Summary
Strategic Issue 1
Eight care processes are not always met - this leads to late diagnosis, poor management and higher complication rates leading to personal, healthcare and social care cost (Hartlepool’s residents frequently commented within the Big Conversation that there was a need for better / easier access to health services).
What needs to be done
Address the inequalities in care specifically around the eight care processes and access to services: through a data-driven approach, which identifies local disparities in GP surgeries and patient populations, to provide tailored interventions. By highlighting areas in underserved communities with poor rates of success in meeting the criteria, targeted outreach in these areas can offer tailored support to promote health behaviours aimed at reducing risk of T2 diabetes.
Strategic Issue 2
Targeted outreach no longer in place regarding risk factors in areas of high prevalence of diabetes, increased risk factors and deprivation (i.e. a program aimed at supporting diabetes management and health behaviours). By upskilling community health workers in existing hubs and programmes the reach of each of the 4 hubs will increase. With increased reach, targeted outreach can be developed to improve access to care and services and provide culturally appropriate education.
What needs to be done
Develop existing services/facilities to provide a greater outreach: hubs within the community are already known to people. Promotion of services within the hubs specifically targeting higher risk groups can help improve health outcomes. Upskilling existing workers that are trusted within the community develops the existing service to provide further care in the area where both the service and its users are familiar with each other.
Hartlepool’s residents have identified a need for leisure activities and improved facilities within the Borough as well as education on food and cooking.
The development of existing services that are known to the community and are well-advertised would allow for community-based programmes, food education, smoking cessation and physical activity to be held within one convenient, knowledgeable location.
Strategic Issue 3
Digital and health literacy gaps need to be addressed due to the requirement of health literacy for personal diabetic management and digital literacy for use of tools for diabetic management.
A drive for increasing the uptake of structured education following diagnosis should be done as just 2.6% of newly diagnosed Type 2 Diabetics attended this in 2023. This can be achieved by the ICB supporting practices with low achievement of these goals.
Providing community support through GP surgeries which has been chosen through data-driven targeting and providing information through community hubs.
What needs to be done
There are very low proportions of newly diagnosed Type 2 Diabetics attending Structured Education within 12 months of diagnosis. Newly diagnosed patients require support and education to manage their condition and prevent exacerbation. By addressing health literacy gaps this will empower patients to improve their health outcomes. Support is required for the management of the new condition and for addressing barriers to digital health tools often used for diabetic management and prescribing.
Hartlepool’s residents have stated there is a need for better / easier access to health services. Solutions for managing digital barriers and tools will diminish digital and health literacy gaps within this population group.