work was ongoing to ensure a consistent platform such as the Joy App was accessible and fit for purpose.

·       A chatbot had also been introduced on the website to direct users to relevant organisations and services, particularly those supporting refugee communities. However, efforts were still needed to bring more organisations onto the platform.

·       The persistence in connecting with vulnerable individuals was praised. It was acknowledged that face-to-face communication yielded stronger engagement, and there was hope that this work would continue beyond the initial pilot. Questions were raised about sustainability and the next steps for ensuring long-term impact.

·       The importance of learning from experiences during the COVID-19 pandemic was emphasised, including proactive outreach and door-knocking campaigns. Members stressed the need to direct resources where health inequalities were greatest and to provide evidence that the work delivered value for money.

·       There was support for capturing both qualitative and quantitative data to demonstrate the economic and social value of the work. It was noted that some reports had not been published, and there was a risk that if projects stalled, priorities would shift before they were completed.

·       Opportunities for collaboration on evaluation were welcomed, with suggestions to align with existing projects in acute settings and to submit work for national recognition as a gold standard approach to integrated care and neighbourhood working.

·       Members noted the strength of the project as an example of true neighbourhood-level collaboration, incorporating data, governance, and a range of system partners. It was felt that more could be done to enable access to this data, especially for frontline services like the police.

·       It was recommended that evaluation should be embedded from the outset of any PCN-funded project, with a suggested 10% of the budget allocated for this purpose. The importance of drawing on collective expertise across the system was noted.

·       Proportionate universalism was raised as a key principle  ensuring services were available to all, but with additional support targeted where needs were greatest. Members encouraged linking available funding, such as CAPE, to support these efforts at a PCN level.

·       Challenges with staff recruitment and retention were discussed, particularly around staff trained under local authority terms not wanting to transfer to NHS roles due to concerns over pensions and banding.

·       Data sharing and the lack of integrated record-keeping systems were identified as ongoing barriers. Members questioned what could be done to improve access to shared care records.

·       The importance of standardisation was highlighted, to ensure data from projects could feed into the LLR Shared Care Record. An IT process was underway to improve visibility via the system’s viewer.

·       Members asked who would be responsible for taking this work forward, and what role the Board would play in enabling continued progress.

·       It was suggested that neighbourhood-level governance structures were key to driving the work forward. The proposal was made to take the findings to the neighbourhood group meeting at the end of the month for further discussion.

AGREED:

1.    The board notes the report.

2.    The Chair to send a letter to the Neighbourhood Board outlining the work to date.

3.    A follow up report to return to the board in 6 months’ time.