Data about assisted rubbish collections can play a key role in improving the health care of frail people, according to one GP.

Dr Shashidhar Khandavalli, who is also clinical director for Chorley Central Primary Care Network in Lancashire, said the link between frailty and bin collections was vital when he and his colleagues worked with the council and other partners to establish which people needed more help.

After attending an NHS England Population Health Management programme, the GP and his colleagues examined data with professionals in areas such as data analysis, council, public health, finance teams and social prescribers, focusing on moderately frail people aged 45-60 who are high-intensity users of primary care – those who have 10 or more visits to a GP every year.

“We worked closely with our partners to collate and link datasets to bring a deeper insight to the needs of our identified cohort,” he writes. “We wouldn’t ordinarily have that linked information but by working closely we were able to pinpoint residents we were unaware of in primary care who clearly need more help.”

He says it was this process that highlighted the fact that the residents needed assistance for bin collections. After linking the data, they wrote to residents to see if they would take part in a project.

Those who agreed were visited by a social link worker in their home to assess them for multiple issues, including mental health, physical and social needs all, before making personalised recommendations for that person.

Dr Khandavalli said 90% of the participants were obese, which created new challenges and questions surrounding wider structural social issues. He said if people found it difficult to lead a healthy life because of their local environment and amenities, it can lead to mental health problems, obesity, unhappiness and loneliness.

“We cannot fix these problems on our own. However, by helping our communities on a local and individual basis alongside our fantastic council and third sector colleagues, who hold the key to so much expertise, we can do so much more together,” he writes.

“When we think about predicting the future needs of the health service, we are often only able to look at people based on their medical condition in isolation, unaware of the wider determinants impacting on that individual and their community. Here reside the real reasons they are ill and indeed the meaningful solutions to their problems.”