Integrated care in action – Health inequalities

Case study summary

Understanding how integrated care systems are tackling health inequalities.


The NHS was founded to provide universal access to healthcare, but healthcare is only one of many factors that influence our health. The social and economic environment in which we are born, grow up, live, work and age, as well as the decisions we make for ourselves and our families, collectively have a bigger impact on our health than healthcare alone. Reducing health inequalities means giving everyone the same opportunities to lead a healthy life, no matter where they live or who they are.

Wider action on prevention will help people stay healthy and also moderate demand on the health and care service. Integrated care systems provide stronger foundations for working with local government and voluntary sector partners on the broader agenda of prevention and health inequalities.

Wakefield partnership making the home healthy

The right home environment is essential to health and wellbeing, and the condition and availability of housing can have a significant impact upon health and wellbeing. It is estimated that poor housing conditions are responsible for over 1,164 harmful events requiring medical treatment every year in Wakefield.

As part of the area’s plan to tackle wider determinants of health, Wakefield CCG and Wakefield District Housing (WDH) have been working together to fund several schemes to improve housing and community health which has potentially reduced costs to the local health service by up to £1.5 million a year.

Mental health navigators take referrals from the WDH Debt Team, housing officers and community safety officers on problems like hoarding, poor tenancy management and anti-social behaviour. They can prevent eviction and potential homelessness which place a greater strain on NHS mental health services and other secondary services. The navigators engaged with over 377 clients in 2018/19 while WDH wellbeing caseworkers engaged with 688 people yielding a joint social return of £1.9 million.

In homes across Wakefield, 3,400 people have access to a care link responder service, an alarm with a response team that can help with crises including falls, no response calls, manual handling and assistance and reassurance. People fresh out of hospital also get free Telecare while they recover, which is a direct helpline to a team that can help with issues like falls and mobility, reducing pressure on the NHS.

A housing support coordination service based on local hospital wards means key workers begin addressing property barriers that might prevent a return home when a tenant is admitted to hospital, such as broken heating, cold homes or the need for new mobility equipment. They reduce delayed transfers of care by using the home improvements team to rectify any issues.

Stubbing out smoking in Manchester

Research suggests that 87,782 Greater Manchester households which include a smoker fall below the poverty line. Smoking causes around 7 in 10 lung cancer cases in the UK, which is also the most common cause of cancer death. By helping these smokers to quit and removing the economic burden of buying tobacco, 34,131 households and 62,133 people could have improved health outcomes.

In October 2018 the Greater Manchester Health and Social Care Partnership launched the CURE programme at Wythenshawe Hospital – a UK-first approach for treating tobacco addiction which ensures that all smokers admitted to Wythenshawe Hospital will be prescribed medication to tackle their addiction to tobacco and offered intensive support to help them stay smoke-free during their stay at hospital and once they go home.

Following the initial six-month phase at Wythenshawe Hospital, CURE is due to be rolled out in hospitals across Greater Manchester by 2020. Once embedded, the programme aims to support over 18,000 people to successfully quit smoking, and save over 3,000 lives in its first year alone. It is also estimated to deliver savings of nearly £10 million per year, reducing hospital readmissions and releasing around 30,880 bed days a year across Greater Manchester. This is equivalent to 84 additional beds per day across the region.

Tackling alcohol-related illness

A hospital service in Wakefield has saved the local NHS an estimated £1.5 million over the past four years by dramatically reducing the number of admissions due to alcohol-related illness and injury. The Alcohol Liaison Service currently employs two full-time alcohol liaison nurses who provide support and treatment for a wide range of alcohol-related concerns.

This includes advice on safer drinking, clinical alcohol detox, support managing alcoholrelated health conditions and signposting to partner agencies which provide access to counselling and community recovery.

The team supports colleagues in the hospital by overseeing discharge planning between  hospital care, recovery services, GP and community services. They also facilitate regular substance misuse training for frontline staff in departments which see the highest levels of alcohol-related admissions.

The service led to 34% fewer alcohol-specific hospital admission episodes in 2016/17 compared to 2013/14. Over the same period, the number of hospital readmissions reduced by 36% and the number of associated bed days per year by 26%.

Supporting the homeless

Vulnerable people and rough sleepers in Doncaster will now be able to access a monthly town centre pop-up hub which provides support and an opportunity to reconnect with health services, in a bid to help them turn their lives around.

The hub was developed by the Doncaster Complex Lives Alliance, a partnership of support agencies working to engage with and help people caught in a cycle involving rough sleeping, addiction and mental ill health. The aim is to help people access accommodation and support and to help them on the road to recovery and re-integration into community life.

The hub follows a successful pilot in July 2018 which saw people attend and receive support and advice from health and social care experts, with financial and housing advice all coming together in one place. Nurses and a street doctor were on hand to provide mental health support and wound care treatment to help tackle addiction and mental and physical health issues.

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