top of page
THC Advert (1).png

Sevenoaks Primary Care Network Case Study: Health Inequalities Workstreams

Updated: Sep 13, 2023

At THC Primary Care, we provide resources to support Primary Care Network leaders. As part of this, we love to promote excellence and examples of best practice and ideas from other networks.

In this blog, we introduce you to Sevenoaks Primary Care Network Operations Manager and Digital and Transformation Lead James Monet and Deputy Operations Manager and Health Inequalities Project Lead Meg Vest where they share the fantastic work they are doing engaging with local partners and providing holistic support to their patient population.

We discuss:

1️⃣ The 6 key workstreams within Sevenoaks PCN’s health inequalities programme

2️⃣ Seeking funding, investment, and buy-in for an improvement project

3️⃣ What’s working well so far?

4️⃣ Where are the current challenges?

5️⃣ Future aspirations

6️⃣ Top tips for PCN managers

Let’s jump in!

Sevenoaks Primary Care Network case study: Health Inequalities Workstreams

The Sevenoaks PCN construct

Sevenoaks Primary Care Network spans eight practices across their local area in Kent, serving a population of 85,000 patients (circa. 79,000 patients per adjusted population).

Working alongside James and Meg, the PCN is headed up by two Clinical Directors and is comprised of a team of clinicians and support staff, including a securely embedded ARRS workforce of Clinical Pharmacists, Physician Associates, Care Coordinators, Social Prescribing Link Workers, Health and Wellbeing Coaches, and First Contact Physiotherapists.

Where to start when designing a project or service?

Stemming from Meg’s background (and special interest) in public health and her previous experience of working within social prescribing as a Deputy PCN Manager, Meg was keen to establish a series of projects focused on:

➡️ Building stronger partnerships with other local providers.

➡️ Promoting the work of the practices and PCN more widely.

➡️ Establishing a number of initiatives to address the existing health inequalities within the Sevenoaks PCN area.

The team began by working through a combination of public health and census data, and current patient waiting lists (and referral numbers) for services such as CAMHS, community paediatrics and charitable support providers, to pinpoint the highest areas of deprivation and patient need.

From this data, they were able to design and shape six key health inequality projects.

1. The Six Health Inequalities Workstreams

Here’s a quick overview of the projects Sevenoaks PCN are running at present:

1️⃣ The establishment of two social kitchen hubs to provide free, fun, family-friendly cookery lessons for foodbank users, helping them to maximise their food parcels in both an economical and healthy way.

This includes a free food parcel, and a minibus service, to enable direct transportation to the two kitchen sites. The PCN will be running four cohorts in total across the year.

2️⃣ An initiative to improve the mental health and well-being of children and young people locally.

This project is split into two parts; the first part is to encourage the use of the pre-existing free online wellbeing platform Kooth, supporting secondary schools to onboard via engagement and attendance at local sports days, school assemblies and increased marketing provision within the services.

Part two is concerned with commissioning the national children's charity Spurgeons to provide a number of children with access to six weeks’ worth of free counselling provision. Both approaches are to adopt a preventative rather than reactive approach to mental health.

3️⃣ In partnership with the mental health charity MIND, Sevenoaks PCN has set up a support group called ‘Parents Supporting Parents’.

This group is aimed at parents with children with complex needs who are either stuck on long waiting lists or whose needs are not currently being met.

The group is open to all parents and carers in Sevenoaks and is designed to provide a safe space to come together to discuss their experiences of supporting a child with mental health needs or complex needs and access peer support.

This group is supported by parent volunteers with lived experience.

4️⃣ Organisation of training and eco-friendly focused days out for young carers in the community to ensure they are better supported.

The PCN is working with Kent Young Carers, who continue to support them in identifying hidden young carers and who are responsible for delivering training.

5️⃣ Integration of two PCN-level Health and Wellbeing Coaches.

Working across all eight practices, they provide coaching support to patients seeking to make lifestyle changes.

They offer both face-to-face and group support and will be working closely alongside the PCN’s Social Prescribers and Care Coordinators.

6️⃣ Local Food Banks

As a result of Meg’s previous experience working in social prescribing, the PCN’s care coordinators now spend a dedicated amount of time working within local food banks to engage directly with the most vulnerable within the community.

This additionally supports the PCN to identify and reach out to people who may not be registered within mainstream health or social care services (and who are therefore not already on the general practice radar) to better understand where there may be barriers to access and to offer support.

2. Funding, investment and buy-in for an improvement project

To better understand how the above initiatives were funded, Meg shared there was anticipation that these projects would require a significant amount of funding.

Funding was required for venue hire and provision of trained counsellors, and smaller, hidden costs such as food items and equipment and these costs were covered by a bid for funding via their ICB, which aligned to the following priorities.

🎯 Development of Integrated Neighbourhood Teams and the establishment of joint working within the community.

🎯 Establishment of strong connections within community providers and identification of key community stakeholders to ensure sustainability of services for the long-term.

