Improving services for vulnerable adults

In 2019-20, NHS Norwich CCG extensively engaged with organisations that represent vulnerable people and service users who may find accessing NHS services challenging.

CityReach, a GP-led service at “Under 1 Roof” on Westwick Street in Norwich, currently provides a range of services, like treatment for minor illness or injuries, immunisations, sexual health or blood borne virus screening, advice on mental health or substance misuse, to people and families that may be homeless, living in hostels or without permanent accommodation, asylum seekers, gypsies or travellers and former prisoners.

The CCG recognised the service needed further investment to meet the needs of local people and ensure they had equal access to primari care services, so we spoke with service users and a wide range of experts and professionals to co-design the new service with them. We ran workshops and an online survey (promoted through outreach teams at local support organisations) to gather feedback that would enable us to begin co-designing an improved service.

You told us…

  • I can’t access the service or person I need over the phone
  • I can’t get an appointment when I need it
  • Sometimes my medication is started and stopped, impacting on my mental health
  • Appointments are much harder to obtain under an ‘open surgery’ system, and lots of the regular staff have left
  • The service is understaffed and could probably use the knowledge and expertise of organisations that are a part of the Pathways consortium
  • I’m frustrated that I have to see a nurse when I need to see a professional due to my mental health issues.
  • I like outreach. Where I go on the streets they know where to find me.


Here is how this feedback has shaped the new service:

  • Enhanced Primary Care from 7 GP Practices in central Norwich including some close to hostels, so care is closer to access.
  • An Inclusion Health Hub within the Under One Roof premises (the current City Reach Health Services location) hosted by St Martin’s.
  • Refugees and asylum seekers are already registered with a GP Practice in Norwich; the model will ensure they receive enhanced primary care from their registered GP Practice
  • Increased support worker capacity to support the current service offer from partners c/o the Pathways Consortium.
  • Increased nurse capacity as part of the People from Abroad (PFA) team.

  pdf  We have reported back to partners and the community via a briefing, issued in February 2020, that contains more details - read it here (341 KB)