Health Inequalities Strategy Implementation Plan - Case Studies

Activity to tackle health inequalities in London takes place in many different ways, led by many different organisations, every day. The following selection of short case studies - submitted by colleagues working in the NHS, Integrated Care Systems, local authorities and the voluntary and community sector – provides just a snapshot of the broad range of fantastic projects that are being delivered across our city. These support a shared vision to create a healthier, fairer London. More case studies will be added to this page shortly.

Theme – Healthy Children

Project: Young People’s Mental Health Charter

Partners: Waltham Forest Council with NHS, VCS and schools

Location: Waltham Forest

Challenge: Raising the profile of pro-active action on young people’s mental health and wellbeing.

Response:

On Thursday 10 October 2019, the council and partners launched the Young People’s Mental Health Charter. It consists of 20 statements of intent, detailing ways in which different organisations and individuals can foster good mental health in young people. The charter has been co-produced with our Public Health and education teams, schools, organisations, services and local young people. The commitments depend on a range of bodies including NHS services, council services, voluntary sector organisations, youth health champions and schools.

Impact/outcome:

So far, 44 local schools and more than 10 organisations have signed up to the charter.

Theme – Healthy Children

Project: School Meals Initiative for Learning Healthy Eating KS1 Pilot

Partners: Barnet Council

Location: One primary school in Colindale

Challenge: The Grahame Park Estate in Colindale, has been identified as being one of the most deprived areas in the borough Barnet and according to data, over 30% of children on the estate, at reception age, are overweight or very overweight (2019/20 NCMP).

Response: To tackle the prevalence of childhood excess weight from the Grahame Park Estate, we re-designed a school-based healthy weight project called SMILE (School Meals Initiative for Learning Healthy Eating). The project aims to help KS1 children at the local primary school to learn about healthy eating and encourage children to make healthier food choices. The project involves delivering a healthy eating discussion and replacing the traditional school meal trays with health-promoting SMILE trays. The SMILE project is currently being delivered in Orion primary school that serves a large cohort of children from the estate.

Impact/outcome: Post-intervention assessments and reporting will take place in December 2021.

Theme - Healthy Children

Project: CHILDS framework

Partners: Child & Young People’s Health Partnership: Evelina London Children’s Hospital, Variety Children’s Hospital at King’s, South London and Maudsley Hospital, Lambeth and Southwark Primary Care and Councils’ Public Health, Kings College London.

Location: Southwark and Lambeth

Challenge: Early intervention care for children and families

Response: The CHILDS framework was designed by CYPHP (Child & Young People’s Health Partnership). We are child health clinicians and researchers who worked with families to design a system that improves outcomes and reduces health inequalities. We use a proportionate universalist approach to providing early intervention care. We leverage real-world data from the NHS and public health and use advanced analytics to identify children and families in the local population who would benefit from proactive care. We deliver targeted and personalised early intervention care through a deeper understanding of children’s physical, mental, and social health needs. The CHILDS approach was initially applied to the tracer conditions of asthma, constipation, and eczema but it can be adapted to any long-term condition or risk factor according to context and needs of the local population and health system.

Impact/Outcome: We have demonstrated impact in improved health and healthcare quality outcomes, reduced acute service use, and reducing inequalities in care. For more information click here - the trial is due to finish next year.

Theme: Healthy Children

Project: School Superzones in Southwark

Partners: Southwark Council Public Health Division, Transport and Highways Teams, other council departments and schools in the Superzone area.

Location: Southwark

Challenge: Creating healthier spaces outside of school settings by taking a place-based approach to improving, approximately, the 400 metres outside a school setting. The Southwark Superzone decided to focus on three specific priorities linked to the urban environment: childhood obesity, air quality, and youth violence, including knife crime.

Response: Mobilising stakeholders around the area helped to identify assets and harms. The key interventions include:

• testing streetscape interventions to reduce traffic in the school vicinity

• enhancing active travel opportunities

• improving lighting and navigation for local school children to address community safety issues

• using local voices to start influencing and shaping the fast food and healthier advertising policies for the council

Southwark prioritised engaging with children and young people to understand their perspectives.

