Schemes to improve health equality given £2.7million

Innovative schemes to improve health equality across England have been given £2.7million to fund and support people at risk of poor health.

NHS England and NHS Improvement (NHSE/I) has funded a £65k project in 41 Integrated Care Systems (ICSs) to identify and target at risk groups.

It is part of a wide-ranging programme to improve health equality, further highlighted by the COVID-19 pandemic, and will help partners working across systems to think together more innovatively about their local communities.

Areas have chosen different local priorities from homelessness and deprivation to specific ethnic minority groups and those digitally excluded.

For example, in Surrey Heartlands, tech angels will help people with the latest virtual opportunities like apps and online groups and in Bath, North East Somerset, Swindon and Wiltshire rough sleepers, gypsies, boaters and travellers will be among those helped to access the flu vaccine.

Celebrating ICSs having rolled out across the whole of England on April 1, Sir Simon Stevens, Head of NHS England and NHS Improvement, said it was time to make better use of population health management techniques – used to identify individuals with a greater risk of COVID-19 for the UKs successful vaccination programme – to tackle the big killers such as heart disease, cancer and strokes.

The Health Equalities Partnership (HEP) Programme will similarly allow professionals to get into communities and identify those who need more support.

Statistics on health inequalities in the UK show that black women are four times more likely to die in pregnancy or childbirth, the healthy life expectancy gap between the most and least deprived communities is 19.6 years and people with learning disability have a life expectancy gap of 15 years compared to the average population.

Systems can use the funding to expand an existing programme or kickstart a new project exploring a systemic problem affecting the local population.

This could include working with community groups to improve access to local health and care services, or identifying at-risk cohorts as part of preventative outreach.

The HEP programme supports systems to improve patient care from the ground up, by strengthening new and existing partnerships, developing skills and knowledge of leaders and providing practical support to systems from the NHS England and NHS Improvement System Partnerships team.

The HEP programme builds on work over the last two years, that has seen more than 4,500 leaders take part in the NHS England and NHS Improvement funded locally delivered place-based leadership programmes.

ICSs are central to the NHS Long Term Plan delivery by bringing together local organisations to redesign care and improve population health, creating shared leadership and action. From April 1 2021, the final 13 areas of the country became ICSs hitting a major milestone of the NHS Long Term Plan by covering the whole of England. One of their four aims is to tackle inequalities in outcomes, experience and access.

Here are four examples of the schemes being developed:

South Yorkshire and Bassetlaw

South Yorkshire and Bassetlaw plan to focus on social prescribing in the Rotherham ethnic minority community. The uptake of social prescribing in the area is currently two to four per cent amongst ethnic minority residents – data currently suggests practices making the fewest referrals also have the highest ethnic minority populations. They plan to explore, review and analyse GP referral data and start focus groups, workshops, and cultural competency training for workers across the community. Teams will work with community groups to strengthen Voluntary, Community and Social Enterprise (VCSE) leadership using insight to produce supporting materials and resources for local engagement campaigns.

Bath and North East Somerset, Swindon and Wiltshire

Bath and North East Somerset, Swindon and Wiltshire are planning to focus efforts on vaccinating those more susceptible to contracting the flu. Local health and social care services have identified multiple at-risk community groups including; rough sleepers, gypsies, boaters and travellers, and people with learning difficulties, and are using Population Health Management (PHM) tools to further focus on those most at risk of flu; such as those with respiratory conditions. They plan to increase vaccination awareness through funded additional training and equipment for health and care teams, who work directly with seldom heard groups in the community.

Surrey Heartlands

Surrey Heartlands has launched Tech to Community Connect, a programme of trained volunteers paired with local residents who are digitally excluded. The team, known as ‘Tech Angels’ have identified areas of risk, where digital exclusion is particularly high, and will work with the paired patient to assist with a range of digital tasks, including booking GP appointments online, online shopping, and attending virtual faith or social groups. The programme was launched in March 2020, a couple of weeks into the pandemic and uses PHM data with local insight from system partners to support increased access to digital services for 200 – 400 residents over the next year.


Derbyshire is planning a system care project enabling trained staff to engage with patients on clinically prioritised elective waiting lists. The conversations will enable staff to target appropriate support to patients at the greatest risk, including referrals to social prescribing link workers, community lifestyle services and voluntary sector support services. The project will use a quality conversation model, which will ensure health and wider equality impacts are considered, with the aim of reducing risk of harm to patients on waiting lists whilst alleviating the strain on the local system through treatment intervention.