2023 Awards - Addressing Health Inequalities

SPCT Homeless Inclusion Service

Salford Primary Care Together delivers an inclusion service across Salford targeting the most vulnerable patients. Our aim is to remove barriers to accessing health care; we can register patients who have no fixed abode with links to Salford. This includes people who are rough sleeping, sofa surfing, staying in emergency or temporary accommodation such as hostels, hotels, B&Bs. Our current case load is over 400 patients.

The inclusion team is comprised of expert staff including a service lead, 2 health care navigators, GPs and ANPs, nursing and HCA support.

The team also have a base at the acute trust and work closely with our care navigators at the Urgent Treatment Centre. This enables our care navigators and clinical staff to identify the most vulnerable patients or those experiencing homelessness and escalate these to the inclusion service.

The inclusion service can register the patient under their care, to provide the support they need following an ED / UTC attendance. We also provide hospital in-reach for patients who have already been admitted to hospital. Our in reach and front door work receives on average 36 referrals a month.

Our in-reach teams also link in with embedded Housing Officers at SRFT, Ward and Emergency Avoidance. We provide expert advice and clinical advocacy around homeless and inclusion health issues (such as substance misuse and substitute prescribing) for inpatients, improving care and treatment outcomes. This includes ensuring patients with complex needs are able to engage with health and other services through holistic inpatient support and care, thereby reducing rates of early self-discharge. We help homeless patients find somewhere safe and appropriate to stay on discharge, taking into account their needs around health, care and general support, support patients with financial issues, welfare entitlement and to access specialist legal help where possible and ensure patients are registered with a GP for ongoing care.

The service also offers a drop clinic at a local charity, with no documents required to register. Our outreach also includes street walks alongside the Salford RSI team, accommodation and bedding sites visits, joint visits with Salford Dual Diagnosis and Rough Sleeper Drug and Alcohol Team, hostels, women’s center and out of hospital accommodation.

We also offer a WhatsApp contact number so inclusion patients can contact the team for non-urgent queries realising that not all patients would have the credit to make outgoing calls but can contact in area with Wi-Fi facilities.,

FCMS Know your Numbers Bus

NHS Health Checks & Know Your Numbers Campaign FCMS Bus

The NHS Health Check is a 20-minute appointment for adults in England aged 40-74. If helps detect early signs of cardiovascular disease and other long-term conditions. As part of the health check provided, we offer point of care testing for cholesterol and HBA1C which provides instant results to our patients. The instant results enable the clinician to offer lifestyle advise and any follow-on care accordingly. A regular donation is given to the British Heart Foundation which allows us to share their booklets & leaflets with our patients.

This service is delivered using a single decker bus which has been fully refurbished into a mobile clinic with disabled access. Upon designing the service, the locations were carefully selected based on partnership work with population health focusing on the Core20PLUS5 patient cohort which in the Blackpool area highlighted the need for hypertension reviews. We provide this service across 7 days to ensure accessibility for all patients.

Blackpool is a very busy seaside town with a very transient population and severe deprivation, the areas we have chosen to focus, have been highlighted through data shared through our close work with the population health team. The local council have commissioned us to do this work following on great pre-existing work we have done throughout the pandemic and beyond.

As an extension of the NHS Health Checks, FCMS in collaboration with Blackpool Council also offer an additional service called Know Your Numbers. This is providing local workplaces the opportunity for their employees to attend our mobile unit for a BP, Pulse and Cholesterol check despite their age to help highlight the early detection of hypertension/hypotension.

We are delighted to report that since the start of this service, we have delivered 1562 Health Checks.

Patient feedback:

“If it wasn’t for the service you provided, I am not sure I would be here”.

“I feel so much better for knowing my results”

“I feel so reassured that the lifestyle changes I have made have helped my results”

“Very clear instructions and advise”

“Answered all my questions, would recommend to my friends and family”

“Very efficient and easily accessible service”

“Very informative and reassuring”

“Amazing service, everyone should do this for monitoring their health”

“I do not like doctors surgeries so this health check was a breath of fresh air”

“Pleased and grateful I was offered the service”

LCW 111 Action Card for Asylum Seekers

The NHS 111 service is under huge demand nationally. In June 2023, an NHS publication reported 1.55 million calls answered by 111 in April 2023, which is an average of 51.7 thousand a day.