Impact/Outcome: The project brings together local neighbourhood partnerships to tackle neighbourhood issues and gives a voice to local people and young persons and pilot hyper-local working with partners. Further information on School Superzones including best practises and success factors can be found here: Superzones-LastDraft.qxd (london.gov.uk)

Theme: Healthy Children

Project: Barnet Young Brushers

Partners: Barnet Council, Central London Community Healthcare, Early Years settings and parents.

Location: Barnet

Challenge: Improving oral hygiene and tackling under 5’s teeth decay

Response:

The Barnet Young Brushers project is a targeted supervised toothbrushing programme in Early Years’ (EY) settings in the most deprived areas of the Barnet. Forty Early Years settings will take part between November 2021 and March 2022. The Barnet Young Brushers introduces twice daily supervised toothbrushing to early years settings for all children with parental consent. Training and equipment are provided as well as information sessions to parents.

Other Barnet inequalities projects include work on food insecurity, cardiovascular disease prevention, childhood immunisation and place-based approaches.

Impact/outcome: The project begins in November 2021, evaluation will be available after March 2022.

Theme: Healthy Children

Project: ABC Parents

Partners: North Middlesex University Hospital (NMUH) and VCS

Location: Enfield and Haringey

Challenge: High A&E use by babies under one year. Enfield and Haringey wards located near NMUH are some of the most deprived and diverse in London. Parents from these areas can often be young, unemployed, poor, speak limited English and are socially and digitally isolated.

Response:

To address this NMUH has been running workshops (basic child health and family wellbeing curriculum) covering child health concerns, Basic Life Support (BLS), illness prevention, and health services education for young parents. The programme has been developed with parents, who have informed the curriculum and the way the support is delivered.

Parents are invited to stay in touch through a network of parent champions, offering peer support and help grow diverse and inclusive networks building community resilience. They are trained and supported by the voluntary sector, strengthening relationships between the voluntary and statutory sectors in tackling health inequalities.

Impact/Outcome:

Preliminary findings indicate a positive impact on parents’ confidence in managing their children’s self-limiting illnesses and reduced presentation to A&E. One parent states that ‘ABC Parents empowered me.’

Theme: Healthy Children

Project: Healthy Schools London – Tower Hamlets

Partners: Tower Hamlets Council and schools

Location: Tower Hamlets

Challenge: Improving children’s health

Response:

The Healthy Lives Team in Tower Hamlets runs the Healthy Schools London programme which focuses exclusively on improving health and wellbeing in schools. The team’s objective is to improve the mental and physical health of pupils, parents and school staff, and to reduce health inequalities borough-wide. They seek to support sustainable change by identifying health needs and developing long-term projects to reduce health inequalities. They work closely with schools to plan, deliver and evaluate holistic programmes of advice and support across a broad range of areas including Healthy Eating, Oral Health, Physical Activity, Mental Health and Resilience, Drug Education and Relationships and Sex Education. School-level interventions are one of the strongest ways to tackle health inequalities.

Impact/Outcome: Thanks to our local Healthy Lives team, Tower Hamlets is celebrating the highest number bronze, silver and gold awards in London!

Theme - Healthy Communities

Project: Communities Driving Change

Partners: Bromley by Bow Centre and community volunteers

Location: Tower Hamlets

Challenge: Improving local health by responding to community needs.

Response:

The Communities Driving Change projects brings residents and organisations together to understand what matters to local people how best to improve health and wellbeing. Coordinators work on local housing estates to discuss ideas and plans and help bring them to life. They allocate small amounts of funding through voting days which involve the local community.

Impact/Outcome:

Thanks to the project, new community-run groups have emerged with the support of over 20 volunteers. They include walking groups, coffee afternoons, arts projects, film-making, cookery, clubs for kids, exercise for adults, mental health support and a death café. 

Theme - Healthy Communities

Project: BRACES project

Partners: Brent Mencap and funded by Brent Council

Location: Brent

Challenge: Increase confidence of patients with long-term health conditions to engage with services.

Response:

BRACES will address the concerns of Brent people with chronic health conditions including long COVID and those shielding but who don’t consider themselves disabled. The project will record and share lived experiences and ideas and provide individual, group support and advocacy.

Impact/Outcome:

Looking forward, participants will become more confident in fully engaging with services to influence decisions makers and shape future provision.

