Our analysis identified those with diagnosed learning disabilities were at 6.36 times greater risk of admission to hospital with flu in 2020, compared to the population as a whole. This allowed to us to ensure that these at-risk individuals received the flu vaccine to help reduce their chances of becoming ill. In the end, 92% of those targeted received their vaccination.

Our work in HealtheIntent^® identified having a learning disabilities diagnosis was the greatest contributor to increased risk in Wirral – more than twice that of COPD (6.36 times to 2.97 times).

We know that those with learning disabilities have poorer health outcomes, a life expectancy 25 years lower than average in the UK, and significant inequity in accessing measures for healthy life expectancy and long-term condition management. Healthy Wirral is committed to improving the existing status quo for our community.

Healthier South Wirral Primary Care Network (comprising six GP practices and serving 50,000 people) sought to address the gaps in care for people with learning disabilities during winter and the pandemic response. We knew this was a vulnerable population we could support.

With the objective of improving health through new roles adapted to patients with learning disabilities, the team included a care coordinator, wellbeing practitioner (social prescriber) and trainee nurse associate. The team made great progress in improving identification and engagement with flu and COVID vaccination, as well as the NHS Health Check uptake amongst those with learning disabilities.

Previously, it has been difficult to know the greater risk that the learning disabilities community faced compared to the rest of the population. Now, we had the ability to use advanced analytics to quantify the risk and reach out with vaccinations for those with learning disabilities. We wanted to act on our new intelligence in an area that has been historically difficult.

To support a drive to increase uptake, we hosted clinics exclusively for patients with learning disabilities.

Adaptations were made to the local leisure centre to make the experience as friendly, comfortable and positive as possible. This included longer telephone and face-to-face conversations to discuss concerns about the clinical settings and vaccinations. Easy-read materials were provided in advance to understand the vaccination process and pre-invites to the clinic were sent out to help people become familiar with the facility and its staff. Addressing the known wider gaps in care, people were offered the opportunity for a health check on the same day and – for reassurance – we allowed carers to receive their vaccination at the same time.

We found that analysing data for a single contributing factor doesn’t tell the whole story, as people in Wirral with four or more long-term conditions are at a 1.4 times greater risk of admission with flu. It is multi-morbidity that increases the risk, and our population health management approach has been able to identify the people at greatest risk and reach out to them.

Accessible primary care is key for the delivery of proactive care and population health, but the system needs the infrastructure and intelligent support to deliver the targeted interventions. Healthcare will change after COVID – the pandemic provided the opportunity to accelerate digital innovation, with health information exchange now regarded as business as usual, and we can see how advanced analytics can identify and target an underserved population. Addressing inequalities is the post-pandemic goal, and as a clinician and chair of the commissioning group, my drive is to use these tools to enhance and improve the quality of care for the time we need to play a part in the rest of our patients’ lives.

We can support them in living healthier and happier lives through data science and analytically evidenced insight that drives the interventions.

- Paula Cowan - GP and chair, NHS Wirral CCG

“The feedback was really positive – it reduced anxieties for the patients and carers and overall was a success. By having our LD team on-site, they were able to recognise challenging behaviours and make quick and efficient adaptations, whilst communicating with patients to allow the vaccination to be completed safely. Staff found the clinic to be a real success as they felt able to give adequate time to explain the procedure in a patient-friendly way, which helped them build on the trust and good rapport they already had with patients.”

- Rachel Stott, project leader and practice manager at Eastham Group Practice

"The organisation of the clinics was well thought out and adjusted to suit the needs of the patients. The large sports hall gave a quiet, calm, and spacious atmosphere. The patients all enjoyed the warm welcome they received from the stewards and the learning disability team. I gave some of the vaccinations outside in the mobile clinical unit because some patients found the sports hall quite intimidating. This was a huge success and the patients seemed excited to be returning in a couple of months’ time. The clinic could not have gone better – from the friendly multi-disciplinary team, to the well-thought-out organisation and the management team, the atmosphere was calm, efficient and confident from start to finish."

- Healthier South Wirral’s nurses and healthcare assistants

“I was scared before. I am brave now I had my vaccine.”

“Thank you very much for the vaccine today. I came here actually for my son, for him to get his vaccine and then being his primary carer, I was offered one as well, so I am really grateful for that. Thank you."

Neeraj was invited with his mother Rama for the COVID-19 vaccine. Despite fearing needles, he received his jab and had a health check after speaking to our LD wellbeing practitioner.

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