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Community services - working to tackle health and social inequality in Brent
Brent is one of London’s most diverse boroughs, but it also has significant health and social inequalities. It has a high number of people who suffer from chronic disease and long-term conditions. Research has shown that 30% of patients in acute hospital settings in north west London would have their needs better met at home or in a community setting. Andre Nolan, Brent Health Inequalities Team Lead, and Ravi Chandra Polineni, Integrated Care Partnership Team Lead, explain the role that community services are playing in helping to tackle health and social inequality in Brent. Advanced care practitioners, Veronica Anagbo and Adesola Efunbajo, also highlight the work being done to enhance healthcare for care home residents.
Integrated Care Partnership
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Brent’s Integrated Care Partnership (ICP) was set up to work proactively with those patients who are at high risk of hospital admissions. The service aims to provide the best possible specialist GP led care, supported by a consultant in the community, for up to 6 weeks to address the needs of patients, enable them to self-manage their condition and prevent unnecessary hospital admissions. Ravi says: “Our team of specialist clinician’s work alongside other community services including district nurses, mental health, rapid response, and social services to achieve best possible outcomes for patients.
“The ICP’s holistic approach addresses the health and social needs of patients with an emphasis on patient engagement and education to achieve the best possible outcomes.
“The ICP has successfully introduced the community heart failure and respiratory service and runs community heart failure clinics twice a week with plans to add another clinic to meet the increasing demand. “As a result of the pandemic the service was extended to support the delivery of flu vaccines, COVID testing and supporting GPs to deliver COVID vaccinations in care homes and extra sheltered homes.”
Tackling health inequalities
The significant health and social inequalities that exist across the local population became more evident when COVID-19 hit Brent in early 2020. There was a clear link between patients dying following a COVID infection and underlying long-term health conditions such as diabetes, cardiovascular disease, high blood pressure, COPD and asthma. Andre explains that: “In response to the first wave, Brent Council and Brent Clinical Commissioning Group worked with the Trust to develop a service that would help to reduce inequalities, increase quality of life and achieve better health outcomes for residents. As a result, on 30 November 2020, the Brent Health Inequalities team was launched. “In collaboration with 10 GP practices who were most affected by COVID, the team uses population health data and local feedback to target those “hard to reach patients” in the community. “We engage with people about their health issues, offer holistic health care assessments, advice and education to help them to selfmanage their conditions. “We have opened a patient advice line for residents to contact for information, or to be sign posted to relevant community services for any non-clinical queries that they may have. The advice line is open between 10am and 3pm, Monday to Friday. “The pandemic has also had a significant impact on the mental health of many local people caused by isolation during lockdown, financial concerns, unemployment and bereavement. Our team is working alongside the Brent community mental health team to offer support to patients who have low level mental health needs. We can then signpost them to services available in the community, “The support of the council has led to the recruitment of community champions, health educators and local volunteers to help engage with residents. This underpins Brent Health Inequalities team philosophy “to take ordinary people, to do extraordinary things for the people of our community!”
Members of the ICP team
Enhancing healthcare for care home residents
Care home residents represent some of the frailest, most dependent and vulnerable members of our society. In Brent there are 10 nursing homes and 52 residential care homes providing care for people with a range of physical, mental and emotional needs. Adesola says: “The NHS Long Term Plan, published in January 2019, includes a commitment to enhanced health in care homes. Brent CCG recognised that care home residents would benefit from an enhanced, proactive primary care service, providing access to multidisciplinary and specialist services that could work together to improve care and outcomes.
Veronica outlines how the service works: “The support team has a single point of access number which enables care home staff to easily contact an advanced care practitioner for advice, support or clinical interventions from 8am to 8pm seven days a week. “With a designated team of GPs working alongside advanced clinical practitioners within the service, any acutely unwell residents referred to the team can receive care assessments and management interventions. “The ECHST offers education and training to care home staff. Where appropriate, the team also provides a review of residents following their discharge from hospital and, in discussion with their GP, can make direct referrals to community services and review care plans. “The team reviewed its service delivery at the start of the pandemic, then extended to all 62 care and nursing homes in Brent to ensure that all care homes were supported and also worked to deliver COVID testing and vaccinations to all residents in care homes.”