Theme - Healthy Communities

Project: COVID-19 Vaccination

Partners: NHS, OHID, London Councils, Boroughs, GLA, FVCS, business

Location: London-wide

Challenge: Delivering population wide vaccination programme.

Response:

The London programme is led by the NHS and delivered through partnerships at a citywide, ICS, borough, locality and hyperlocal level. It was shaped by the grassroots information gained by community champions. The vaccine was made more accessible through:

• flexible booking approaches, appointments and walk-ins
• innovative transport and outreach models to reach vulnerable groups
• pop-up clinics informed by data where people needed them
• using accessible community-based venues

High-profile surge vaccination events were popular with younger groups and raised the programme’s profile. More targeted outreach was locally focused and worked closely with faith and community groups. This helped reached groups with low uptake including older people, migrants, faith groups supported by local communications. Collaborations on homeless health with drug/alcohol agencies and mobile vaccinations also worked well.

Impact/Outcome:

The COVID-19 vaccination programme has been one of the most successful London vaccination drives of all time.

Theme - Healthy Communities

Project title: Tackling HIV Stigma in London

Partners: NHS, GLA, London Councils, People with Lived Experience of HIV, VCSE

Location: London-wide or other – London Wide

Challenge: HIV stigma remains a significant factor in people’s experience of living with HIV. Stigma inhibits people’s willingness to test for HIV, take up opportunities for prevention interventions and ongoing treatment. 

The Positive Voices survey found that 14% of people with HIV experienced discrimination in the NHS in one year.

Response:

Self-Stigma – Launch an empowerment programme in January 2022.  FTCI will be working with 6 VCSEs to support people living with HIV to develop programmes that will support individuals to tackle their own stigma and develop the skills to support others.

Organisational Stigma – We are launching an HIV Friendly Charter. Initially working closely with 2 London NHS Foundation Trusts and partners to develop the Charter and plans to roll-out out further.

Societal Stigma: Work with national Government-led campaigns, developing a London action plan that will amplify national key messages.

Impact/Outcome: An improved awareness and strategy to address stigma on an in individual and societal level.

Theme – Healthy Communities 

Project: Migrants Resource Toolkit for Social Prescribing Link Workers

Partners: GLA, HEAR, Doctors of the World and London Plus

Location: London-wide

Challenge: Social Prescribing Link Workers need more information about migrants and refugees access to health care.

Response: The Mayor and HEAR held a consultation event with London Plus to respond to the PHE national consultation on access to social prescribing for migrants. This identified that social prescribing link workers needed better information about rights to healthcare. The GLA commissioned a dedicated resource to support link workers. This was developed by Doctors of the World in collaboration with social prescribing link workers and refugees. The Toolkit for social prescribing link workers has been cascaded through link worker networks and promoted at national PHE events.

Impact/outcome: December 2021 - there have been 371 downloads (248 of the toolkit and 123 for the poster) and there are currently circa 300 NHS funded link workers in London.

Theme - Healthy Communities 

Project: Social Prescribing Garden 

Partners: The Wilson Hospital working with NHS Property Services and Groundwork London.  Funded by NHS Property Services, The Span Trust, The Worshipful Company of Gardeners and the Wimbledon Foundation. Design by Groundwork London. Construction by Ginkgo Gardens.   

Location: Merton 

Challenge: Developing a sensory garden for patients, staff and the local community 

Response:  NHS Property Services commissioned the award-winning team of Landscape Architects at Groundwork London to design and implement a sensory garden in the grounds of The Wilson Hospital.  The garden is for the patients, staff and visitors to the hospital and is being used by the social prescribing team to improve the health and wellbeing of hospital users and local people.   The accessible design focused on creating a welcoming garden with plenty of seating, wide paths and deep planting beds.  The plant species, bird boxes and insect hotels were chosen to increase biodiversity as well as for sensory enhancement.  Many of the plants were donated by the Wimbledon Foundation. The construction was carried out by Ginkgo Gardens.    

Impact/Outcome:  A programme of garden maintenance and visits by the Social Prescribing team at The Wilson Hospital, begins with bulb planting.  The garden has gained attention from the Duke and Duchess of Cambridge on their social media sites. NHS Property Services and Groundwork UK are undertaking projects country-wide.  