The organisation commits to putting patients first and aims to ensure quality and safe care whilst addressing inequalities.

In April 2023 during a clinical meeting, it was identified that we were receiving calls from public places whereby the Operational team and Clinical Navigator were unable to identify correct demographics. The 111 Health Advisor assessment was taking extended periods of time which meant care could be delayed. We investigated the pattern and origin of these cases. We identified that these patients were from public places and in particular hotels. Further investigation revealed patients were likely to be asylum seekers and most needed a translation service.

These cohorts of patients presented with language difficulties, poor medical and drug history which could result in a patient experience which did not align with the orgaisations’ mission to give the best possible care.

The NHS 111 service is the first point of contact for any patient entering the service therefore the team agreed it was at this point action could be taken to ensure the patient was navigated to the best possible care at the right time.

The Clinical Lead produced an ‘action card’ to facilitate the journey of these patients to enable the Health Advisor to provide a high quality NHS 111 Pathways assessment. This was a collaborative approach with both the operational and clinical team and circulated to all NHS 111 staff.

The aim of the action card was for the 111 Health Advisor to be given support throughout the initial call and provide immediate assistance if there was any doubt about a symptom or disposition (outcome). The objective is to offer equity in care without any hindrance as a result of patients demographic.

FCMS Trailblazer positive ageing pilot service

Across Lancashire & South Cumbria (L&SC) there are several older adults with mental health needs (especially dementia) who don’t always receive the right care, at the right time, in the right place to age positively and experience good mental health and wellbeing. Arguably this contributes to and exacerbates significant pressures facing Older Adult Mental Health Services around assessment and review functions including an increasing complexity. This is demonstrated through a 22% increase in the number of people requiring 1:1 support and an overall increase in annualised costs of 19% from 2019/20.

FCMS supported in addressing the challenges that faced the service user, their family and the system, around avoidable admissions, reducing length of stay, delayed discharge, and repatriation of those who are in out of area placements.

We hoped that that this new model would provide truly personalised care that meets need and will provide positive outcomes for the individual and their family. In turn, this will provide efficiencies and create flow across the system through the prevention of avoidable admissions, reduction in length of stay and delayed discharges (addressing issues relating to non-medical right to reside/ ‘hospital complete’), and repatriation of those who are in out of area placements.

Suffolk Very Important Invitation Project - Cervical Screening

Cervical screening is a vital preventive measure for detecting early signs of cervical cancer and reducing mortality rates. It emphasises the importance of early detection through regular screening, which can significantly improve treatment outcomes and survival rates. However, disparities in access to cervical screening services create health inequalities, particularly affecting low-income individuals, racial and ethnic minorities, and those with limited healthcare access.

The Suffolk GP Federation, a not-for-profit community interest company has been funded by the Suffolk and North East Essex Integrated Care Board (SNEE ICB), to operate The Very Important Invitation Project. This project aims to address health disparities in cervical screening in Suffolk, aligning with the objectives of the NHS Long Term Plan. It provides training sessions to clinical and non-clinical staff members from all fifty-six GP practices in the county, focusing on best practices for cervical screening and addressing barriers related to health inequalities.

In England, women and individuals with a cervix, including non-binary and transgender patients, are eligible for cervical screening from the age of 25. Routine invitations are sent every three years between the ages of 25 and 49, and every five years between the ages of 50 and 64. However, approximately one third of patients do not attend when invited.

The project covers diverse areas, including urban, rural, and coastal regions, some of which experience high levels of poverty. It acknowledges these barriers and collaborates with primary and secondary care, community-based organisations, and charities to reach underserved groups. Social media platforms are also utilised to expand the project's reach. Additionally, Suffolk GP Federation's extended access service, GP+, provides appointments in the evenings, weekends, and bank holidays across nine different sites, ensuring accessibility for all individuals registered with a GP practice in Suffolk. An appointment booking request system through the project's website facilitates contact and booking into GP+ clinics.

The project aims to meet the specific needs of the local population and provide a valuable service to those who may not otherwise engage with the national cervical screening program or the healthcare system in general. It aligns with the NHS Long Term Plan's goal of diagnosing 75% of cancers at stage one or two by 2028.

