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Dr Priya Kumar outlines how four PCNs in Slough, Berkshire, are joining forces to create a multi-generational household home visiting project
NHS Frimley integrated care board (ICB) covers a diverse area across the three counties of Surrey, Berkshire and Hampshire. Of its five places, Slough has the highest levels of deprivation and more than 150 languages are spoken in this region. The town’s four PCNs – SPINE, LOCC, SHAPE and Central Slough Network (CSN)face significant challenges to achieve the same health outcomes as neighbouring networks. There is a ten-year life expectancy gap with the rest of the ICB region and a four-year life expectancy gap compared with the England average.
In addition, 13.9% of Slough’s population lives in multi-generational households, a fact that was highlighted to us during Covid, where we focused on communicating how to reduce the spread of infection in these households.
We have further explored this concept and our local immunisation team was keen to address the low levels of herd immunity for general childhood illnesses and childhood vaccination uptake in Slough. The majority of practices in Slough were below the 87% QOF target for pre-school boosters despite the best efforts of the practices. Feedback from parents suggested they were not opposed to vaccination per se but that other factors, perhaps work schedules or caring responsibilities, were preventing them taking up the offer of routine immunisations.
This planted the idea that we could target multi-generational households that had outstanding immunisations for home visits and use the opportunity to do other health checks that family members might need.
The programme was funded by the local vaccination board, who wanted to address the stark inequalities in uptake within the pre-school booster cohort. We identified all the multi-generational households with children who had not had their pre-school booster and were up and running a week later.
The immunisations list was matched in the practice records to identify other household members who had outstanding health checks including medication reviews, QOF indicators, pre-diabetes and blood pressure checks, severe mental illness reviews, adult immunisations, breast screening, cervical and bowel screening.
Each PCN was tasked with organising and arranging the visits for the households on the lists. Families were called in advance and visits arranged for those happy to take part. We advised them that all members of the family would be reviewed in one visit and practices arranged many of the visits after 4pm to ensure all the children were at home after school.
The hour-long home visit was done by two staff members, and a variety of different professionals were involved, including GPs, nurses, healthcare assistants, pharmacists and physician associates.
Initially, we identified 145 households. In total 103 households were visited and 68 more pre-school boosters were given by the end of the QOF year, within the space of two weeks. Through this approach, we were finally able to achieve some of these targets with those residents not engaging through the traditional routes of primary care.
We quickly realised we could achieve much more than we initially thought by visiting the family home, understanding the patients’ home environment and social situation. We were able to complete most of the outstanding checks as well as booking appointments at the practice for follow up where needed. This included QOF check-ups as well as social prescribing referrals and encouragement to engage with national screening programmes.
While the aim of the pilot was to boost our childhood immunisation uptake, it soon became clear that home visiting was also important for the 40 to 60 age group.
This is usually the cohort we struggle to reach in general practice because of the pressures of daily life. In one example, a 39-year-old gentleman had missed his pre-diabetic check-up for the past two-and-a-half years. By visiting him at home at the right time we were able to take his bloods and complete the check as well as discussing important secondary prevention advice with him. His wife also asked if we could offer smoking cessation advice, highlighting the importance of the peer support element within the household.
Another example was a household where a woman had seven children. We did the immunisations that were needed, including 12-month immunisations and flu. Given her situation, she hadn’t made time to have her cervical or breast screening. We booked her appointment and the following week she came in for her smear test. By reaching out to these residents, we were able change the narrative, which meant they were empowered to self-care and engage in their check-ups.
It was fascinating for me as a GP to visit these homes. The conversations I was having with the family as a whole were much more meaningful. Families appreciated we had taken time out of our day to visit them specifically and said they were more likely to invest in their own health and wellbeing in the future.
Furthermore, some residents did decline the offer of the home visit, but they engaged with us at practice level and we were able to complete the necessary checks.
Given the success of the pilot, we are extending this project to multi-generational households (with more than five people) with individuals who have less than 40% QOF indicators completed as of 31 March 2023 with the majority of these households in the Core20plus5 cohorts. We have been able to automate the household lists through the Connected Care platform, which is an integrated dataset across primary, secondary, social and urgent care activity across the system to identify all outstanding check-ups in the household. We have now identified 441 households with approximately 4,000 individuals that fulfil these criteria.
As well as visiting, we will also connect families with social prescribing teams, community development workers and the voluntary sector if required and offer our digital buddies programme for those who have digital accessibility needs. Information packs have also been created to inform families of the support available in out of hours, apps such as healthier together, getUbetter, the Slough wellbeing website as well as directing them to the local GP website for further support.
The aim of phase two is to improve prevention and health outcomes of the disengaged families. There
could be a variety of reasons for their lack of engagement, which are out of their control. We want to move from a reactive to a proactive way of accessing health. My hope is that this will be rolled out widely to reduce the health inequalities gap and improve life expectancy, especially those in the underserved communities.
Dr Priya Kumar is Slough health inequalities lead and finance lead at SPINE PCN in Berkshire
As told to Emma Wilkinson