🎯 Building on what is already in place to further existing opportunities in better meeting local health and social care needs, and to foster the bringing together of passion to support each other.

🎯 Working through the recommendations set out in the Fuller Stocktake to improve patient access, strengthen community networks, and working towards personalised and preventative care.

PCN investment and buy-in

As with all new initiatives, momentum is generated from those directly involved with the establishment of the projects.

James, Meg and the two PCN Clinical Directors, as a senior team, were enthused from the start and continue to work as a single unit to continue to pitch ideas and to tweak and develop the Sevenoaks health inequalities agenda.

Careful consideration of how to involve and engage wider PCN staff can be more tricky, but with consistent communication and, again, making the long-term benefits clear to all, this has been achievable.

Meg says that there was a gradual build-up in buy-in from individual partners across the network’s practices through word of mouth, increased awareness and a shared passion and interest in reducing local health inequalities.

Practice support staff also became involved in the distribution of an updated frailty leaflet, and senior level stakeholders were kept updated within senior meeting forums and monthly Board meetings.

3. What’s working well so far?

There have been three successful community stakeholder meetings, with another potentially planned for October, which has given the opportunity for many wider stakeholders to co-design the health inequalities work and lead towards future collaborations.

The Health and Wellbeing Coach integration project has been chosen by the local ICB as a pilot for the move towards Integrated Neighbourhood Teams from April 2024!

4. Current Challenges

One of the key challenges with all six projects has been in evaluating and best demonstrating their success. Meg says: “one of our key lessons learned from this work is trying to find metrics that we can use to measure all projects to most effectively showcase their impact”.

5. Future aspirations

Meg outlines their key objectives going forward:

➡️ Employment of a Health Inequalities Coordinator – to help support the projects and any future health inequalities-based working in the PCN.

➡️ Working towards the Personalised Care Triad (Health and Wellbeing Coaches, Social Prescribers & Care Coordinators) for preventative and proactive care.

➡️ To continue to expand and grow engagement with stakeholders.

➡️ To continue to support the move towards proactive and preventative working in Primary Care.

➡️ To support the career pathway for Public Health students into Primary Care to springboard the health inequalities agenda further.

6. Top tips to ensure success

With such a huge programme of work to manage, I asked James and Meg to share their advice about how they still manage to progress within their roles at the same time as leading these initiatives.

Their key advice for others is:

  • Don’t discredit the health inequalities agenda. It is everybody’s responsibility and if you have capacity, whether personally or professionally, try to get involved in identifying opportunities to make positive change.

  • Do your homework. Familiarise yourself with the Fuller Report, what’s on the public health agenda and start to think about where there may be opportunities to offer preventative care.

  • Think collaboratively. You can’t do this alone, so spend time identifying where your key partners and potential stakeholders are, and consider who could be involved from a PCN perspective.

  • In line with the above, give staff space to grow, develop and understand where their individual skills (and experience) may be best utilised.

  • Ensure you have buy-in from everyone, and don’t be afraid to play to your strengths and your passions.

  • Take time to understand individual practice (and personal) priorities and issues.

  • Do what you can to actively ingratiate and involve yourself within the practices, offering support where appropriate and communicating clearly when there are gaps in your own knowledge and understanding.

And if you’re not within a supportive environment?

  • Ensure you have a career plan of sorts and work out where, as an individual, you can be most effective.

  • Take a step back to review and consider what you would like from your role and where you’d like to go next (and whether your existing environment is a fit for this).

  • Lastly, don’t be afraid to make a move if your skills and interests can be put to better use elsewhere.

Finding out more

If you have been inspired by the work James and Meg are doing in Sevenoaks, check out the Sevenoaks Facebook page. They are also on LinkedIn too!

The Sevenoaks PCN website is accessible here.

Meg and James are equally happy to speak to anyone who would like to get in touch to talk through what they are doing directly...

Meg is contactable via email here or through her LinkedIn page here.

You can link with James here.

We hope this is helpful!


Never miss a blog again!

We promise not to spam you!

Find out more about THC Primary Care at:

And follow Tara on Twitter: @THCPrimarycare


About the Author

I'm Tara; I am the founder of THC Primary Care, an award-winning healthcare consultancy specialising in Primary Care Network Management and the host of the Business of Healthcare Podcast, where we have now published over 200 episodes.

I have over 20 years of project management and business development experience across the private and public sectors, and I have supported over 80 PCNs by providing interim management, training and consultancy.

I have managed teams across multiple sites and countries; I have an MBA in Leadership and Management in Healthcare, I'm published in the London Journal of Primary Care, and I am the author of over 250 blogs.

I have 3 children. My eldest has Asthma, my middle child has a kidney condition called Nephrotic Syndrome, and my youngest daughter has Type 1 Diabetes, so outside of work, healthcare plays a huge role in my life.


Ardens Manager Blog Advert.png
bottom of page