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Tackling health inequalities through innovative community outreach

Written by: Adele Bunch - 23rd May 2024

In this blog, Adele Bunch, Head of Portfolio for Health Inequalities, Mental Health and Patient and Public Involvement and Engagement, highlights our involvement in NHS England’s Innovation for Healthcare Inequalities Programme (InHIP), the successes so far, and the future plans for the second wave of the programme.

Over the last 12 months, we worked closely with our Integrated Care Systems (ICSs) to scope, develop and support the rollout of community-led projects tackling cardiovascular disease (CVD) and respiratory illness.

Health inequalities are unfair and avoidable differences in healthcare across the population and are estimated to cost the NHS £4.8 billion each year. Starkly health inequalities increase premature mortality amongst our populations, typically those from deprived communities and individuals who either struggle to access healthcare or do not actively access health advice for a multitude of reasons.

If our health and care systems are to reduce health inequalities, we need to explore different models of accessing health and care services and importantly co-produced solutions with the communities experiencing the greatest challenges. This is what InHIP sets out to do and I’m pleased to say, this programme has had great success across our three ICSs.

To generate interest from the system in this programme, we highlighted its benefits at our bi-monthly population health roundtable where we convene Integrated Care Board’s population health leads, combined authority colleagues, our innovation hub teams and colleagues in the system with an interest in improving population health. Here we were able to identify areas of greatest need aligned to communities in deprived areas. These communities are struggling to access healthcare services and are suffering, and in some cases, dying from health conditions that are often preventable.

Working with the three ICSs in our region, we secured nearly £300,000 of funding from this programme for Yorkshire and the Humber. This funding has supported clinical teams in Leeds, Barnsley and Hull to identify, diagnose and treat underserved communities. The programme centres around the NHS England Core20PLUS5 approach.

Our projects in Yorkshire and the Humber included:

Improving asthma care in Humber and North Yorkshire

The asthma biologics project developed by the Humber and North Yorkshire Health and Care Partnership, targeted rural and coastal areas with lower-than-expected referral rates for severe asthma. Through 22 clinics held in GP surgeries, specialist asthma advice became more accessible, resulting in higher clinic attendance rates. The project identified and referred 253 severe asthma patients for clinical review, ultimately benefiting 17 patients with asthma biologics. Moreover, over 430 healthcare professionals received specialised asthma education, empowering them to better support patients in their communities.

Empowering communities to improve cardiovascular disease in West Yorkshire

In South-East Leeds, a community-based CVD and lipid outreach project successfully identified and reached underserved communities. Collaborating closely with community organisations, the project engaged Gypsy, Traveller, and Roma communities, facilitating health discussions in community settings. Notably, the project identified and optimised treatment for 251 patients at risk of coronary heart disease, showcasing the impact of targeted outreach and community engagement.

Improving cardiovascular health in South Yorkshire

In South Yorkshire, the Barnsley Place CVD and Lipid Community project built on the success of the ‘How’s Thi Ticker’ campaign to reach individuals at high risk of CVD. Through innovative approaches such as taking blood pressure clinics to community settings and partnering with Barnsley Football Club, the project effectively led to 2,000 people accessing blood pressure checks and lipid advice, with 40% of attendees identified as having high blood pressure and referred for further evaluation. Overall a total of 4,443 patients were involved in these projects, with 116 referred, 1,072 diagnosed, and 94 treated.

Improving access to healthcare through community health checks

In partnership with the Bradford Improvement Academy, Bradford Institute for Health Research, and Bradford Teaching Hospitals NHS Foundation Trust, we funded the extension of a project that delivers health checks within diverse communities, including local faith settings and community hubs.

Historically these communities have faced barriers to primary care access, putting them at a higher risk of CVD. The health checks project, which was shortlisted for an HSJ award, has proved successful in identifying undiagnosed hypertension, diabetes, and CVD among underserved populations, enhancing access to essential healthcare services. So far, the approach has assessed 423 patients, identifying 153 individuals with abnormal blood pressure, of which approximately 43 were previously undiagnosed cases.

Its reach is expanding organically to tackle other critical health areas such as cancer and hepatitis C. Collaborating organisations have forged partnerships with charities like European Drum, engaging Roma populations through targeted communication strategies and tailored materials to raise awareness of CVD within these communities.

Ensuring sustainability, the project is tapping into the capacity of pharmacy students, who can gain clinical experience and fulfil their training requirements by volunteering at health check events. Future plans include developing an implementation toolkit, serving as a valuable resource for those looking to replicate this successful model in their respective regions.

Next steps

Scoping for Wave 2 of the InHIP programme is now underway and we are looking at the health needs of our population, identifying projects and considering evaluation plans.

Building on the success of the first wave, the programme will aim to tackle inequalities by improving the experience and access to healthcare services for underserved populations. Wave 2 will run for two years and includes the children and young people strand of Core20PLUS5, where innovation plays a pivotal role.

All projects must have a NICE-approved technology in the pathway, including early value assessments, ensuring they are evidence-based and effective. ICSs are tasked with identifying groups facing inequalities within specific clinical areas, collaborating with networks and communities to find suitable innovations and addressing barriers to accessing health and care services. Based on our experience of supporting the first wave of the InHIP programme, we are ideally placed to support our ICB colleagues in engaging with with target communities facing health disparities, ensuring they have access to the services they need.

However, there is no additional central monies being allocated to this next phase, so ICBs are encouraged to consider their health inequalities funding and prioritise some of this to local InHIP projects. To support this, the NHS Confederation in collaboration with the Care Quality Commission and Leeds Beckett University worked with a selection of ICSs across England to understand how they are tackling inequalities in access, experience and outcomes. ‘The Putting money where our mouth is?: Exploring health inequalities funding across systems’ report summarises effective principles and includes a set of recommendations for government, national regulators, NHS England and ICBs.

Specifically for ICBs there is a toolkit which acts as a practical guide to inform future spending and build system leader confidence in tackling health inequalities. The toolkit highlights that leadership at the top of the organisation is an enabler for change. Health inequalities is ‘everyone’s business’, attention and investment should focus on building capability and capacity to mainstream strategic actions.

If you would like to find out more about InHIP, the success we’ve seen in Wave 1 and how we can help you identify Wave 2 projects, please reach out to