Theme - Healthy Communities 

Project: Community Immunity initiative to increase COVID-19 vaccination access and uptake

Partners: Royal Borough of Kensington and Chelsea, Public Health, NeoHealth PCN and FVCS

Location: North Kensington, RBKC

Challenge: Community concerns, questions and barriers and low take up of vaccinations.

Response: A “Community Immunity” project was initiated by a local Primary Care Network (NeoHealth) in North Kensington to work collaboratively with local authority, public health and community partners to bring Covid-19 vaccines to the community, and address concerns and barriers. Working with community partners, faith leaders and grassroots organisations the partnership were able to deliver Community Immunity COVID-19 Vaccine Pop-ups at 16 locations. One of these locations was the Al-Manaar Muslim Cultural Heritage Centre, where a series of walk-in clinics were held. Virtual Q&A sessions in Arabic language were scheduled prior to the clinics, and staff and volunteers were trained to become vaccinators.  

Impact/Outcome: Successfully vaccinating a total of 675 individuals with their first doses.

Theme - Healthy Communities

Project: Neighbourhood “deep” engagement and Let’s Talk About the Vaccine

Partners: Greenwich Council and local residents, with SEL CCG, Primary Care Networks, VCS and volunteers

Location: Royal Borough of Greenwich

Challenge: Targeting the most at risk neighbourhoods for COVID to increase vaccination take-up and raise awareness of Covid response support

Response: Seven neighbourhoods at most risk from Covid and its broader health inequalities impacts, were identified. Risk factors included deprivation, ethnicity, the prevalence of Covid and vaccine uptake, Resident led Delivery Teams worked with residents and community influencers to create and communicate key messages, identify support needs and build trusted local connections. This programme goes beyond engagement to engage directly with residents, including those who are not part of existing faith or community networks. Locally recognised faces were used in posters and self-produced videos, creating sharable social media. Building on insight from neighbourhood engagement, the Council trained up Vaccine Champions (Council and VCS staff and resident volunteers) to knock on doors in these neighbourhoods, targeting everyone who may have been left behind as well as building residents’ vaccine confidence. Residents were signposted to walk-in vaccination clinics close by and immediately available, and home vaccination was arranged. The door knocking was backed up by videos in community languages.

Impact / Outcome: “To save lives you must engage” Woolwich Common Delivery Team member. The Vaccine Champions door-knocked 72,000 homes. The campaign and local vaccination centres had a measurable impact on vaccine uptake in higher risk groups.

The two-way communications informed Corporate Communications messaging on Covid as well as new volunteering capacity and opportunities, creating social capital and better awareness of community need.

Theme – Healthy Communities

Project: Community engagement for Covid vaccination take-up

Partners: Redbridge Council

Location: Redbridge

Challenge: During the pandemic, Redbridge Council created a community engagement role to engage with community groups. 

Response: This council officer works with underserved community groups who do not engage with mainstream services to improve uptake to the Covid vaccination and address vaccine hesitancy with Black, Asian and other minority groups like the Gypsy-Roma community. More recently the focus is moving to improving access to wider prevention and early intervention services as part of wider Covid recovery.

Impact/Outcome: This programme has reinforced the value of having trusted professionals within the community to understand and work with community members to improve health and reduce inequalities.  Uptake to Covid vaccination has improved with increased awareness of how to get vaccinated.

Theme: Healthy Communities

Project: Covid impact on Ealing’s BAME Communities

Partners: United Anglo Caribbean Society, Golden Opportunities Skills and Development, Came Women and Girls Development Organisation, Ealing Somali Welfare and Cultural

Organisation, Horn of Africa Disability and Elderly Association, The Tamil Community Centre.

Location: Ealing

Challenge: Tackling institutional racism and endemic inequalities.

Response:

A rising sense of concern amongst BAME-led organisations that the recognition of inequality and the promises to tackle the root causes of inequalities will be forgotten once Britain gets back to 'normal' led to collaboration on this report .Case studies and survey data have been brought together with an overview from across the six partners BAME led VCS organisation with input from a further eight BAME organisations. These organisations engage daily with BAME residents serving up to 2000 residents every year.

Impact/Outcome: The findings highlight six themes to tackle BAME inequalities.

The six themes: health and social care, housing and welfare rights, local policies, the digital divide, recognition of BAME-led organisations, and care in reference to different communities.

