Learnings from a pandemic: wellbeing health checks

In the early stages of the COVID-19 pandemic, we decided at Hillview Surgery to review our elderly and vulnerable patients over the telephone in ‘wellbeing health checks’. The idea, initiated by the nursing team, was that they would ring patients to organise electronic prescriptions and discuss their general health, including mental health and their ability to cope with daily activities.

Vulnerable patients were identified by a search on SystmOne and categorised into the following groups: 90 years and over, 80–89 years, 70–79 years, patients with mental health conditions, patients with learning disabilities, and patients with more than one health condition. A spreadsheet was created to record the details, and the nursing team went through the list systematically.

The telephone consultations included discussions about general wellbeing, ensuring patients had received the shielding letter,1 and provided patients with contact details of support that was available to them, with the option to refer to voluntary NHS support services such as GoodSAM.2 The team either encouraged patients to self-refer or referred on their behalf. A ‘review call’ was set up and patients were followed up regularly; those with ongoing issues lasting 4 weeks were referred to our social prescriber.

Initial verbal feedback from patients was that many had not been aware that they could access voluntary support and were thrilled to become part of the service offered by the NHS healthcare team. Patients welcomed the idea; many were lonely, and this made them feel recognised and valued in the community. The most vulnerable were also able to get the help they needed with shopping and getting medications delivered.

The nursing team took the opportunity to update patients’ next of kin in their record for onward planning of care. The team also addressed physical needs in addition to the social aspects of care, providing home visits for blood tests and blood pressure checks. This project was worthwhile and satisfactory, and our elderly vulnerable patients felt especially grateful that they were continuously looked after during these hard times.

As lockdown eased and there was an increased need for our nursing team to offer face-to-face consultations for essential services, wellbeing health checks were offered mainly by our health care assistant (HCA), who was shielding during the pandemic and working remotely. She followed up routinely with patients via telephone, and any medical or social concerns were discussed in our weekly clinical meetings. Written feedback from patients after 6 months was encouraging.

We decided to use the skills of our remote-working HCA to involve her in ongoing annual health checks of our patients with learning disabilities. An electronic annual health check document, named a ‘personalised holistic care record’, includes information about patients’ health, likes and dislikes, eating habits, how best to communicate with them, and more, on a series of colourful pages. The aim is to provide a document that can be read by any health professional, so that the best care can be given to the patient in any situation, particularly in an emergency.

The document is sent electronically (for example, through AccuRx) with instructions to the patients and carers, and with a telephone appointment date. The HCA then calls the patient or carer and goes through the document and completes it as much as possible. The patient is offered a further, longer, face-to-face appointment with the nurse or doctor to discuss any concerns and for physical examination as appropriate; this can include blood tests, medication review, and an influenza or pneumococcal vaccination. The completed electronic document forms the care plan for the patient, which is printed and shared with the patient or carer.

As a result of the personalised holistic care record, when patients with learning disabilities—particularly patients with severe disabilities—come into contact with an out-of-hours service or are admitted to hospital, sufficient information is recorded in the handheld record. If appropriate, this invaluable document could incorporate details of a do-not-attempt-resuscitation form, providing ready access for healthcare professionals to such information.

An individual care record alleviates any potential psychological and social burden that patients or carers may experience about queries related to their medical, psychological, and personal information. Initiation of a holistic record was welcomed by all of our staff, as well as patients and carers. I feel that this is the best outcome for the care and support of our patients with learning disabilities during the pandemic. This idea could also be extended to other groups of patients, such as those diagnosed with dementia.


  1. Department of Health and Social Care. COVID-19: letter to clinically extremely vulnerable adults. DHSC, 2020. Available at: www.gov.uk/government/publications/covid-19-letters-to-clinically-extremely-vulnerable-people
  2. GoodSAM. NHS Volunteer Responders referral and Steward Volunteer request form. www.goodsamapp.org/NHSreferral (accessed 30 March 2021).

first published in Guidelines in Practice in April 2021

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