Interview: Dr Priya Kumar discusses how her team is using population health data to tackle health inequalities in Slough.

Health inequalities continue to feature high on the agenda of NHS England. However, identifying and targeting those who are most at risk can be a considerable challenge for an already stretched health service.

On 21 September, Dr Priya Kumar, who is GP Partner Kumar Medical Centre, Health Inequalities lead for Slough, and Transformational Clinical Lead for Connected Care in the Frimley ICB presented at a Graphnet Health webinar, called, ‘Can’t see the wood for the trees.’ She shared how her team is proactively using data within the shared care record to identify patients impacted by socio-economic challenges - and how, in turn, this is driving action in reducing health inequalities.

Following the webinar, which was extremely popular and generated numerous questions and conversations, we caught up with Priya to find out more about the Connected Care team’s approach and results so far.

What is the situation in Slough?

Priya: 69% of Frimley Health and Care Integrated Care Board’s unserved 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) children live in low-income families. Life expectancy for both men and women are lower with a 4-year life expectancy difference 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.

How have you identified residents that require support?

Priya: In line with the national Core20PLUS5 approach to reducing healthcare inequalities, more than 3000 residents living in the most deprived areas, with multiple chronic conditions including diabetes and hypertension, were identified using a Core20PLUS5 dashboard, which we were able to create using our Connected Care population health management platform and integrated shared care record, both developed and powered by Graphnet. Those residents were then asked to take part in a questionnaire.

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.

What kinds of interventions have you introduced to tackle inequalities?

Priya: We have implemented several interventions depending on patient reported needs, so they are personalised – for example, in response to mental health challenges and isolation (reported by 1,974 people), we are piloting mental health and wellbeing appointments at general practice with culturally competent therapist. Those that reported digital inequality concerns (reported by 290 people), we invited them (via posted mail) to join our Digital Buddies programme, which is run by the voluntary sector and supports residents to improve their digital literacy. To help those that reported food poverty (268), we reached out to offer food vouchers and other assistance.

We have also used the population health data to roll out a multi-generational household project, targeting those living in deprived areas that aren’t engaging with primary care, and might benefit from additional support.

Slough has the largest number of multi-generational households in the country, and we thought that by engaging with them as one unit, we could improve the productivity and efficiency of primary care. Amongst other objectives, we wanted to improve the uptake of NHS health checks, QoF indicators, immunisations, and screening for cervical and breast cancer. This approach has been well received by residents, enabling us to conduct health checks and immunisations for whole families, including those that weren’t engaging with us and were prone to missing appointments.

How is the population health approach helping you support fuel poverty in the run up to winter?

Priya: Out of the 3300 residents that we invited to complete a questionnaire; 929 individuals told us that they didn’t have enough money to pay their household bills. We opened up our fuel poverty phone line 2-3 weeks ago, and we have directly texted all of those individuals to invite them to ring us, and to let them know that they can access support – including fuel vouchers.

We also created warm hubs last year using Connected Care to identify where these vulnerable people were living, and therefore where those hubs were most needed.

What results have you seen so far from the population health approach?

Priya: 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.

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 population. There was also a reduction in A&E presentations, NHS 111 and emergency calls and inpatient admissions for those who completed the questionnaire. They’re engaging more with primary care and less with emergency care, so we’re shifting from reactive to proactive.

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.

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 ‘pull’ or self-refer for listed services at any time helping to improve access for the Slough population.

What’s next for Slough?

Priya: Understanding the experiences of our residents is key to improving their health outcomes and narrowing inequalities. Through this social engagement process and the leadership of the social prescribing link workers, we are addressing the wider determinants of health and have seen an increase in chronic health check-ups with a reduction in urgent care use in the identified cohort. Social prescribing is supporting the shift in care from reactive to proactive care and providing better overall outcomes for our population. We hope by scaling up this support and reaching out to more of our residents, we will have a better understanding of the needs of our population as whole and address the underlying health inequalities as well as changing the future of our residents.

 Graphnet’s population health management tools have built in methodologies to identify those who are most likely to experience health inequalities, whilst the Shared Care Record enables these people to be flagged and worked with in a more proactive way. To find out more, visit the Population Health solution page here.