The Community Wellness Outreach (CWO) project in Reading (funded by the Buckinghamshire, Oxfordshire and Berkshire West ICB) was set up to pilot outreach activities to support the reduction in health inequalities in the most vulnerable communities, with a core focus on providing an NHS heath check and advice around improving health and wellbeing.
The challenge
In 2022/23, the number of people accessing the NHS Health Check (delivered to people aged between 40 and 74 years who have not had a check in the previous 5 years) was low at only 6 per cent of the eligible population. This was coupled with an awareness that some people in the local community were not attending their GP.
Strategy
The Community Wellness Outreach (CWO) project in Reading (funded by the Buckinghamshire, Oxfordshire and Berkshire West ICB) was set up to pilot outreach activities to support the reduction in health inequalities in the most vulnerable communities, with a core focus on providing an NHS heath check and advice around improving health and wellbeing.
The approach
In a collaboration between the borough council, primary care, the voluntary and community sector (led by Reading Voluntary Action) and the Royal Berkshire Hospital’s Patient Experience and Engagement Team (Meet PEET) service, regular health and wellbeing outreach sessions were set up in community settings, providing NHS Health Checks and holistic wellbeing support to enable people to take action to improve their health and address issues that were important to their welfare. Primary Care services sent Invitations to people that were registered with them but had not accessed a health check, using the Core20PLUS5* approach to focus on those most at risk of poor health outcomes in areas of deprivation.
The invitation lists were generated by the GP surgeries from the local Shared Care Record “Connected Care”. This is a platform that pulls an agreed core dataset from GPs, hospitals and social care services where consent has been given by a patient to present a holistic view of a person and their needs, to consequently provide joined up care. The shared record can be accessed by authorised users from all contributing partners, and in addition the ambulance service, out of hours primary care and community hospital, and intermediate care services. This also enables the health and social care system to take a Population Health Management (PHM) approach to informing the commissioning of services and target activities to address areas of increased risk.
A link was provided to the project website to make a booking for one of the sessions. There were also opportunities for people to drop-in which was initially on a 50/50 booked/drop-in basis, but latterly moved to a higher percentage of booked sessions, depending on the location and flow.
The project team also recognised that digital literacy could be a barrier and so included wider communications through newsletters, posters in venues, leaflet drops and word of mouth. The outreach programme is offered to all people in Reading over the age of 18 who met the eligibility criteria, and is running alongside the GP health check service for people aged 40 to 74.
Outcomes
The number of NHS Health Checks delivered through GPs and the Community Wellness Outreach project provided to people aged 40 to 74 increased from 6per cent (2,502) of the eligible population in 2022/23 to 10per cent (4,526) at the end of March 2024. The annual data for NHS Health Checks for 2024/25 will show the continuing positive impact of the community outreach programme.
- By the end of February 2025, 2,780 people had attended a Community Wellness Outreach session due to their accessibility in the community (1,671, 60 per cent, of these were in the age group 40 to 74, and 32 per cent were below the age of 40, enabling early intervention and behaviour change for long term impact). 2,267, 82per cent, were from the identified priority groups for the project, including ethnically diverse groups (58 per cent of attendees) who are at greater risk of developing diabetes and heart conditions resulting in poor health and wellbeing.
- 28 per cent of the 2,780 people seen at the community outreach sessions by the end of February 2025 were referred back to their GP for follow-up, and where required, support was provided to register with a GP or to book an appointment, including urgent on the day requirements.
- 23 per cent of people have been referred to other services, including 21 per cent to Health Behaviour Change Support (Lifestyle).
Contact
- Email: [email protected], Integration Programme Manager, Reading
- *Core20PLUS5 – An approach to reducing health inequalities for children and young people
- Connected Care
- Frimley Health and Care (ICS)