Derbyshire Trailblazer Fellows lead the way in tackling health inequalities

GPs in Derby and Derbyshire are leading the way in tackling health inequalities by improving care for groups including Roma and traveller, young people with mental health issues and people living with addiction.

The Trailblazer Deprivation Fellowships spend a year working on projects to improve health for specific groups of people in their area, researching the issues affecting their health and bringing together data, insight and the partners who can help improve services.

There are currently seven fellows, including GPs and advanced care practitioners, funded by NHS England, and supervised by the Hub Plus which provides Derbyshire’s primary care training and development offer.

The Hub Plus, Derbyshire Team support the Trailblazer Fellows across the county, co-ordinating, signposting and connecting to ensure the projects create the maximum impact.

Hub Plus Medical Director Dr Susie Bayley said: “These projects show what’s possible when clinicians are empowered to think differently. They’re not just improving care – they’re reshaping the system.”

Dr Catherine Bell, a GP at The Valleys Medical Partnership in Eckington, has been addressing the fragmented landscape of children and young people’s mental health (CYPMH) services. Motivated by the lack of clarity and access – especially for neurodivergent individuals and those aged 16-18 – Dr Bell conducted a survey of 41 GPs, revealing a 50/50 split in confidence when managing young people’s mental health.

Her findings sparked conversations at the Integrated Care Board (ICB) and led to the introduction of GP training sessions, audits on self-harm and appointment trends, and improved collaboration with CAMHS advisors. She’s also working to establish a youth engagement group and streamline referral pathways using digital tools like Accurx.

“This project has been a fulfilling complement to my clinical work,” said Dr Bell. “It’s about making services more visible and accessible for young people who often fall through the cracks.

“It’s also given me space to be creative and self-directed, and I’ve developed skills I wouldn’t have otherwise—from leadership coaching to presenting at masterclasses.”

Dr Lucy Bradley, another GP fellow, has been following a mission to improve care for people with addiction and complex needs. Through a weekly outreach clinic at Derby Recovery Partnership in Ripley, the project offers 45-minute health MOTs focusing on long-term conditions like diabetes, cardiovascular disease, and high blood pressure.

Despite challenges like missed appointments, the clinic is building trust through word-of-mouth and community partnerships. The project also highlights systemic barriers such as stigma, housing instability, and the lack of preventive services for people with addiction.

“This started from a place of deep frustration – watching patients with addiction miss appointments and struggle to engage with healthcare. One woman’s story, someone my age with recurrent cancer, really stayed with me. She died without the dignity she deserved, and I knew we had to do better. This work has reignited my passion for general practice,” she said. “It’s about offering dignified, holistic care to people society often overlooks.”

Working within a 47,000-patient PCN, another fellow Julia Mason has focused on improving health outcomes for the Roma community – one of the most underserved groups in the region. After identifying high rates of cardiovascular disease and low screening uptake, the GP launched a targeted blood pressure clinic and formed a Roma Health Collaborative with local partners.

The initiative used Slovak interpreters, culturally tailored videos, and direct outreach to engage the community. This has led to a significant increase in smears, vaccinations, and blood pressure checks – even among those who didn’t attend the clinic directly.

“In general practice, you rarely get time to step back and think,” said Julia.

“This fellowship gave me that space – to learn, reflect, and choose a direction. It’s been energising and inspiring. It has changed how I practice. It’s about understanding the wider determinants of health – like housing, education, and food security – and acting on them.

“Projects like this help with resilience and retention. They remind us why we came into medicine – to make a difference. It’s been one of the most rewarding parts of my career.”

All three projects are part of the GP Trailblazer Programme, a programme designed to allow recently qualified GPs to work in practices in areas of socio-economic deprivation.

Gail Walton, Hub+ lead for the Trailblazer Fellowships, said: “The fantastic outcome of fellowships is seeing a motivated clinician given a finite amount of time to follow a specialist interest, and how – in a short time – their innovations, and networking with systemwide colleagues, bring changes that benefit Derbyshire patients and frequently gain national recognition.”

The aim is to develop the skills, knowledge, experience and resilience to stay working in these areas and give GPs the time, tools, and support to address the root causes of poor health in their communities. It aims to develop a workforce of professionals who integrate population health into their daily responsibilities.