Dr Neil Modha, a GP at Thistlemoor Medical Centre in Peterborough, Cambridgeshire looks at how mitigating the impacts of disadvantage and marginalisation in high intensity service users and unvaccinated children, many from minority ethnic backgrounds, can lead to better health outcomes
Across the country we know health and healthcare inequalities exist within and between communities. We also know these differences in health status are often avoidable and driven by the wider determinants of health or the ‘building blocks of health’ such as the conditions in which people are born, grow, live and age.
Given that GPs are all too often the front door of the health service for most people, what role we have in combating the causes of health inequalities and dealing with their effects?
Thistlemoor Medical Centre is an inner-city practice in Peterborough, Cambridgeshire. The practice population has grown fourfold to 32,000 during the last 15 years and is very diverse with a large population from both black and minority ethnic and Eastern European heritage with more than 45 languages spoken locally.
Like many practices operating in the most deprived areas of the country, the inverse care law – inequitable distribution of health services and workforce – is still very much in existence which often limits the ability of health professionals to address patient needs.
Thistlemoor benefits from a financial uplift from NHS England to support its diverse population, which enables the team to employ and train staff members from the populations they serve as well as bringing in additional nurses and doctors to help provide more appointments to their population.
High intensity service users
At Thistlemoor in order to identify, understand and appropriately manage those patients using high levels of GP and emergency department services the GPs and practice managers decided to employ a population health management approach.
Of the 400 patients identified as using the GP services most frequently, 290 (73%) engaged with the programme. Most were referred to a team including social prescribers, GP trainees and members from the voluntary sector and council.
This team spent an hour with each patient individually and used motivational interviewing techniques to explore their social, financial, housing and employment situations and prioritised, with the individual, the interventions that would support them the most.
The initiative helped the primary care team understand the challenges faced by their patients and to then put additional support into place through council services, social prescribing and health and wellbeing initiatives. As a result GP clinic attendance substantially reduced from once every two weeks to around once every two months. Visits to A&E also dropped by around a third.
Measles, mumps and rubella
During the recent measles outbreak, the practice was conscious of the low levels of measles, mumps and rubella (MMR) vaccine uptake across the patch in children. The practice decided to engage its local communities to understand patient needs and ways to boost vaccination rates.
They found that the nature of shift work and rotas for many people in the local area made access to clinics at the times on offer not suitable. So the GP practice set up a walk-in immunisation service, modelled on the Covid vaccination drop in drive during the pandemic, that took place on weekends and in school holidays.
The practice also rolled out a multilingual, community-focused campaign including across social media. As a result, MMR vaccination uptake increased from its baseline vaccination rate by around 300% after three weeks of intense interventions which were then sustained over the programme.
The MMR project aimed for high coverage across specific sections of the population, particularly those with lower incomes and minority ethnic and religious groups who tend to have higher levels of vaccine hesitancy. Uptake increased significantly in some groups, including a 30% rise within the Eastern European and Pakistani and Kurdish communities.
A different future
This work has now been rolled out to the other practices in the PCN and it is a key part of bringing our integrated neighbourhood together around a project. This has enabled the development of relationships between ourselves, the voluntary sector, the community provider and the council. It has also led to an approach across the whole of our Place focused on high intensity users of services.
The work done at Thistlemoor shows that disadvantage within deprived communities and inequitable health outcomes don’t have to be accepted as a given and that there are ways to work more effectively to reduce the divide.
A recent review published in the Lancet recommends five key principles to reduce health inequalities through general practice: co-ordinated services across the system, accounting for differences within patient groups, different patient preferences, cultural differences and community engagement with service design and delivery.
Populations are not hard to reach, nor hard to understand. As GPs we can and should be considering challenges from the perspective of our patients and local communities and designing our services around them. We must attempt to accommodate linguistic and cultural differences.
If we continue to commission services as we currently do and hope that integration occurs naturally, the result will mean that inequalities become ever more entrenched – it’s time to change.
Dr Neil Modha is clinical director of the Central Thistlemoor primary care network and a GP at Thistlemoor Medical Centre in Peterborough, Cambridgeshire and a member of the NHS Confederation.
