>> Jane Waddington: I used to ring up the ambulance - the GP or the ambulance - about once or twice a day.
>> Dr Monica Alabi: Eighty per cent of our health and wellbeing is determined by our social, our economic and our
environmental conditions. In Bedfordshire, people who are in deprived areas have ten fewer good years
than people who live elsewhere.
and 12 per cent of our population are from these deprived areas.
Population health management is a way to proactively look after our patients
so we are able to predict their current and, most importantly, their future needs
using data intelligently.
Health inequalities are things that we deal with every day in practice
and the COVID pandemic just highlighted that gap and it made it even worse.
>> Victoria Harding: Jane has a number of long-term conditions, including diabetes
she has heart failure, she also has some learning difficulties.
Over the COVID period she became very sedentary
she didn't have very many social interactions and she was quite lonely.
>> Jane Waddington: My health wasn't very good, because I was not taking my medication
and I was eating all bad things.
>> Dr Monica Alabi: We came together as a team.
We had GPs, pharmacists, social prescribers, data analysts
as well and we were able to identify the small group of people with heart failure and who were also socially vulnerable
You might think that 37 people is not a lot,
but actually these were the people who were in the highest risk group
and they were the people who were more likely to use healthcare because they didn't have
other options - they didn't know who else to call.
Jane is a typical person in this cohort
and it's interesting because what we think Jane needs usually isn't.
So, for instance, Jane needed help with things like getting a TV, sorting out her sofa
very simple measures to enhance her quality of life.
>> Victoria Harding: We talked quite a lot about what was important to her
identified her various conditions and the problems that she was having.
We worked out a care plan - we worked quite closely with the council
to prioritise the repairs to Jane's ceiling
so it's really improved her mood - she quite looks forward to getting up in the morning.
>> Jane Waddington: I'm a lot happier now because I've got my ceiling all done
and my nice walls painted with a colour I chose.
I feel a lot better.
>> Dr Monica Alabi: Titan Primary Care Network recognised the importance of social prescribers.
So social prescribers, the pharmacists, the community nurse as well, the GPs, wrapping around that support
for them just made things much easier and the patients in this group
were very happy and the feedback was amazing.
>> Victoria Harding: Working as part of the ICS has allowed us to be proactive with finding vulnerable groups
in need of support. It's allowed us to work in partnership with many other groups,
secondary services as well as the voluntary sector.
>> Dr Monica Alabi: Most of what we do as GPs is fire fighting, where patients come
and they ask for help. So this approach helps bring together not just the health aspect
of the patient in front of you, but the social aspect as well.
It's important to all GPs, it's something that we have to continue to do.
Our patients are happier, they are healthier, because we are taking into consideration
things like housing, how they are living, debt.
It feels fantastic to know that we're helping people.
>> Victoria Harding: Some of the people that I support don't have anybody else.
Knowing that I can make a difference just makes every day worthwhile.
>> Jane Waddington: I'm a lot happier since I met Vicky!