PC24 Treatment and Vaccination Programme for Asylum Seekers

Urgently mobilising a treatment and vaccination programme to support Asylum Seekers and the wider community.

Following a Home Office decision, asylum seekers being housed in a large detention centre with an outbreak of diphtheria in the south of the country were dispersed rapidly to other parts of the country, including the area covered by our organisation.

In the space of one week we planned, mobilised and completed an assessment, treatment and vaccination programme to prevent a local diphtheria outbreak in the asylum population and in the wider community.


  • Rapidly engaged our workforce to support this work. Our staff went above and beyond with staff from all areas volunteering to work over a weekend - Finance, Executive Team, Clinicians and administrative staff.
  • Rapidly developed and implemented clinical Governance processes to ensure safe delivery of care (including evidence based operating procedures, Patient Group Directives etc.)
  • Created a temporary clinic in a hotel room.
  • Successfully vaccinated 122 of 124 available patients.
  • Provided support, advice and health promotion advice to this group of vulnerable patients who were frightened and anxious. Psychological support and advice around vaccine hesitancy was provided alongside provision of basic items of clothing.
  • Provided follow up support through our already established Asylum Service to provide seamless care.
  • Worked collaboratively with our key partners - ICB, Public Health, Serco and our local community and hospital trusts to mobilise at pace.

We are recognised as being a collaborative provider within the system and able to mobile quality care at pace. This was recognised by our local system and by Sir Chris Whitty, Chief Medical Officer for England.

We are proud to have made a difference to this group of patients and the wider health community. The commitment from our staff was outstanding. We continue to take such opportunities within our system which particularly fit with our social values and have an impact on our local population.

CHoC Health Matters Scheme

We operate a ‘Health Matters’ service working with third sector organisations, enhancing access for those who may have chaotic lifestyles, homeless, health and addiction problems. The service aims to meet people in places where they’re attending, rather than expecting them to follow the often difficult access to healthcare, which is even harder for those who may be homeless and/or vulnerable.

The service now has four community locations:

  • Women and family hostel
  • Men’s hostel
  • Gateway for Women, a women-only safe space
  • Mealbank, free hot two course meal in a warm and welcoming space

Service attendees can access health checks staffed by GPs, ANPs and Mental Health Nurses. The team provide physical health checks, cholesterol and diabetic blood checks using near point testing. This includes general health and wellbeing conversations, advice support and signposting and can address urgent health needs. Information is recorded in EMIS patient records.

A lot of what is seen at the session’s, concern individual’s general wellbeing. Common presentations are mental health and skin conditions.

The presence of a mental health nurse has been appreciated by the men and staff, at the men’s hostel, particularly to assist with signposting to other organisations who offer support.

Examples of Patient Impact:

One gentleman presented with a history of black stools. In conjunction with his own GP arranged for him to have bloods and an endoscopy. This individual would not have attended his own GP Practice, but by bringing the service to him he received the investigations he required and was very happy with how this was managed.

Another case concerns an IV user with cellulitis in the lower leg. Our clinician provided oral antibiotic treatment. This individual was initially reluctant to see the Health Matters service, let alone attend their own GP Practice. This highlights the benefit of the service; the patient did agree to being seen by the service and appreciated the care and treatment given.

At Gateway for Women we’re looking to provide group sessions covering subjects including weight management, contraception and sexual health, healthy eating. Followed by BP checks or diabetic blood checks relevant to the topic. We have also been approached by local Food Banks to deliver a similar service at their locations.

The focus and drive is to take health care to where people actually are, which is especially important when they are marginalised/experience health inequalities; rather than expecting them to navigate the health care system.

DHU Medication and Treatment to Vulnerable Patients with COVID

Throughout the COVID-19 pandemic members of our communities who were considered at greater risk from the illness were required to shield to reduce the risk of complications, serious clinical intervention, and hospitalisation. When others were returning to a more ‘normal’ life many of these vulnerable adults experienced the opposite, leading to inequality in their everyday life as a result of their on-going health conditions.

In two of the geographies we serve and with the backing of commissioners, we have been able to expand a clinical service that provides treatment to reduce the risk of serious illness that can arise amongst vulnerable people testing positive for Covid-19.

