Tackling health inequalities - Bromley by Bow Centre

Dr Gabi Woolf

Tackling Health Inequalities in General Practice

A man from the most deprived decile in England can expect to die 9 years earlier, and have 18.3 more years of ill health than a man in the least deprived decile. Similarly, women in the most deprived decile on average die 6.9 years earlier with 18.9 more years of ill health than a woman in the least deprived decile (1). A wide range of social and economic inequalities have been found to influence health including financial situation, social environment, biological and psychosocial factors, behaviours, education, occupation and ethnicity (2), (3). Health inequalities continue to be an important contributor to disability and poor physical and mental health, and therefore are directly relevant to our work as General Practitioners.

In General Practice we are privileged to work closely with people from all parts of society – those from different ethnic, social and economic groups. We may be the first port of call or the last hope for patients suffering as a result of the social or economic circumstances.

In reality, however, we often do not have the time or resources to deal with these underlying contributors to ill health. Trying to deal with these issues within the current framework of General Practice and the NHS as a whole can be difficult, leaving both doctor and patient frustrated. We can become hopeless with the increasing pressures upon us. Or we can use these challenges as an opportunity to change the way we practice. 

I have been privileged to interview a number of individuals involved in services which have been implemented around the UK, which seek to tackle some of the wider determinants of health and target those vulnerable individuals who are sometimes forgotten.

Bromley by Bow Centre, London 

The Bromley by Bow Centre was opened in 1984 as a charitable organisation providing services and programmes to the local population in East London, where there is a high level of deprivation.  Eighteen years ago, the centre opened a GP Surgery, with the aim of creating an integrated social provision for the community which would include high quality primary care. This was the first Health Centre in the UK owned by patients. The centre took out a mortgage and built the Health Centre which they rented back to the Health Authority. They ensured that they brought in GPs who understood the relationship between the health and socio-economic needs of patients in this deprived area.
 
How does this service tackle health inequalities?

The GP surgery is located in the same building as the Bromley by Bow Centre. Seventeen years ago social prescribing was pioneered. This was based on the understanding that wellbeing and health is largely socially and economically determined. Therefore, particularly in the more deprived populations, a holistic approach to patents needs is the only effective way to really improve health and help to prevent further ill health. Initially social prescribing was pioneered with the Bromley by Bow Health Centre. However, three years ago it was expanded to five other Practices in the surrounding area.

As most of the UK population is registered with a GP, the Centre believes that GP surgeries are most well placed to engage with people and, through social prescribing, enable them to access information and programmes that meet social and economic needs. They believe that General Practice is an under-utilised resource in improving health and tackling inequalities, given that 90% of patient contact is within general practice, yet, without social prescribing the opportunity to support people in addressing the wider determinants of health is missed. As well as social prescribing, they take advantage of the large foot-fall in the Health Centre with their ‘intelligent waiting room’. Staff from the Centre are pro-active, and take the opportunity to talk to patients about the non-clinical services available, whilst they are waiting for appointments.

Patients can self-refer to a wide range of advice, including social welfare advice, debt advice, skills and employability advice either via advisors in the Health Centre, or through the Community Centre’s connection zone.

How does social prescribing work?

Health care professionals support patients accessing services and programmes at the Centre by referring them to a Social Prescribing Coordinator. The Coordinator receives around 700 referrals a year.  Patients will spend around an hour with the Coordinator discussing their social and economic needs, therefore enabling a more in depth understanding than a GP can develop in a 10 minute consultation.  Subsequently a patient may be directed to an appropriate programme or service within the centre or to a local third sector organisation. The Coordinator often follows up the patients a number of times, rather than having an isolated contact. Patients can also self-refer to any of the services at the Centre.
Programmes provided by the Centre are wide ranging. They include healthy lifestyle and weight management advice, a community gym, advice on managing debt, advice on benefits, English courses, digital inclusion courses, vocational skills development, and support gaining employment.  They also have a number of activities and groups which aim to reduce social isolation such as a community café and community gardens, walking, cooking or gardening groups, arts and volunteer programmes.
The centre employs around 150 staff, around half of whom are local to the area and many started from the volunteer programme.

Have there been any barriers to patients accessing the services?

The Centre is located in an ethnically diverse community and the staff represent that diversity. This is often helpful at putting people at their ease when accessing services.
As with all services targeting patients with high levels of deprivation, some patients may be reluctant to attend due to the multiple pressures within their lives, lack of confidence, a lack of trust towards professionals or feeling overwhelmed by the many issues they face. Other reasons patients may not attend could include mental health problems or drug and alcohol issues.

How does the Bromley by Bow Centre support others setting up similar services?

The Centre runs the School of Integrated Solutions, a programme designed to impart the knowledge and experience they have gained over the past thirty years. They have around 1,200 visitors a year, many of whom are interested in considering how to establish similar initiatives. 

What advice would they give to GP surgeries hoping to support people accessing the services that can address socio-economic problems and tackle health inequalities?

To consider establishing a social prescribing project, which could be at a range of scales:, perhaps to service one GP practice, or a group of GP practices or a wider area. Utilise the large population entering a GP surgery to give advice and information, for example with an ‘intelligent waiting room’. Co-locate surgeries with other services, and ensure that these services are well integrated with good communication. Consider how you might build relationships and collaborate with other organisations that influence and support local health such as, the voluntary sector, health trainers,   children centres, schools and housing associations. 
Social Prescribing is recommended in the General Practice Five Year Forward View
https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf

Have the outcomes of the Bromley by Bow Centre been measured?

Whilst outcomes of individual programmes and services have been measured, as of yet there is no robust and longitudinal data on the combined effects of the integrated services on the local population. However, they are about to start a multi-year evaluation, which is being partly funded by Public Health England and the Wellcome Trust.

Thank you to Dan Hopewell, Director of Knowledge and Innovation at the Bromley by Bow Centre; and Dr Selvaseelan Selvarajah, GP at St Andrews Health Centre, Bow, for speaking with me.

bromley-by-bow

Further sources of Information

Social Prescribing is recommended in the General Practice Five Year Forward View
https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf

The report from the national social prescribing conference is attached and you can find further information about the national social prescribing network at https://www.westminster.ac.uk/news-and-events/news/2016/new-national-social-prescribing-network-addresses-nhs-healthcare-accessibility-issues

More information about the Bromley by Bow Centre can be found on our website www.bbbc.org.uk including three briefing papers (intros below), on our Knowledge and Innovation
Pages, here http://www.bbbc.org.uk/contributing-to-practice-and-policy-

References

(1) Office for National Statistics. Dataset: Inequality in healthy life expectancy at birth by national deciles of area deprivation: England. 2011-2013 data 5/3/2015 http://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/datasets/inequalityinhealthylifeexpectancyatbirthbynationaldecilesofareadeprivationengland. (accessed 1/3/16)

(2) Commission on Social Determinants of Health (2008) CSDH Final Report: Closing the gap in a generation: Health equity through action on the social determinants of health. Geneva: World Health Organization.

(3) Marmot M. Fair society, healthy lives. 2010. http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review (accessed 1 Feb 2016).

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