Addressing missingness by design: proactive health care
Goyder et al highlight the fundamental importance of addressing structural missingness to improve cardiovascular outcomes.1 If improvement is to be achieved, consideration must also be given to wider determinants of health and support offered to address these.
Williamson and team have subsequently co-designed a suite of interventions to address missingness. These include identification of those experiencing exclusion and delivering flexible health care to them, for example, use of a community support worker to build a relationship and provide support navigating the healthcare system.2 An example is given below demonstrating some of these principles.
A local quality improvement project identified that there was a high level of homelessness coded in the Quality and Outcomes Framework exception group, that is, those not accessing health care. This population experience some of the worst health outcomes, demonstrated by the average age of death being 45.9 years for men and 43.4 years for women.3 Despite the prevalence of cardiovascular disease being three times higher, they are less likely to access health care for prevention and management.4
Collaborative working with the local RISE homeless team and Forward Trust (alcohol and substance misuse service) allowed identification and invitation of patients not accessing health care to a proactive health review, comprising two 45-minute appointments. The first was with the GP undertaking a comprehensive physical and mental health review. Health screening was undertaken for hypertension, diabetes, and cholesterol, and a relevant health promotion, for example, alcohol or smoking cessation, was discussed. The second was with a focused care worker addressing issues the patient may be facing related to wider determinants of health, for example, finances, transport, accommodation, food insecurity, support completing forms, and offering ongoing support. Twenty-three patients identified as not accessing but needing health care attended these clinics. Feedback from participants was positive, although the response rate was low. Challenges exist in evidencing benefit in this type of work because of the complexity of individualised support offered.
The principles outlined by the suite of interventions are likely to go a long way in enabling the most vulnerable in society to access health care. Martin Luther King Jr famously said, ‘Of all the forms of inequality, injustice in health care is the most shocking and most inhuman.’ We must take steps to address the current inequalities.
