My name is Dr Priya Kumar, and I am a frontline General Practitioner (GP) who has also been part of the Slough wider team for the past 10 years. During this time, I have held a variety of roles including the primary care strategy lead, urgent care lead and more recently as the health inequalities lead.
As part of my GP vocational training in 2013, I had the opportunity to train in areas with pockets of deprivation, including Lambeth North and Elephant and Castle. Following that, I undertook a Darzi Fellowship placement in Enfield & Haringey, another deprived borough within London. After completing my training, I became a GP partner in Slough, where approximately 70% of Frimley Health and Care Integrated Care Board’s underserved population lives in Slough. Slough is one of the most ethnically diverse towns in the UK where over 150 languages are spoken and has a 10-year life expectancy difference from its neighbouring towns, Windsor & Maidenhead. Approximately 15% (5,540) of children live in low-income families with a 20-year gap with regards to healthy life years. All these challenges demonstrate that in Slough’s population, disease develops earlier in a person’s lifetime, and this is further complicated by its demographic and socio-economic make-up.
One could say, I don’t know any different given my experiences in these deprived areas. I have gained an understanding from the beginning of my career of the potential challenges these communities face with regards to accessing health and the potential knock-on effect on their overall health and wellbeing as a family. I recall as a GP trainee, the practice on calls being demanding with a significant number of home visits compared to the other areas. My clinics would take longer due to the complexity of the patient needs and potential language barriers. However, as a student we were never taught to consider the potential wider determinants of health1 as an additional layer to the consultation and therefore did not appreciate the importance of these factors at the time.
Working as a GP and general manager at the Urgent Care Centre (UCC) in North Middlesex Hospital in 2014, I gained an in-depth insight into the presentations at the front door of the emergency department in the 4th highest deprived borough in London. Over 500 attendances a day with more than 30% being reviewed within the UCC. Many of the presentations were primary care complaints with very few patients being admitted. There was one memorable case, where a 28-year-old gentleman, presented with a minor insect bite and had waited for 3.5 hours to be seen. I took a step back at the time and asked why he didn’t wait to see his GP the next day given it was 10pm by now. He simply said he could not afford to take time off work and would have rather waited. He needed to pay the household bills and his main concern was his ongoing employment. This really opened my eyes to consider the other crucial factors that play an important role in how communities access our services, what their experiences are and the potential impact this could have on their health. Since October 2016, general practice nationally has further opened its doors by extending their hours2 into the evening and weekends to improve overall accessibility. We have also created new digital access routes such as the NHS App and the use of digital consultations through telephony, video, and e-consultation, which may have risen to new digital inequity concerns. NHS England has recognised this as potential barrier to access and published new guidance in September 2023 titled ‘Digital Inclusive Healthcare’3 to support different systems to improve the patient experience.
Since the COVID-19 pandemic, the acceleration of digital access within the NHS, especially in primary care has significantly changed. On 5th March 2020, I was preparing for my Care Quality Commission (CQC) visit, which showed only 20% adoption in my practice for electronic prescriptions at the time. Preparing my answers, I focused on the fact that 96% of my registered population are from a minority ethnic group living in average deprivation decile of 3.6. However, 17th March 2020 hit and within a week our electronic prescription uptake had risen to 97%, illustrating the assumptions we can make about these communities. Many of these communities are very powerful and we need to move to a place of co-creation, where we understand the needs of these communities and empower them to be part of the solution at every level in the system.
This brings me onto where I am today. My past experiences and encounters have been through osmosis and in hindsight has made me a better clinician. Within the health inequalities’ role in Slough, I had the opportunity to implement and embed key initiatives directly related to health inequalities and health inequity with my team. Last year, the Slough team identified a subsection of the population living in decile 1-3 with 2-3 chronic conditions through a population health approach. Social prescribers were empowered within their Primary Care Networks (PCNs) to focus on the wider determinants of health by inviting these residents to answer a 16-part wider needs assessment (DiPCare-Q) questionnaire4, to help identify areas of perceived burden, like payment of household bills, lack of food or clothing, mental well-being, and digital inaccessibility. By taking the time to understand what mattered to them as an individual and the overall needs of their family, this resulted in an objective reduction in urgent care activity and improvement on target health outcomes.
