Jennifer Crozier
Trainee Advanced Clinical Practitioner
Stalybridge, Dukinfield & Mossley PCN
The Challenge
Jennifer noticed that there was a significant impact on the health and wellbeing of patients in her PCN who were socially isolated. She realised that this social isolation not only affected their mental health but also led to an increased reliance on general practitioner (GP) services, with socially isolated patients accessing their GP practice more frequently than other groups in the community.
62% of adults who reported bad or very bad health reported that they felt lonely at least some of the time, compared to 35% of adults with fair health and 18% of those with good or very good health.
(NHS choices, 2021)
The Innovation
In order to address these challenges in a more holistic, coordinated way, Jennifer organised regular multiagency lunches for patients and local services, designed to provide health checks and prevention support while fostering social interaction. The initiative brought together patients, various health and care support services, including the complex care team, cancer care specialists, Age UK representatives, falls prevention experts, infection control and prevention teams, and nutrition and hydration champions, among others. This collaborative approach aimed to deliver holistic care for patients, integrating physical health assessments with social engagement opportunities.
The lunches not only provided health checks, which were recorded on the patients’ GP electronic notes system, but also offered a platform for further education opportunities as well as wide-ranging support. Patients were able to interact with healthcare professionals in a relaxed setting, receiving personalised advice on managing their health and to learn about self-care measures to reduce illness. Jennifer had arranged free transport with the local council, which helped to improve access for a number of patients, so they could attend the lunches when they experienced challenges with mobility.
What is your ability to connect services to manage your own health and wellbeing?
The Impact
- Improved health outcomes for patients have been observed following multiagency lunches, with participants reporting increased self-assessed ability to manage their health, contributing to potential reductions in GP visits over time.
- Enhanced social connections among patients and within communities have been a key benefit of the multiagency lunches, fostering new friendships and future meetup plans among attendees.
- Improved access to health-related information and resources has been facilitated through these events, empowering patients with knowledge and support beyond traditional healthcare settings.
- Increased activation among both staff and patients has been noted, with heightened engagement and proactive involvement in health management and community activities.
- Improved integration of services across multiple agencies has resulted from these lunches, enhancing collaboration and resource sharing to better meet the diverse needs of patients and communities.