Theme: Healthy Communities

Project: Beyond the Data Community Participatory Research

Partners: Tower Hamlets Council and FVCS

Location: Tower Hamlets

Challenge: Engaging communities in participatory research

Response:

We have used the recommendations of the Beyond the Data report as a framework for shaping our response to Black, Asian and Minority Ethnic Groups and other groups disproportionately affected by the pandemic. This has resulted in a step change in using community participatory research to commission voluntary sector organisations and work with community stakeholders to coproduce approaches to addressing inequalities eg through COVID champions, ambassadors and targeted outreach commissioning (including Bangladeshi, Somali, people living with disabilities and faith settings).

Impact/Outcome:

We are embedding the learning through a broader piece of work to develop the resilience of the voluntary sector to understand and address the underlying drivers of the inequalities.

Theme: Healthy Communities

Project: Bureau of Speakers public health ambassadors

Partners: PHE London and the speakers

Location: London-wide

Challenge: Increasing confidence in COVID vaccination

Response:

Our PH ambassadors are a passionate group of regional public health colleagues who have agreed to act as ‘cultural appropriateness tzars’ providing a sense check on products and activities undertaken by the Regional Public Health Operation team.

Webinars were supported by the Bureau of Speakers; our speakers come from a range of medical specialities, scientific disciplines and diverse backgrounds enabling then to have nuanced and relatable conversations with the public about the vaccines.

Impact/Outcome:

Ambassadors have provided insights on webinars that have subsequently fed into a number of new programmes and activities designed to address health inequalities and some of the wider determinants of health.

Theme: Healthy Communities

Project: Lambeth Black Health Day

Partners: PHE London and FVCS

Location: Lambeth

Challenge: Black Londoners have a low uptake of COVID-19 vaccines and poor outcomes across a range of diseases.

Response:

The Lambeth Black Health Day adopted a holistic and hyperlocal approach to raise awareness on health issues, signpost into health services and encourage Covid-19 vaccine uptake for Black Londoners.

The health day entailed the provision of stalls which were run by health charities and covered a wide range of health issues - prostate cancer, breast cancer, diabetes and cardiovascular conditions. In addition, Flu and Covid-19 vaccines were offered, a wellbeing bus was present for mental health awareness and to signpost into mental health services.

Impact/Outcome:

The health day was attended by over 500 people and addressed the inequalities encountered by Black Londoners by offering interventions focused on addressing their structural and health needs.

Theme: Healthy Communities

Project: Accelerating social prescribing activity – NEL personalised care/ social prescribing programme

Partners: NHS, PCN, Social Prescribing Link Workers

Location: North East London ICS

Challenge: Supporting patients to access sources of support in their local communities

Response:

Social prescribing has been pivotal during the pandemic in supporting patients as it provides a mechanism through which primary care can refer people to sources of support in their local communities. Social prescribing leads in NEL have been convened and meet regularly to collaborate and enable transformation. Some of the work includes:

-Identified a gap for social prescribing for children and young people. In Oct 2020 NEL ICS awarded funding to six boroughs to develop plans and pilot approaches for how models of social prescribing in babies, children and young people could be implemented locally. Link

-Developing a proposal for a Community Chest to support VCSE sector to support social prescribing and tackle health inequalities.

-Developed a NEL emerging leaders link worker development programme.

-Mature collaboration of social prescribing teams across boroughs.

Impact/Outcome: We have collected a range of personal case stories which show success of social prescribing for individuals in need of support. More details: https://www.eastlondonhcp.nhs.uk/ourplans/social-prescribing.htm

Theme: Healthy Communities

Project: Stay Safe Champions

Partners: Waltham Forest Council, volunteers, FVCS

Location: Waltham Forest

Challenge: Asian and Black groups were particularly under-represented in attendance at our local testing sites.

