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Lewisham Health and Care Partners

Population health in action: Addressing health inequalities

Revisiting Lewisham

Since the inception of the NHS, the population has not only grown in size, but people are also living longer. An ageing population means that people are living with long-term conditions, increasing the demand on local health and social care services.

Primary care networks (PCNs) are groups of practices, building on existing primary care services – GPs working with community, mental health, social care, pharmacy, hospital, and voluntary services – to enable a more integrated health and care provision for people in their local area.

The vibrant southeast London borough of Lewisham has a diverse mix of ethnic groups as well as higher-than-average deprivation and poorer health outcomes. Across Lewisham, there are six PCNs that provide the structure and funding for services, in response to local need. North Lewisham PCN (NLPCN) has developed an innovative programme to address health inequalities, placing co-production and community engagement at the centre.

NLPCN previously shared its work-in-progress story about addressing health inequalities through targeted health checks. Here, we revisit this work with an update to the project.

Building trust

NLPCN knew the importance of building trust within its local community – trust of the health and social care system means that people will be more likely to come forward for health checks when invited. Prior to this project, there had been poor uptake from residents for routine health checks, so a community engagement exercise was set up to tackle this issue.

As a direct output from the community engagement, NLPCN is now fortunate enough to have a dedicated community link worker, Joyce Jacca. Joyce’s role has may aspects including being ‘the face of primary care’ and running the quarterly Community Forum to codesign initiatives and feed back on activities that impact health inequalities.

Joyce emphasises how important it is to earn the trust of the community through this programme, with communication being a key part of the process, “Whether the outcomes are good or bad – go back and feed back. And that’s your trust.”

Prioritised health checks

Dr Aaminah Verity, GP and NLPCN lead for health inequalities, believes in the power of data to focus resources and efforts towards those most in need of support. In the north of 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 data to identify those cohorts deemed to be at greater risk, they were then proactively invited to attend a health check to help identify any underlying health conditions.

As of October 2022, the team has carried out a total of 934 health checks. 80% of those invited for a health check took up the offer to attend their screening appointment. Combining the at-risk flags with socioeconomic deprivation and ethnicity data to identify those at highest risk, results to date show that this targeted proactive approach has proven to be more effective than the standard NHS health checks.

  Lewisham targeted health checks National health checks1
Raised blood pressure (hypertension) c. 20% 3-5%
Diabetes 18% with pre-diabetes
3% with suspected type 2

Katherine Curell, one of the senior care coordinators who is responsible for carrying out health checks with individuals across NLPCN, has numerous examples of members of the community she has been able to help – identifying potential conditions that were previously unknown and directing people to the best course of treatment or prevention. She is proud of the work they have done and is keen to highlight the benefits, “Most of the time, if you catch it early, it can be sorted by diet and exercise and then you don't [even] need medication, which is always a good thing.”

Promoting health and wellbeing across the borough

The success of the project at NLPCN has inspired the ICS to fund similar targeted health check programmes within each of the other PCNs. Lewisham will be able to have a borough-wide focus on closing gaps in health equality, identifying health conditions earlier, and promoting healthy behaviours.

As Dr Verity explains, “Our approach is collaborative, community-driven, and data-driven – together, we are working to achieve population health outcomes.”



View all client achievement stories
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.