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We are in this together: People Powered Results in West Essex

Back in June 2015, five multidisciplinary teams across West Essex signed up to a 100-day challenge with the aim of improving outcomes for people across the area by integrating the provision of care and breaking down barriers between organisations. A range of focus areas (diabetes, older people and children) were agreed by team members, and the leadership team, and the Rapid Results teams each signed up to unreasonable but believable goals within these.

One of the teams chose to focus on diabetes, taking a preventative approach and aiming to support people to ‘reduce at least one diabetes risk factor for people who are on the risk of diabetes register across 5 GP surgeries...’ Over the 100 days, the team experimented with new ways of working to: identify the cohort through a risk stratification process; develop a range of interventions and activities; and measure the impact of these on risk factors within the cohort.

This blog was written by Dr Ian Perry, who was the team leader and who is also a GP Partner working in West Essex.

Working as a healthcare professional in the community can be lonely. Frequently, one feels unable to change a system, particularly when a problem is recurrent and especially if the problem transcends multiple organisational boundaries. Often, the issues that we are faced with are inextricably linked to problems that are not purely medical, but social and societal. Furthermore, population-based public health can seem so disconnected from personal and family health and well-being.

My enduring memory from our 100-day challenge was the opportunity to meet other members of the health and social care team. For the first time, we had representation from all parts of the system around one table (practice nurses & diabetes nurse specialists & healthcare assistants, GP practice managers, pharmacists, social worker, Diabetes UK & Patient Representative, CCG Commissioner & Communication Officers, a Public Health Specialist Registrar & GPs).

We were able to discuss and agree upon a goal that we wished to achieve, and to use our personal strengths and shared responsibility to take our team forward and make progress. At various times during the process, we also asked people to join us who were able to advance our cause, including a local dance teacher!

We found surprising strengths and talents in our team that we were able to draw upon. We were able to exercise parts of our brains which have had to be boxed and stored away on a shelf, because our daily workloads do not exercise the creative or innovative parts of the brain so much or so often.

I think that our progress can be defined as: identifying questions to answer and obstacles to overcome that arose as a result of thinking about a problem, not just in developing our ideas and creating innovative solutions, which included: risk assessment clinics, signposting to activity and exercise programmes and putting on a health fair.

Our goal was ambitious, and this inspired our team to work to produce many different solutions and lots of different results with overwhelmingly positive outcomes. An important part of the journey was also identifying learning points and areas for development. In the end, because we set ourselves such an unrealistically ambitious goal, we achieved so much more than we first imagined.

The process was a significant investment of our time and effort, and it was tricky to shoehorn our various meetings into a busy week. But upon reflection we had the opportunity to work together and share the challenge, develop our ideas, and to evaluate and redesign, so there was a real sense of camaraderie and a sense that “we are in this together” - of ownership and empowerment, and problems seemed more tolerable and manageable.

We realised how we were able to challenge and change “the system”, and that has made working within the system a more positive experience.


Dr Ian Perry

Dr Ian Perry is a GP Partner working in West Essex.