When Advanced Nurse Practitioner Sarah Gallagher realised vulnerable and homeless people within her local area weren’t always able to access timely healthcare services, she developed a trailblazing project which centred on a new way of reaching out to people with challenging lifestyles.

Sarah, who is Health Inequalities Lead for the Cheltenham Central Primary Care Network (PCN), embarked on a data analysis exercise as part of her role. As Health Inequalities Lead she focuses on tackling the unfair and avoidable differences in health across the local population.

Taking a closer look at practice data led to the detection of an unmistakable trend in people with vulnerabilities (often homeless) which then prompted Sarah to start thinking about solutions – how she and her colleagues might take a fresh approach in their efforts to improve health outcomes.

Sarah said:

“Before COVID, at an Integrated Locality Partnership (ILP) meeting we were discussing substance misuse and data for practices in Cheltenham.

“One practice in particular really stood out for us and had more of an issue with substance misuse.

“I went through the data and found 56 people who had problems with substance misuse, nine of whom had died before the age of 50.

“I then cross-referenced people who engaged with Change Grow Live (CGL) which is a voluntary sector organisation specialising in substance misuse and criminal justice intervention projects.

“Anyone who had not engaged with CGL was sent out a wellbeing questionnaire to try and ascertain why they hadn’t reached out to services”.

Following the questionnaire, Sarah contacted local organisation Cheltenham Open Door, a charity that supports vulnerable, disadvantaged and lonely people through a variety of services.

People who are supported by the charity are referred to as ‘guests’ in order to combat stigma and help service users feel supported.

“We very quickly realised that people needed healthcare provision and just weren’t getting it because of their circumstances,” said Sarah.

“It became clear that they weren’t going to engage with hospitals or GPs, in other words what people consider to be traditional services.

“Rapidly we began to think; ‘Instead of expecting them to use services, we need to send the service to them’, so that’s what we did.

“It’s really an example of how we can use innovation to improve health outcomes for some of the most disadvantaged citizens we look after.

As a result of Sarah’s project, a number of interventions have been put in place during the past nine months including:

  • Artlift art classes to help with mental health and wellbeing.
  • Nurses from the Blood Born Virus Team screening for Hepatitis C. Guests are given counselling and treatment.
  • Screening for aortic aneurism for people 65+.
  • Forging links with the Social Prescribing Service and Community Wellbeing Service, ensuring colleagues know to signpost.
  • Visits from the Flu and Covid Vaccination Outreach Team.
  • C-Card scheme (free condoms for under 25s),
  • Nature on Prescription is assisting with garden improvements to help people’s wellbeing.
  • Ongoing work with the Mental Health Team at Gloucestershire Health & Care Foundation Trust looking at ways of getting more mental health provision and increased access to psychological therapies.
  • Simple health checks from the Health Outreach Team.

“It’s amazing, I never imagined we would get to this place so quickly”, said Sarah.

“The feedback from guests is fantastic.

“One man we helped was homeless and had problems getting his migraine medication and our help meant that he was able to obtain a regular prescription which made a huge difference.

“We are trying to engage with other PCNs with a view to replicating this work.”