Response:

Stay Safe Champions - council officers and local volunteers have directly engaged residents, informing, reassuring and supporting them. Handing out over 80,000 free masks has proved a practical way of starting conversations, helping us to understand people’s worries and offering the chance to remind people of ways to protect themselves and others from COVID-19. Around 60% of physical engagement activities were carried out in wards where the highest proportion of residents are BAME. After London was placed in Tier 4, the Stay Safe Champions adapted and we encouraged residents to sign up to be virtual champions. We have provided them with the latest information about COVID-19 via e-newsletters, WhatsApp and Zoom sessions. They are then encouraged to share this information with members of their communities however they feel appropriate and effective. We currently have over 300 virtual Stay Safe Champions, who have links to over 500 hyper-local communities, such as faith groups or street WhatsApp groups. Importantly, they let us know what is and is not working, so we can adapt our approach.

Impact/Outcome:

We continuously measure the success of our communications and engagement programme through resident surveys, our Citizens Panel and feedback from Stay Safe Champions, numbers getting tested and vaccine uptake among certain population groups.

There is a lack of trust from many residents across the borough, and a huge amount of misinformation online and within communities about COVID-19, testing and vaccines. Through our communication and engagement work, we actively break down barriers by providing factual information delivered by relatable messengers.

We learned to work in more agile and responsive ways than previously; testing content and methods, learning from evidence and resident feedback, communicating faster than we have before and embracing creativity and innovation.

Messages work best and most powerfully when they have been coproduced with residents.

Theme: Healthy Communities

Project: Pharmacist Led Hypertension Review Project in Black (African or African-Caribbean origin) Patients

Partners: City and Hackney CCG

Location: City and Hackney

Challenge: Black people (African or African-Caribbean origin) have a much higher prevalence of hypertension and subsequent cardiovascular disease, stroke, renal failure and dementia and therefore the potential risks associated with uncontrolled blood pressure are greater for this patient group.

Response:

Practice Supports Pharmacists (PSPs) who work in general practice, but who are not normally patient facing, were tasked with setting up hypertension clinics to review Black (African or African-Caribbean origin) patients with uncontrolled blood pressure in practices within City and Hackney CCG. The PSPs attended a one day training session delivered by a consultant cardiovascular pharmacist. PSPs then searched GP records for patients using the specified criteria outlined in the project protocol and sent out a letter inviting them to an initial hypertension clinic. Patients were then followed up in clinic 1-3 months later.

Impact/Outcome:

114 patients took up the service with the following results:

• No change in systolic blood pressure in 4 (4%) patients

• A reduction in systolic blood pressure in 66 (58%) patients

• An increase in systolic blood pressure in 44 (38%) patients

There were multiple reasons for non-adherence including patients forgetting to take their medicines. The hypertension review project has demonstrated that using pharmacist led consultations to review hypertensive patients can lead to an improvement in systolic blood pressure control.

Theme: Healthy Communities

Project: COVID-19 education and prevention campaigns developed in partnership with local stakeholders

Partners: City and Hackney Public Health have worked in partnership with Volunteer Centre Hackney and Hackney CVS to design and deliver the programme. To date, 57 Voluntary and Community Sector organisations and two GP practices are involved. Wider partners include CCG, Primary Care and other local authority teams.

Location: City and Hackney

Challenge: Ensuring accurate, timely and accessible information about COVID-19, local services and support available was communicated to all communities across City and Hackney.

Response:

We have developed a programme with two core elements that aim to share accurate information and respond to local community insight.

-Grants support to 27 Voluntary and Community Sector (VCS) organisations with reach into communities to carry out public health messaging and promotion work. Funding is available for ‘messenger grants’ or for VCS organisations to act as ‘contact points.’

-142 Public Health Community Champions recruited and trained in safe volunteer practice and Making Every Contact Count.

-Communications Toolkit developed and regularly updated, which provides COVID-19 information and guidance in accessible formats and a variety of community languages. This also includes bespoke, locally produced videos by our Champions.

-Monthly forums delivered for both grant funded organisations and Community Champions.

Impact/Outcome:

We receive regular feedback from Community Champions and grant funded organisations about the impact this work is having on the communities they support through key performance indicators and reporting requirements. We are developing a more formal evaluation to measure the impact of the programme.

Theme - Healthy Living

Project: Homeless Patients Legal Advocacy Service

Partners: Southwark Law Centre (SLC) and Guy’s and St Thomas’ NHS Foundation Trust Homeless Team

Location: Hospital patients

Challenge: Tackling some of the root causes of homelessness and reducing demand for health services.

