Addressing inequalities

Working in collaboration with Norwich City Council, OneNorwich Practices is making a concerted effort to reduce unwarranted variation in primary health outcomes. Work undertaken by Norwich City Council on the Reducing Inequalities Target Areas (RITA) has influenced how we deliver services at scale. The newly developed primary care high intensity user service pilot will initially support practices situated in the 7 RITA areas.

We are working with system partners on a joint community transformation funding bid to support people with frailty in over or under-occupied housing in an anticipatory approach to care. This will bolster the already substantial work the IMPACT team is undertaking in proactively contacting and supporting those not currently engaging with health and care, thus reducing the need for them to rely on general practice in future.

The primary care community officer (PCCO), commissioned by ONP is working with voluntary and community providers to understand how primary care can be better accessed by those who might ordinarily decline help. We are seeking ways to deliver a health outreach service in community spaces with a particular focus on patients with a learning disability and serious mental illness as well as those in the most deprived areas of the PCN.

In Q1 2021/22 the Living Well team (social prescribing) was fully migrated to ownership of the PCN following the cessation of local authority funding. Subsequent to offering support to practices during lockdown, the team is now operating as usual. Social prescribers are starting to work from practices to support those less able to attend appointments elsewhere.