When it started in 2022, it was the first time in the UK that such medication was available outside of a hospital setting. Now this essential and potentially life-saving initiative is also accessible digitally which means that if an ‘at risk’ individual tests positive for COVID all they have to do is fill in a short online form and they are contacted and assessed by a clinician to discuss treatment options.

We are now much better at recognising who will benefit the most from this form of treatment so the digital application is available to all and means we can provide care in a more timely manner. The patient doesn’t have to wait in a queue, be referred or triaged; if they have underlying health conditions, the form comes straight through to us and we can contact the patient promptly.

Although the World Health Organisation has downgraded Covid-19 it is still a concern for those with long term conditions. We have been able to ensure that these vulnerable patient groups have access to the most impactful antivirals, known as nMABS (Neutralising Monoclonal Antibodies).

The treatment is provided at home or in GP surgeries and out of hours clinics. It reduces the barriers that vulnerable patients may have previously experienced during the pandemic and allows them to get on with their life, with the knowledge that additional care and treatment is available if they need it.

BrisDoc Homeless Health Service

Our Homeless Health Service (HHS), stands as a pioneering initiative that challenges and diminishes health-inequalities within the homeless community. Recognising that the ability to access standard healthcare services is not universal, we have crafted a service that prioritises the needs of the most marginalised.

The gap in healthcare provision for homeless individuals is stark. Conventional GP surgeries have barriers to registration, leaving the majority of homeless individuals without access to primary healthcare. This is despite the shocking life expectancy rates for homeless individuals: 45 for men and 43 for women.

We actively address the root causes of such inequalities. Our Lead GP with 35 years of experience, states, "Studies upon studies show the richer you are, the better treatment you get and the poorer you are, the worse your outcomes – it shouldn’t be that way." The majority of our patients come from backgrounds of extreme adversity, including birth to drug or alcohol-dependent mothers and conditions such as epilepsy, ADHD, or cognitive impairments due to alcohol dependency.

The design of our services caters specifically to these unique challenges. Our clinics are drop-in, circumventing the issue of missed appointments due to mental capacity constraints. We offer specialised outreach clinics for street sex workers, and operate "wet" clinics that serve patients with severe alcohol dependencies even whilst still under the influence. Our strategic partnerships extend to Bristol Drugs Project, specifically aimed at those with substance misuse issues. We go out to the most challenging hostels in our area to treat patients who are homeless due to serious mental illness.

Our dedication is holistic, providing not just medical care but also fresh clothing for patients with leg ulcers and a range of specialist services including podiatry, dental hygiene, dietetics, and counselling. Six years ago, we began with 60 patients; today, we serve over 600, a testament to the effectiveness of our action plan.

The service has expanded in scale and depth of its care. It focuses on offering respect and dignity to its patients, embodying our core value that everyone "deserves as much health and social care as the next person."

Our Homeless Health Service operates on the core principle that healthcare should be a right, not a privilege. Our proactive, community-based approach has improved the lives of hundreds of homeless people. We offer an exemplary model of how to understand and eradicate healthcare disparities through safe, effective, and compassionate care.

BrisDoc Nutritional Assessment of the Homeless Population

It is well recognised, especially in the current environment with the rising cost of living, that many in our society struggle to meet their basic nutritional needs. While the understanding of the importance of good nutrition for health and prevention of disease gathers pace, those on the lowest incomes fall further behind. None more so than the most vulnerable in our society, those experiencing homelessness.

As a dietitian, employed in a new role under the Additional Roles Reimbursement Scheme, I am in a unique and novel position of bringing my dietetic skills into the primary healthcare environment of Homeless Health.

When setting out in this new role I canvassed healthcare professionals, organisations providing free food to the homeless and the patients themselves to understand the difficulties experienced with access to food and managing disease related malnutrition. I was met with frustration, confusion, and a general lack of awareness regarding the needs of this population.

Clinicians observed that their patients ‘looked’ malnourished but did not meet the criteria for disease related malnutrition and therefore prescribing of nutritional supplements as set out by the local formulary.

Charity food providers described ‘providing a hot meal’ as a goal when designing free food provision, with little understanding of the protein and micronutrient deficiencies experienced by this population.