Response:

The Homeless Patients Legal Advocacy Service was set up in January 2020. SLC legal specialists cover immigration, housing, welfare rights and community care advice and representation. The partnership with hospitals has enabled them to reach and support a disadvantaged group of people who face multiple barriers to accessing legal advice. As well as direct case work support, the team offers training and support to help NHS staff. One said: “I feel better prepared to support patients with immigration issues, knowing the different types of legal statuses and what they entail as well as when to direct patients for professional legal support”.

Impact/Outcome:

It has changed lives of homeless people with grants of leave to remain in the UK and housing for patients. NHS data shows an 87% drop in inpatient admissions and an 81% reduction in bed days. The project won second prize in the London Homeless Awards 2021. 

Theme - Healthy Living

Project: Nicotine replacement therapy for pregnant women

Partners: Greenwich Council with Charlton Athletic Community Trust

Location: Greenwich

Challenge: Supporting pregnant women to stop smoking during lockdown.

Response:

The challenge was to identify the women who needed help to quit and getting Nicotine Replacement Therapy delivered. It started with telephone support and weekly follow up sessions. Some women were alone with young children and afraid of catching COVID for both themselves and unborn child. The service offered supportive care with signposting to services like financial, health queries, food parcel delivery. With Charlton Athletic Community Trust help, NRT products were delivered to their door. 

Impact/Outcome:

The service helped 165 pregnant women with 76 of those managing to stop smoking - that is a 10% quit rate above national average.  

Theme - Healthy Living

Project: E-cigarette starter kit for pregnant women

Partners: Greenwich Council with local Vape shop

Location: Greenwich

Challenge: Stop smoking during lockdown

Response:

During lockdown, the Tobacco Treatment Service launched an e-cigarette starter kit service for pregnant women. The aim was to reach smokers who had tried everything else, and wanted something different. Clients included pregnant women and those with mental health issues. They bought e-cig starter kits from a local Vape shop, who offered delivery on the day ordered.

Impact/Outcome:

More people were accepted to the service and they also increased engagement with the smoking community, leading to better quit rates. 

Theme - Healthy Living

Project: Community Partnerships Network

Partners: Hackney Council, the CCG, voluntary and community sector and local businesses.

Location: Hackney

Challenge: COVID-19 put some of the most vulnerable residents at risk of significant harm.

Response:

In response, a Community Partnerships Network was formed. It trained Covid-19 helpline agents to support people to help themselves, and made sure direct support was available for those in greatest need. Through the network, they provided culturally specific food and other support to vulnerable residents. They also grew their volunteer base and linked up with the local network of health navigators and community champions.

Impact/Outcome:

Since October 2020, the project has delivered 3,000 meals and 2,000 food parcels a week. They have established four community food hubs, deployed 1,500 plus volunteers and made over 600 welfare calls to people shielding.

Theme - Healthy Living

Project: Co-production for better weight management

Partners: Lewisham Council, Kings College London, Guy’s, St Thomas’ NHS Foundation Trust and Kings Health Partners

Location: Lewisham

Challenge: Poorer outcomes of weight management service for Black-African and Black-Caribbean communities

Response: Lewisham Public Health has used the one-year additional Adult Weight Management Services Grant, from the Department from Health and Social Care, to commission King’s College London (KCL) and Guy’s & St. Thomas’ Trust (GSTT) to work together with Lewisham borough health commissioners and residents to co-produce a weight management service tailored for the Borough’s Black-African and Black-Caribbean communities. In Lewisham analysis of weight management services has shown outcomes were not as positive in comparison to other ethnic groups for Black-African and Black-Caribbean communities, thus highlighting the need for a tailored approach. In this collaborative project, Dr Louise Goff (KCL) will lead on community co-production, together with Shola Oladipo (Dietitian and CEO FfP). Rhys White and Dr Al Duncan from GSTT will lead on intervention delivery. Our longstanding collaborative experience will enable us to provide an effective project, meeting the needs of Lewisham’s Black-African and Black-Caribbean communities.

Impact/Outcome: The project is currently in the process of undertaking rigorous co-production in order to develop tailored intervention, the first patients are expected to begin on the service in mid-2022.

