Dr Priya Kumar, GP and Health Inequalities Lead for Slough and Transformational Clinical Lead for the Connected Care programme at Frimley ICB, explains how social prescribing link workers in the area have taken a lead in finding out about and responding to the needs of the population.
Key lessons from this case study
- Identified residents who may have unmet health needs through a population health management approach, and proactively engaged with them.
- Embedded the new social prescribing workforce within the primary care infrastructure.
- Built the relationship between primary care and the wider support in the system, including the voluntary sector, housing, citizen bureau, drugs and alcohol, mental health services.
- Identified the potential linked outcomes in health from a social prescribing intervention.
The issues we wanted to address
69% of Frimley Health and Care Integrated Care Board’s underserved population lives in Slough, one of the most ethnically diverse towns in the UK where over 150 languages are spoken. The health of people in Slough is varied compared with the England average. About 15.1% (5,540) of children live in low-income families. Life expectancy for both men and women are lower with a 4-year difference in life expectancy between Slough and the England average.
Throughout late 2022 and 2023, we have seen a significant decline in our residents’ health outcomes. As the cost of living rises sharply it’s crucial that we think carefully about the impact on patients and citizens and make sure we use data-driven decision-making to provide the best possible care. Taking the time to understand what matters to an individual and their most pressing needs will enable a more holistic, meaningful relationship, affording residents the time and headspace to take more control of socio-economic factors impacting their health.
The overall aim was to empower people to make positive changes to help themselves.
What we did and how
In line with the national Core20PLUS5 approach to reducing health inequalities, more than 3,000 residents living in the most deprived areas, with multiple chronic conditions including diabetes and hypertension, were identified using our population health management tool. These identified residents were then called by a social prescribing link worker or booked in by a receptionist and asked to complete in a questionnaire (DipCare-Q) on the wider determinants of health so we could better understand their needs.
The responses helped us identify those who were most likely to benefit from a needs assessment and the support of our social prescribing teams as well as identify areas of perceived burden, like payment of household bills, lack of food or clothing, mental well-being, and digital inaccessibility. Responses and subsequent targeted interventions were all coded digitally to create a powerful dataset that informed our social commissioning offer through richer, deeper insights into patient reported needs.
Our challenges and how we overcame them
This patient group had a lower level of trust in primary care. We needed to understand the barriers that these patients were experiencing so that we could improve future experiences and overall health outcomes. By using a population health management method, we were able to proactively engage with these patients and offer social prescribing through a personalised approach via the questionnaire.
The Slough Place team led on the design of service delivery between general practice and the community services. Social prescribing link workers in the primary care network workforce spearheaded the implementation and tapped into alliances within the community, including housing support, citizens advice bureau, food banks, clothing, mental health and drugs and alcohol support. They also developed a strong network with community development workers from the local authority, faith leaders and the voluntary sector to support residents from diverse cultural backgrounds.
Results
3,300 questionnaires have been completed, with 28% of people reporting fuel poverty needs, 25% concerned about isolation concerns and 17% had mental health issues.
Fuel vouchers were sent to those identified and warm hubs specifically set up in areas of need. Those that indicated they were living with food poverty were sent a text message or redirected to the local food banks in Slough.
The questionnaire process uncovered 250 individuals who felt they had mental health issues but were not coded primary care registers. They were invited to come into practices for mental health and wellbeing assessments and a culturally specific talking therapy offer has been piloted.
Following interventions from our social prescribing link workers there has been an increase in the number of completed health checks among our diabetic and hypertensive populations. Compared to people who did not take part in the questionnaire, there was a 3% reduction in emergency calls, 59% reduction in NHS 111 queries, 9% reduction in A&E presentations, and 15% reduction in inpatient admissions. The results showed that these residents are engaging more with primary care and less with emergency care, so were shifting from reactive to proactive.
The project has led to the setup of a monthly poverty forum and a WhatsApp group to share information and ideas. This spurred the development of an online directory of services which was launched in celebration of Social Prescribing Day on 8 March 2023. Residents are now able to self-refer for listed services at any time helping to improve access for the Slough population.
What's next?
We have now developed the DipCare-Q questionnaire into a digital holistic health needs assessment which is being trialled in one practice. The intention is to reach the 90% of our population who are digitally enabled, gathering data from them which can be further analysed, and giving an automated response with options for support. This would free capacity to proactively contact those who did not engage through the digital process so that they can be offered a face-to-face or telephone appointment.
You can find out more about the population health management approach within primary care with this video.