Patients described their barriers to accessing food such as poor mental health, avoiding those pushing drugs or owed money, or provision of store cupboard foods that they didn’t know how to cook.

As I have limited capacity within my role (3 hours per week) I have developed a new EMIS template targeted at the homeless population with substance addiction, supported by an RFC1 funding award. This template can be used by all those involved with this cohort of patients with no requirement for specific nutritional training, making every contact count.

The template seeks to address the specific nutritional deficiencies common in this population, providing clinicians with a clear rationale for prescribing nutritional supplements if required and to gather information which will inform future provision of food to the homeless population.

Having reached out to key opinion leaders in this field, in London, Dublin and across the UK they are excited to hear of a proposed population specific nutritional assessment tool and have agreed to integrate this template into their care pathway once finalised.

SELDOC Improvements in Palliative Care

Situation: In SE London, the provision of Palliative Care during OOH’s faced significant challenges. There were notable gaps in end-of-life (EOL) care services, particularly during daytime hours. These gaps were exacerbated by a lack of continuity of care, hindering the support provided to patients and their families during their final hours.

The Need we Identified: The critical need was to improve the accessibility and standardisation of EOL care, which was previously ad hoc and cumbersome, involving multiple touchpoints through the 111 Service. Furthermore, the scale of out-of-hours EOL care needs had not been adequately recorded.

What we did:

  1. We improved decision-making processes to provide EOL drugs faster, despite pharmacy closures.
  2. We improved patient care by working with community healthcare providers, reducing wait times and improving quality.
  3. With Guy's and St Thomas's Pharmacy team, we deployed new methods to cut wait times and improve EOL drug availability.
  4. We established interdisciplinary meetings with palliative care experts and nursing staff to maintain high-quality treatment in the ever-changing care landscape.
  5. We improved our palliative care strategy through staff training and updated policies.

Result: There have been significant improvements:

  • EOL cases increased to 200 annually, with direct access to OOH GPs bypassing the 111 Service.
  • Simplified and standardised EOL care process minimises unnecessary touchpoints, ensures safe drug administration, and collaborates with local pharmacies to reduce patient wait times and secondary care provider burden.
  • Patient and community feedback confirms our success in reducing final-moment anxiety. We provide these vital services for free, removing financial restrictions.

St. Christophe Hospice said of the service: “SELDOC are committed to improving services for patients in the out of hours’ time frame. This is particularly evident in their approach to streamlining access to Palliative and End of Life Medicines. A recent example of their approach has included attending a multi-disciplinary meeting to discuss the pathway for a dying lady who required medication. The team engaged well ensuring that they examined their processes while working across a variety of systems and providers. They clearly demonstrated a questioning approach to the issues, in addition to demonstrating a passion for improving services. Communication is excellent and I feel confident that if we had any issues with service provision I could pick up the phone and be able to resolve the concern immediately.

Conclusion: SELDOC's SE London operations represent a major change in community healthcare. Our partnerships and creative solutions have redefined unplanned acute palliative care, ensuring compassionate and dignified care 24/7. Our commitment remains steadfast as we continue to collaborate with local hospices, community care units, and pharmacists to provide comprehensive care for all.

Wales Palliative and End of Life Working Group

I am nominating the Goal 2 Palliative and End of Life working group which is chaired by 111 Clinical Lead Pharmacist Alex Gibbins. The group consists of clinical leads from 6 goals of urgent and emergency care, urgent primary care, WAST and palliative care.

The Project Initiation Document describes, ‘timely and efficient access to Urgent Care, Advice & Support for patients with life limiting conditions, in the last weeks and days of life’.

One of key policy priorities for the Six Goals National Programme is to ‘establish a palliative care pathway, helping people with life-shortening illness to access a specialist 24/7 after dialling 111’. With the policy directive clearly defined, there is a need to further develop 111 services with an enhanced clinical pathway to address the needs of specific patient populations with palliative and end of life (PEOL) care needs.

The group is looking at a way of getting palliative care patients and carers access to a single point of access of care in a timely way for assessment, reassurance, advise and coordination of care.

This improvement will ensure end of life and palliative patients would be able to access advise and care with minimal delay. The group has a clear project plan and is innovative in ways to ensure this patient group gets improved care without delay.