MEDICAL students learn about a care law that states: “The availability of good medical care tends to vary inversely with the need for it in the population served” (Tudor Hart). It is borne out by evidence that there are significantly fewer GPs per head of the population in deprived areas than in wealthier areas, and that they tend to be less highly qualified.
Laura Neilson, a medical student who lived on an estate in Oldham, Greater Manchester, as part of a church project, was troubled by what she had learned, and by the poor access to medical services that her community experienced.
Socio-economic graphs show Oldham to be in the lowest bracket of deprivation. Life expectancy here is 73 for men, against a national average of 79, and 77 for women, compared with 83. With others in the community, Dr Neilson challenged the local NHS commissioning group to do something about it.
A Department of Health report in 2008, High Quality Care for All, offered a vision of an NHS managed less from the centre and more by local clinicians who knew their area and their patients’ needs. Spurred on by the report, Dr Neilson — with five other Christian leaders and health professionals — formed a not-for-profit community-interest company, Hope Citadel Healthcare CIC, and tendered for new primary-care practices.
They were awarded four contracts, all in socially deprived communities.
Dr Neilson and a small team set up the first Hope Citadel surgery — Hill Top Surgery, in Oldham — in 2009, working initially out of a Portakabin. Today, the group has nine GP practices in three areas of Greater Manchester, employs about 150 staff, and is regarded as a model of holistic care.
THE chance to open new practices was a once-in-a-decade opportunity, a moment to be seized, Dr Neilson, the CEO of the company, says. “There was this brief window it was going to happen in. After that, it was a bit of adventure. It hasn’t happened overnight. It’s been ten years of work, not an easy run, and with lots of tests on the way. It’s quite bonkers really.”
She says that they employed people “who had a sense of passion for the work, and felt it could be done. You need a team who believe it can happen, and will work hard for it.” Dr Neilson’s Christian faith is the anchor through which decisions are made, and many staff also have a faith. But a passion for social justice is the calling of the organisation.
“We are not your typical GP practice, and our aim is to do health care a little differently,” their practice websites say. “Patients are people, and we believe that sometimes it takes a little more than medication alone to bring lasting improvement to someone’s health. There may be social, financial, educational, or other factors within the household, where medication alone is not enough to fix the problem.”
To facilitate and support health and social transformation, they work alongside myriad partners, including Christian charities, churches, housing providers, debt agencies, work placements, foodbanks, toddler groups, job centres, and more. Agencies such as the ADS Drugs and Alcohol Misuse team, and MIND (which runs anti-stress workshops), visit the sites weekly to support patients.
For “those for whom life has just got too chaotic”, each practice employs a Focused Care Practitioner to help patients with access to additional services. There are qualified counsellors at every site, who can refer patients directly to an on-site GP, and healthcare assistants are given time to meet needs in the community.
By giving vulnerable people time — the GPs, for example, offer 13-minute appointments — they are already seeing results in preventing further problems, reducing patient A&E attendance, and helping patients to move on with their lives.
“It can be quite tempting, sometimes, to think that we have all the answers ourselves, but that’s not true.” Dr Neilson says. “You build better and more exciting things if you work collaboratively. You have a much bigger, broader vision. The communities we work in are quite needy; so sometimes it’s about survival, to get the best for our patients and our community. It’s symbiotic. It helps us, and it helps them.”
So far, three of Hope Citadel’s surgeries have been judged “Outstanding” by Care Quality Commission inspectors. At Hill Top, aside from clinical excellences, they particularly praised the BLISS group for young, isolated mothers, started by reception staff; Mucky Monkeys for young children and their parents; Inspire, a social group for older patients and retired people; Hill Top Growers, a gardening group that encourages healthy eating and exercise; and Healthy Lifestyles, which patients can join to participate in group walks and exercise and keep track of their weight.
Being not-for-profit makes a significant difference to the structures, Dr Neilson says, “affecting the way we think . . . and run. It makes us accountable to our communities.”
BY THEIR very nature, the communities are not static. “It’s a bit of a never-ending game, where you fix people, and then they move on and get replaced. So it’s a bit tiring, but we have seen the stats improve,” she says. “We are definitely showing that it is possible to do really good medicine and engage with people in these areas.”
Dr Neilson was the recipient of the Health Service Journal’s Rising Star Award in 2016 (she is still only in her thirties). But it is the patients whom the practices laud, and it is in the list of the monthly Patient Hero Awards where the fruits of Hope Citadel’s holistic approach can be seen: Lisa, for having “lost five stone in weight, improved her mood through exercise, and sorted out her marriage through counselling”; and Elaine, for “leaving her violent husband and taking her children to a refuge. . . For her courage to give her children a better life.”
Sean got an award “for going to school every day for a term”; Jane, for “getting her diabetes under control for the first time for five years”; and Dillon, for “sticking by his girlfriend when she got post-natal depression”. These stories are not one-offs, Dr Neilson emphasises.
“They are who we are now. A lot of people working in health and social services are probably a bit jaded and don’t think change can happen, or that people can get out of these situations, and that the best they can do is manage them and pass them on to somebody else. It’s really important that we believe people can change. We believe they can.”