Tackling Health Inequalities Through Innovation in Primary Care

To tackle health inequalities, a GP practice in Newcastle-upon-Tyne established a one-stop health service inside a local food bank, improving access to primary care for vulnerable populations

CREDIT: This is an edited version of an article that originally appeared in Nursing Times

West Road Medical Centre, located in one of the most deprived areas of Newcastle, faced numerous challenges in delivering primary care. Patients experienced barriers such as poverty, homelessness, mental health conditions and learning disabilities. A further obstacle was language: 21% of the practice’s population do not speak English as their first language, making it difficult to navigate digital health systems required for registering, ordering medications, or booking appointments.

Tackling Challenges Head On

To address these issues, the practice secured funding to place an advanced nurse practitioner (ANP) at the heart of the community – within a food bank – to deliver drop-in, one-to-one health sessions. The initiative aimed to forge stronger links between primary care and the local community, making services more accessible and responsive to patient needs.

The service proved transformative. Patients sought help for a wide range of issues including respiratory conditions, diabetes, Raynaud’s phenomenon, musculoskeletal pain, recent cancer diagnoses, gynaecological concerns, children’s health and immunisations, mental health support, smoking cessation and prescription problems. In addition to direct clinical care, patients were connected to wider support networks such as mental health services, physiotherapy and social prescribing.

Positive Results and Benefits

One notable outcome was the identification of ten patients with previously undiagnosed hypertension. These individuals received targeted education on managing their condition and were referred back to the practice nurse for ambulatory monitoring to ensure accurate diagnosis and ongoing care.

This community-rooted service not only reduced the number of GP appointments required but also built crucial relationships across the healthcare and voluntary sectors. Collaborations emerged with organisations including Age UK, Cancer Research UK, local hospices, dental services, maternity services, paediatrics, diabetes nursing teams, NHS England and safeguarding bodies. These partnerships broadened the support network available to patients and reinforced integrated care delivery.

An Award Winning Approach

The success of this approach was recognised when it won the Nursing in Primary Care category at the 2024 Nursing Times Awards. The initiative stands as a model of how healthcare can be reimagined to directly address access barriers and health inequality.

Looking ahead, West Road Medical Centre plans to expand the initiative further. Proposed developments include targeted health education sessions in community settings, such as schools, to engage teachers, parents and pupils. The model has shown strong potential for replication in other food banks and community services, making it a highly transferable solution to a widespread problem.