Primary Care 24, working with Light for Life (a homeless charity in Southport), delivers a nurse-led health inclusion service through North Park Practice for people experiencing homelessness in South Sefton. The service enables patients to register with a mainstream GP practice and receive structured, continuing primary care rather than relying on crisis services or being directed into a separate specialist clinic. The challenge Many people experiencing homelessness were unregistered with a GP, excluded from routine healthcare and reliant on emergency departments when their health reached crisis point. Fragmented interactions provided little continuity and contributed to unmet health needs, missed monitoring, medicines-related risks, avoidable deterioration and wider health inequalities. Patients also experienced mistrust, anxiety, mobility difficulties, stigma and barriers created by traditional appointment systems. An innovative, preventative approach Patients are proactively identified through partnerships with hostels, outreach services and multidisciplinary teams. They are supported to register with a consistent GP and receive a nurse-led medication review within seven days. Key workers accompany patients to appointments, while flexible scheduling, continuity with known clinicians and trauma-informed care help overcome practical and psychological barriers. Links with outreach, probation and addiction services strengthen referrals and follow-up. Co-produced, sustainable and transferable The approach was co-produced with patients and incorporates “My Story”, helping primary care understand what matters to each person. The model is anticipated to expand across all commissioned accommodation providers in South Sefton, with interest and support from local authorities, housing providers, the Integrated Care Board, GP practices and regional commissioners. As a non-profit organisation, Primary Care 24 combines nurse-led clinical expertise and existing primary care infrastructure with the community knowledge, advocacy and trusted relationships provided by homelessness organisations and key workers. The model avoids creating another separate service. Instead, it brings excluded patients into mainstream primary care and uses partnership working as the relational link that prevents missed care. It requires no new estate or specialist clinic and is designed to be simple, sustainable and transferable. Preventative impact The initiative primarily provides secondary prevention through early identification, rapid GP registration, medicines review and detection of untreated conditions before they escalate. It also provides tertiary prevention by reducing the impact of existing ill health and complex needs through continuing care, chronic disease monitoring, safer medicines use and supported access. It aims to prevent medicines-related harm, missed care, avoidable deterioration and repeated crisis presentations. Over the six-month period reported, 100% of registered patients received a medication review within seven days. The submissions also report reduced A&E attendances and DNA rates, increased chronic disease monitoring, improved appointment attendance and stronger QOF compliance. Patients reported feeling respected, understood and safe, while staff described stronger multidisciplinary collaboration. These outcomes were evidenced through practice data, operational feedback and patient narratives. The model uses existing infrastructure and does not require significant additional investment. Reduced emergency attendance, fewer missed appointments and earlier intervention indicate potential efficiencies and avoided costs. Recognition The initiative has won several prestigious awards: Nursing Times Awards 2025 – Nursing in the Community Nursing Times Awards 2025 – Nursing in Primary Care HSJ Partnership Awards 2026 – Patient Safety Collaboration of the Year (and is shortlisted for the HSJ Awards 2026) Hannah Rahmani, Head Nursing for Primary Care who led the work on behalf of PC24, won BAME Nurse of the Year 2025, and BJN Nurse of the Year 2025 How to scale up this approach Wider adoption would be supported by embedding proactive registration, rapid medicines review and supported access within homelessness and complex-needs commissioning pathways; enabling formal partnerships between GP practices, accommodation providers, outreach services and key workers; and supporting regional commissioning frameworks aligned with CORE20PLUS5 and health inequality priorities. • More case studies of prevention in public service delivery
Primary Care 24, working with Light for Life (a homeless charity in Southport), delivers a nurse-led health inclusion service through North Park Practice for people experiencing homelessness in South Sefton. The service enables patients to register with a mainstream GP practice and receive structured, continuing primary care rather than relying on crisis services or being directed into a separate specialist clinic. The challenge Many people experiencing homelessness were unregistered with a GP, excluded from routine healthcare and reliant on emergency departments when their health reached crisis point. Fragmented interactions provided little continuity and contributed to unmet health needs, missed monitoring, medicines-related risks, avoidable deterioration and wider health inequalities. Patients also experienced mistrust, anxiety, mobility difficulties, stigma and barriers created by traditional appointment systems. An innovative, preventative approach Patients are proactively identified through partnerships with hostels, outreach services and multidisciplinary teams. They are supported to register with a consistent GP and receive a nurse-led medication review within seven days. Key workers accompany patients to appointments, while flexible scheduling, continuity with known clinicians and trauma-informed care help overcome practical and psychological barriers. Links with outreach, probation and addiction services strengthen referrals and follow-up. Co-produced, sustainable and transferable The approach was co-produced with patients and incorporates “My Story”, helping primary care understand what matters to each person. The model is anticipated to expand across all commissioned accommodation providers in South Sefton, with interest and support from local authorities, housing providers, the Integrated Care Board, GP practices and regional commissioners. As a non-profit organisation, Primary Care 24 combines nurse-led clinical expertise and existing primary care infrastructure with the community knowledge, advocacy and trusted relationships provided by homelessness organisations and key workers. The model avoids creating another separate service. Instead, it brings excluded patients into mainstream primary care and uses partnership working as the relational link that prevents missed care. It requires no new estate or specialist clinic and is designed to be simple, sustainable and transferable. Preventative impact The initiative primarily provides secondary prevention through early identification, rapid GP registration, medicines review and detection of untreated conditions before they escalate. It also provides tertiary prevention by reducing the impact of existing ill health and complex needs through continuing care, chronic disease monitoring, safer medicines use and supported access. It aims to prevent medicines-related harm, missed care, avoidable deterioration and repeated crisis presentations. Over the six-month period reported, 100% of registered patients received a medication review within seven days. The submissions also report reduced A&E attendances and DNA rates, increased chronic disease monitoring, improved appointment attendance and stronger QOF compliance. Patients reported feeling respected, understood and safe, while staff described stronger multidisciplinary collaboration. These outcomes were evidenced through practice data, operational feedback and patient narratives. The model uses existing infrastructure and does not require significant additional investment. Reduced emergency attendance, fewer missed appointments and earlier intervention indicate potential efficiencies and avoided costs. Recognition The initiative has won several prestigious awards: Nursing Times Awards 2025 – Nursing in the Community Nursing Times Awards 2025 – Nursing in Primary Care HSJ Partnership Awards 2026 – Patient Safety Collaboration of the Year (and is shortlisted for the HSJ Awards 2026) Hannah Rahmani, Head Nursing for Primary Care who led the work on behalf of PC24, won BAME Nurse of the Year 2025, and BJN Nurse of the Year 2025 How to scale up this approach Wider adoption would be supported by embedding proactive registration, rapid medicines review and supported access within homelessness and complex-needs commissioning pathways; enabling formal partnerships between GP practices, accommodation providers, outreach services and key workers; and supporting regional commissioning frameworks aligned with CORE20PLUS5 and health inequality priorities. • More case studies of prevention in public service delivery