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North Lewisham Primary Care Network

Population health in action – a PCN approach to addressing health inequalities


North Lewisham Primary Care Network (NLPCN) has developed an innovative programme to address health inequalities, placing co-production and community engagement at the centre.

NLPCN has nine GP surgeries and serves over 85,000 residents in the vibrant south-east London borough of Lewisham. A large proportion of the population are from Black, Asian and ethnically diverse groups, and the area has higher-than-average levels of deprivation. Many of those living in the area have poorer health outcomes compared to other groups, both across Lewisham and England. These health inequalities are partly driven by differences in the uptake and provision of health and social care services, but are also substantially influenced by the structural determinants of health, including education, housing, physical work environment and poverty.

Areas of focus

The team at NLPCN initially conducted a community engagement exercise to further understand why health inequalities were perpetuated in north Lewisham. After a mapping exercise, they engaged 32 different local community organisations to gather their views and feedback. As a result, the group were able to identify key themes that have helped to structure their targeted interventions and associated workstreams. The three key themes are:

  • Barriers to accessing care services, e.g. digital exclusion
  • Lack of trust from the population towards mainstream health organisations
  • Social determinants of health as a driver for ill health

Using this themed feedback and collaborative ideas, the community group were then able to establish five workstreams to focus on addressing health inequalities across the patch.

Figure 1: Visual artist captures minutes from community forum meeting1

  • Appointment of a dedicated community link worker: The ‘face’ of primary care and responsible for community engagement, and the point of contact at NLPCN for health inequalities. A local resident with 25 years’ experience was recruited into this role – she also runs the Community Forum.
  • Community Forum: Establishing a quarterly open meeting for individuals and organisations to co-design initiatives and provide feedback on activities that impact health inequalities.
  • Improving access to GP services: Co-design of information sharing about navigating remote triaging and online appointments and weekly Digital Hub for residents who are digitally excluded.
  • Integrated data strategy: Designed to identify and proactively manage residents at risk of health inequalities, mapped those at risk against population health categories of CORE20PLUS52 .
  • Prioritised NHS Health Checks: Proactively targeting the population cohorts identified through the data strategy.

Using data to prioritise

Dr Aaminah Verity, GP and NLPCN lead for health inequalities, believes in the power of data to focus resources and efforts towards those most deserving of support. Defining a clear data strategy enabled the team to identify those residents at risk of health inequalities and provide proactive screening. By using a combination of 300 SNOMED codes recorded in the primary care system to identify those patients from inclusion groups for attention by front-line clinicians, staff have access to clinical and administrative guidance to help ensure these people do not get lost in the system. In north Lewisham, those at risk of health inequalities are more likely to experience long-term health problems at a younger age and are less likely to come forward for a health check.

Using the identified cohorts from the data strategy, an initial small-scale pilot invited patients who had been flagged as at-risk to come in for a free health check. This pilot exercise was targeted at those who had not had a blood pressure reading recorded in the past five years and included all people over the age of 18.

A total of 70 people attended and 60% of these were found to have an abnormality that was picked up during that health check appointment. These included diabetes, pre-diabetes, obesity and high blood pressure. 40% of those were aged under 40, which demonstrates the value of picking up underlying health issues earlier upstream in these at-risk groups. Patients were referred for weight and cholesterol management, and smoking cessation services.

Individuals in these groups are at greater risk of developing conditions at an earlier age due to the impact of the social, environmental and financial conditions in which they live and work – it is known that they spend more years in poor health. The graph below depicts the difference in age at the onset of multimorbidity depending on socioeconomic status – with one being the most affluent, 10 the most deprived.

Figure 2: Prevalence of multimorbidity by age and socioeconomic status3

Enhancing the data

The team secured the go-ahead for this pilot to be rolled out more widely across the PCN, focusing on NHS Health Check cohorts aged 40-74, to ensure financial value to practices, highlighting the difficulties of incentivising this work within existing funding targets for primary care. The at-risk data has been further enhanced by the Lewisham population health management team using the integrated dataset (which also includes hospital, community and mental health data) within Cerner HealtheIntent® to identify CORE20PLUS54 cohorts across the entire PCN, allowing for a more proactive approach to prioritise health checks. In NLPCN, this is done in collaboration with the population health team, who are monitoring outputs to determine if this approach is delivering improved case finding over the existing NHS Health Check programme.

This project is still ongoing and while the full data is not yet available, it has so far demonstrated significant results.

Combining the at-risk flags with socioeconomic deprivation and ethnicity data, the team has now carried out a total of 350 health checks over a six-week period. Results to date show:

  • 31% with pre-diabetes
  • 27% with raised blood pressure (hypertension)
  • 11% with suspected diabetes
  • 10% with a raised QRISK score5
  • 8% of people with a body mass index (BMI) of over 35

Research6 shows the diagnosis rates from the standard NHS Health Checks are:

  • For every 6 to 10 people having a check, one person is identified as being at high risk of cardiovascular disease
  • For every 30 to 40 people having a check, one person is diagnosed with high blood pressure
  • For every 80 to 200 people having a check, one person is diagnosed with type 2 diabetes

In comparison, results from NLPCN demonstrate that their proactive data-driven approach is even more effective at picking up hidden health problems. The graph below directly compares One Health Lewisham (OHL- the GP Federation) health checks (which is running for all practices across Lewisham) against the targeted health checks for NLPCN.

PDID rates graph

Figure 3: Improved outcomes of targeted health checks when compared to the standard approach

Collaboration is key

The NLPCN model for health inequalities is community-led and collaborative. This work is prioritised by the organisation, which means that any new initiatives within the PCN have a focus on health inequalities. Most importantly, in Lewisham this work has been recognised and appropriately resourced by the public health team and the ICS. As Aaminah Verity says:

“If you resource people properly to do this work, there is passion and excitement around coming up with innovative solutions around this.”

The work at NLPCN is being replicated and there will be a funded health inequalities lead role per PCN across Lewisham. This proactive approach puts the PCN on the front foot in terms of targeting resources in the most impactful way, identifying health conditions earlier and having a real impact on closing the gap on health inequalities across the borough.

What is an NHS Health Check?

The NHS Health Check is a national prevention programme that aims to reduce the chance of a heart attack, stroke or developing certain forms of dementia in people aged 40 to 74. A check includes an assessment of:

  • Alcohol consumption
  • Blood pressure
  • Cholesterol
  • Diabetes risk
  • Physical activity
  • Smoking status
  • Ten-year cardiovascular disease risk
  • Weight

Individuals should be supported to manage risk factors and cardiovascular disease risk where their results are abnormal. This can involve support to change behaviours, brief intervention and referral to stop smoking, weight management, and alcohol, diabetes prevention and physical activity services.

Read the NHS Confederation case study on improving population health outcomes with integrated datasets.


2 NHSE health inequalities strategy defines the CORE20 as the most deprived 20% of the national population as per the Index of Multiple Deprivation (IMD), with the PLUS defined as inclusion health groups (e.g. those experiencing homelessness, substance abuse, vulnerable migrants), and Black, Asian and ethnically diverse residents (>52% of NLPCN residents) |


4 In addition to the CORE20PLUS, there are a further five areas of clinical focus: chronic respiratory disease, early cancer diagnosis, hypertension case finding, maternity, and severe mental illness

5 QRISK determines risk of developing cardiovascular disease, i.e. greater than 10% risk chance of having a stroke or heart attack within the next 10 years


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Client outcomes were achieved in respective settings and are not representative of benefits realised by all clients due to many variables, including solution scope, client capabilities and business and implementation models.