This year, the team embarks on three projects within primary care to support these underserved populations, including the Core20PLUS55 prescribing incentive focusing on reducing cardiovascular complications in adults and asthmatic children, an in-depth culturally specific mental health assessment and the multigenerational household6 project. 13.9% of Slough’s population live in multigenerational households, approximately 3,761 households in total, a fact that was highlighted to us during COVID, where our messaging focused on the importance of reducing the spread of infection.
Phase 1 of the multigenerational project focused on the uptake of outstanding preschool boosters by reaching out to specific families identified. By arranging a home visit, the team also used this opportunity to complete the remaining health checks for the entire family in one setting, benefiting up to 3 generations of residents. Initial results showed a further 68 injections achieved within a 2-week period at the end of the Quality and Outcomes Framework7 (QOF) year in March 2023 as well as multiple other health indicators completed. Furthermore, 25% of social prescribing referrals were generated as a result of visiting the patient’s family home and assessing the home environment. These families wanted their health checks but perhaps due to their circumstances which were out of their control, they were unable to engage through the traditional routes of primary care. Given the initial success, phase 2 of the multigenerational household pilot has identified 5 or more individuals living in one household with less than 30% of their QOF indicators completed as of 31st March 2023. Our teams are reaching out to these specific households, and we are looking forward to analysing the learnings from this extended pilot.
Leadership within the health inequalities space takes courage, resilience, and innovation. It involves influencing your current colleagues and system to focus their attention on the need rather than simply the target. This is very challenging in current climates and many of my colleagues have questioned me in these potential new ways of working and rightly so. However, I fundamentally believe we need to shift to a place where we can influence the current funding processes to reflect the need, use national levers to make this a priority for systems, empower residents to be part of the solution and share the risk across the different leaders within our integrated systems. If we achieve this, we will potentially create resource, time, space, and better outcomes for our entire population.
Frimley ICB and Slough hope to change the narrative, build further trust with these families, and ultimately narrow the health inequalities gap. By supporting the residents with their needs, we hope to shift care from a reactive way to a proactive way of accessing health by addressing the wider determinants of health. The Royal College of General Practitioners (RCGP) has placed health inequalities as one of its’ top four strategic priorities8 over the next few years, which is a breath of fresh air as they have made a solid commitment in making a difference to these communities.
Acknowledgements: Slough Place Team, Slough Primary Care Networks, Connected Care Team, Frimley Leadership Team who have all supported this work and been an integral part in the development of these programmes.
References:
1Wider Determinants of Health – OHID (phe.org.uk)
2Seven day, 8am – 8pm, GP access for hard working people – GOV.UK (www.gov.uk), published October 2013
3‘Inclusive digital healthcare: a framework for NHS action on digital inclusion’ (NHS England September 2023) NHS England » Inclusive digital healthcare: a framework for NHS action on digital inclusion
4Kumar P, ‘Addressing health inequalities in Slough through social prescribing’ (NHS England, 2023) <https://www.england.nhs.uk/blog/addressing-health-inequalities-in-slough-through-social-prescribing/> accessed 28 August 2023
5Core20PLUS5 (adults) – an approach to reducing healthcare inequalities(NHS England) NHS England » Core20PLUS5 (adults) – an approach to reducing healthcare inequalities
6Kumar P, ‘Healthcare and prevention through a multi-generational household approach’ (NHS England, 2023) NHS England » Healthcare and prevention through a multi-generational household approach > accessed 3rd August 2023
7Quality and Outcomes Framework – Wikipedia
Author
Dr. Priya Kumar, BEM
Dr. Priya Kumar has been a GP Partner at Kumar Medical Centre since 2013 and holds a variety of other roles. This includes being the Health Inequalities lead for Slough, Transformational Clinical Lead for Connected Care in the Frimley ICB and an Urgent Care Clinical Advisor for East and North Hertfordshire Trust. She has also recently been named the ‘Digital Innovator of the Year’ 2023 at the Digital HSJ awards.
Priya completed both her undergraduate medical degree and GPVTS training at GKT & Kings College in London. After completing the Darzi Fellowship Programme in 2014, she understood the importance of co-production and clinical leadership within the NHS. Priya has been involved in transforming care across the system by working with various stakeholders including the residents, primary care, secondary care, social care, the voluntary sector, and public health. Her main passion lies in developing innovative clinical pathways by using a population health approach and applying digital solutions to improve patient outcomes, as well as building in efficiencies and productivity whilst incorporating the residents’ views and underlying circumstances.
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.