A Health and Wellbeing Support Worker explains how a population health management approach helps her deliver personalised care to clients in Blackpool who need more than a ten minute GP appointment:

When we hear that only 20% of our health needs can be met by medical interventions it’s hard to imagine why we don’t invest our time and money more heartily in finding and fixing the other 80%.

As a Health and Wellbeing Support Worker in Blackpool, along with our newly recruited Social Prescribers, I’m lucky enough to be one of thousands of people like me across the country now trying to help individuals understand what’s driving their illness and help them get well, stay well and enjoy their lives.

Not only am I lucky enough to have this rewarding job, I’ve also recently been part of the NHS England Population Health Management Development Programme in Lancashire and South Cumbria which has helped us truly find the people who need the most support.

Working with partners across the council, NHS and third sector, expert data analysts were able to deep dive linked datasets in new ways to find people at rising and high risk and cost. The data looked at people who had seen a GP five times or more a year in the last three years, who lived in multi-occupancy housing and who also had depression as they were using healthcare services more than others.

Why did these people need so much help and what more could we do?

A lot of work went on behind the scenes to get to this point – but my role became key once we started to think about more suitable interventions for these clients.

Together we narrowed down a list of 41 patients in three GP surgeries for me to connect with. Whereas the GP can only offer them ten minutes I can offer them up to two hours to talk informally about whatever they want to discuss. I contacted them and offered them a meeting, and while a selection had reservations or said no, quite a lot said yes.

We met at their homes or in coffee shops, wherever they felt comfortable, and talked about anything and everything until I built up a picture of what might help this person reconnect with their passions, help them make a change, improve their lives and hopefully relieve some of their depression.

I’m able to offer them a lot of support in different ways – for example connecting them with local interest groups like singing or walking or art, helping them fill out forms they might struggle with, helping get them back into employment, organising referrals if they need medical attention and many more. I’m an expert in which local groups are available and have direct contact to many professional organisations particularly the council, housing and social services.

For example, one chap had multiple issues, depression, diabetes, memory loss, a cluttered home, limited mobility and family problems. These issues had all made each other worse, starting with his house which was damp and cold and made him feel ill and less likely to want to go out – but he had filled in his council application to move incorrectly. I helped him fill this out again so he can now be moved somewhere more suitable.

I also helped him clear out the flat so he had more space to move around and this helped lift his mood. The fire brigade also visited to check his house was safe and his alarms up to date, giving him peace of mind.

I put him in touch with local employment services which could help him fulfil his wish to get back to work eventually and I also referred him to the memory clinic for an assessment to see what might be causing some of his confusion. Afterwards, he was very pleased because he had limited help from family and friends but was able to begin addressing some of his problems – none of which were easily addressed in a ten minute GP appointment. He has even begun to slowly reconnect with his family which out of everything is probably of greatest delight to him.

This is just one story of many: alcohol, drugs, housing problems, anti-social neighbours, pollution and a lack of social interactions play a huge part in many of my clients’ lives. Guess what? These issues can easily result in depression.

While many of my clients still have a long way to go I’ve learnt it’s often a friendly smile and helping hand which can day by day start to untangle some of the reasons for their depression, unhappiness and isolation.

Heard of personalised care? It might seem like a lot of work but if the alternative is to watch people deteriorate and end up in acute care settings, a cup of coffee, a listening ear and someone well connected to solutions could just be the start of something special.