Dr Peter Scolding: Bringing care closer to home  

#NarrowingTheGapMSE

Dr Peter Scolding is the Assistant Medical Director for the Mid and South Essex Integrated Care System

Working and listening to our local communities in mid and south Essex is at the core of bringing care closer to home and ensuring that all the decisions we make as an Integrated Care System, starts with its people.

At Mid and South Essex Integrated Care System (MSEICS), we know a ‘one size fits all’ approach is not effective. Some of our residents and population groups face difficulties in accessing health and care services, and currently are therefore more likely to have a poorer health outcome. To address these inequalities, we’re making better use of our data to improve our residents’ health and wellbeing, as well as prevent them developing serious longer-term diseases.  We can then identify and support individuals most at-risk, earlier, and deliver better personalise solutions and empower individuals to make healthier lifestyle choices.

Care closer to home

Through understanding what matters to local people, we’re also bringing services into communities and people’s homes, wherever possible, so those who experience difficulties getting to services and appointments because of lack of transport, physical issues or digital poverty are not excluded from vital health and care offers.

Work is already afoot to bring services like hospital outpatient appointments, virtual consultations, blood tests, x-rays and support for people living with long-term conditions like diabetes or breathing problems into local communities. This is being achieved with the support of trusted community representatives and outreach projects. This includes our Respiratory van, a mobile clinic specialising in spirometry testing check for lung conditions such as chronic obstructive pulmonary disease (COPD) and other respiratory diseases.

Supporting people at home

In addition, our Blood Pressure at Home (BP@Home) programme has supported over 54,000 people over the last 18 months to measure their blood pressure where they live.

So far:

• Over 1,500 people have gone on to have their medication reviewed,
• over 1000 people have discussed how changing certain behaviours can improve their health,
• 900 people have also been diagnosed with diabetes,
• and over 100 people have been referred to hospital for specialist care.

Prevention through working together

We’re working, at local neighbourhood level, with GP practices, community pharmacies, dentists, optometrists and other health and care professionals in primary care networks (PCNS), as well as community and voluntary organisations, to collectively improve the health of their residents.

Personalised and holistic approach to healthcare

Through using a data and insight population health management approach, Benfleet PCN led by Dr Khan, has been working with Castle Point Association of Voluntary Service’s (CAVS) to identify a group of patients who would benefit from a more personalised holistic approach that can be delivered either in their home, virtually or at the surgery looking at not only their clinical needs. It included health assessments, through Benfleet PCN Alliance Community Team (PACT), which helps to ensure that issues can be caught early, helping to avoid visits to hospital.

Learn about what Benfleet PCN did here.

Reaching out to vulnerable communities in Southend

The homeless are one of our most vulnerable communities and often suffer from multiple health issues.  Preventing further illness and existing conditions deteriorating further is vital.  In Southend, multiple partners come together to deliver the Southend Integrate Healthcare for Homeless initiative.

GP services, the Hepatitis C Trust team, sexual health services (Brook Sexual Health), mental health services (Southend Mind) and drug and alcohol service, STARS come together to provide health checks and vaccinations to the homeless.

Sessions were held in soup kitchens and at HARP, a charity that houses temporary residents, ranging from those with multiple complex medical and social needs, to those closer to realising independent living.

You can read about the project here

Grants for community and voluntary organisations

Grants to help reduce health inequalities

Microgrants

If you are part of a community of voluntary organisation, you apply for a new micro grant programme to help address health inequalities and the wider determinants of health within your local area. 

Essex Community Foundation Grant

There’s funding available, from the Essex Community Foundation (ECF), to support marginalised communities and address health inequalities for people who have mental health problems. If you are a charity community group working within the mid and south Essex footprint.

Other blogs from our #NarrowingTheGapMSE campaign