North Lewisham Primary Care Network (NLPCN) serves a vibrant, ethnically diverse borough of London, with higher-than-average levels of deprivation. To address health inequalities, the PCN developed an innovative programme which placed co-production and community engagement at its centre.

Workstreams included improving access to GP services with a weekly Digital Hub for digitally excluded residents, and an integrated data strategy, designed to identify and proactively manage residents at risk of health inequalities. An initial pilot, using 300 SNOMED codes, led to at-risk people accepting invitations for health checks; 60% were found to have a condition such as diabetes or high blood pressure.

The at-risk data has been further enhanced by using the integrated dataset within Cerner’s HealtheIntent to identify CORE20PLUS5 cohorts across the entire PCN. Results show that the data-driven, targeted approach is even more effective at picking up hidden health problems than the standard approach.

By harnessing the power of data, and engaging with communities, NLPCN have been able to target their resources in the most impactful way, identifying health problems earlier in people at risk of being lost in the system.

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