IMPROVING PRIMARY CARE ACCESS FOR VULNERABLE PATIENTS: THE IMPACT OF GP OUTREACH CLINICS IN LEAMINGTON SPA

To address significant barriers to healthcare access, GP outreach clinics were established in Leamington Spa. These clinics aimed to support individuals experiencing homelessness and those struggling with complex social and health challenges. By integrating primary care services into community settings, patients received medical consultations, referrals, and health interventions tailored to their needs. Over ten months, 83 consultations were conducted with 46 patients, improving access to care and strengthening collaboration with local health and social services. The initiative demonstrated improved patient engagement, improved care coordination, and the provision of timely medical interventions.

Why change was needed 

A high number of individuals experiencing homelessness and social deprivation face difficulties in accessing primary care. Many have complex health needs, including chronic illnesses, mental health conditions, and substance use disorders. Historically, poor experiences with mainstream healthcare services, stigma, and bureaucratic barriers have contributed to disengagement from primary care. As a result, acute health issues often escalate, leading to increased emergency department visits and preventable hospital admissions.

Recognising these challenges, Leamington Primary Care Network (PCN) partnered with local charities and outreach organisations to deliver accessible GP services within community settings. The Helping Hands drop-in clinic was selected as a key location, allowing patients to access care in a familiar and supportive environment. This initiative aimed to bridge the gap between underserved populations and healthcare services, providing trauma-informed care tailored to their specific needs.

What we did 

17 GP outreach clinics were delivered over ten months, operating on a twice-monthly basis. Patients were referred through multiple pathways, including homeless outreach teams, mental health nurses, and word-of-mouth.

Key outcomes included:

Improved access to care:

• A total of 83 consultations with 46 patients were conducted, with attendance increasing over time (from 5 patients per clinic initially to 6 in the last four clinics).

Targeted health interventions:

• Blood pressure monitoring was recorded for 93% of patients, exceeding the target of 90%.
• Hypertension management pathways were implemented for 87.5% of diagnosed patients.
• Chronic disease screening and EMIS coding were completed for 100% of eligible patients.

Support for complex health and social needs:

• A patient who had been walking on a broken hip for six weeks was identified and referred for urgent orthopaedic care, leading to a successful hospital admission.
• A human trafficking survivor with a severe eye infection was registered and quickly referred for ophthalmology treatment.
• Multiple patients received on-the-day treatment for infections and wounds, preventing unnecessary A&E visits.
• Individuals facing barriers to healthcare registration were supported in re-engaging with primary care services.

Mental health and substance use support:

• Many patients with histories of childhood trauma reported positive experiences, feeling heard and respected.
• A patient undergoing treatment for heroin dependency was medically supported alongside counselling, leading to sustained recovery and voluntary community work.

System-level benefits:

• Collaboration with mental health and addiction services facilitated care coordination, leading to improved case management.
• Referring organisations reported time savings and increased efficiency due to streamlined access to GP services.

What’s next? 

Efforts will continue to refine and expand the outreach model, incorporating proactive interventions such as vaccinations, blood-borne virus screening, and contraception services. Plans are underway to develop structured workflows for GP registrars, improving sustainability and training opportunities. Ongoing collaboration with local agencies will ensure continuous service improvement, with a focus on addressing health inequalities and personalising care for vulnerable populations.