Theme: Healthy Living

Project: Social welfare advice for PCN patients

Partners: North Islington PCN and VCS

Location: Islington

Challenge:

The PCN covers an area with high levels of deprivation and much of the non – clinical need that presents itself at general practice is about:

• low incomes, 

• poor housing conditions

• other issues which need to be addressed through social welfare advice.

Response:

The PCN had worked for some time with a local voluntary organisations; Help On Your Doorstep (HOYD). When DES (Directed Enhanced Service for PCNs) funding for social prescribing link workers came in it felt like a natural progressions for HOYD to employ link worker with a social welfare advice specialism.

Impact/Outcome:

The service is meeting real need in North Islington, particularly with a rise in social welfare related issues due to the pandemic.

Theme: Healthy Living

Project: Stopping the overmedication of people with a learning disability

Partners: PCNs and pharmacists,

Location: North East London ICS

Challenge: People with a learning disability are more likely to be given psychotropic drugs than other people.

Response:

PHE says that every day about 30,000 to 35,000 adults with a learning disability are taking psychotropic medicines, when they do not have the health conditions the medicines are for. NEL have commissioned two specialist learning disability pharmacists whose role is to identify patients that fall into this category, review their medication, and support them to complete a medication reduction plan (if this is safe and suitable for them).

Impact/Outcome: Of the patients identified so far 35% are on medication reduction plans and 6% have come off medication entirely.

Theme: Healthy Living

Project: Long-COVID information and support

Partners: North East London ICS, Healthwatch, FVCS, GPs, Social Prescribing Link Workers

Location: North East London

Challenge: Informing and supporting patients and professionals about Long-Covid

Response:

Support for patients:

-Long COVID patient video, to help our residents understand the common symptoms and to provide information on where to get help. As part of this we are working with local faith and community groups, homeless groups to cascade the video message to our diverse communities in north east London.

-Patient leaflet, including an easy-read version, and have web pages with further information here: https://www.eastlondonhcp.nhs.uk/ourplans/long-covid-2.htm

-Translated versions and information on both medical and non-medical services (things like housing, finance and employment support) is being added to relevant public web pages too.

-A patient education programme is also being worked on which will cover some of the main symptoms of long COVID and how patients can help to recover from these symptoms. This is likely to be a series of webinars and group sessions.

-Support for health and care professionals

-GPs referral form for long COVID, along with a new tool called OneContact, designed to help make the referral process easier for both patients and GPs.

-A training schedule for health and care professionals and an online resource hub including webinars for GPs about local pathways, services and referral processes and social prescribers on the signs and symptoms of long COVID and where to direct residents for further support.

Impact/Outcome:

Working with local Healthwatch, we have a survey going out to local residents to ask them about long COVID symptoms and whether they have tried to access any support. This will help inform future communications.

Theme - Healthy Minds

Project:  Great Mental Health Programme

Partners: Haringey Council with local Voluntary and Community Sector organisations

Location: Haringey

Challenge:  To tackle mental health inequalities and lessen the impact arising from the COVID-19 pandemic

Response: Haringey Council launched the Great Mental Health Programme on World Mental Health Day (10th October) 2021.

This ambitious programme consists of 7 mental health prevention and promotion programmes of work, co-designed and led by local voluntary and community organisations, supporting residents in achieving whatever great mental health means to them.

Face-to-face and digital support tackles key issues such as bereavement, social isolation and domestic violence. The programme prioritises specific populations in Haringey, focusing largely on the east of the borough where local data indicates mental health needs and deprivation are greatest.

 Impact/outcome: Qualitative and quantitative data will be collected and evaluated with the National Institute of Health Research. Supported by pan-London partners including OHID, Thrive LDN, Healthy London Partnership and Good Thinking, this initiative has inbuilt sustainability to ensure continued impact.

Theme - Healthy Minds

Project: Culturally competent bereavement support resources

Partners: Good Thinking, Thrive LDN, Mayor of London

Location: London-wide

Challenge: Due to the pandemic there is a need for existing bereavement support in London to be provided in a culturally sensitive way, given the diversity of Londoners and the varying rituals and bereavement approaches within different cultures and religions.

Activity: Good Thinking, commissioned by Thrive LDN as part of the Mayor of London’s Recovery Mission for Mental Health, has developed a practitioner guide on how to provide culturally sensitive bereavement support. This guide includes practical conversation starters, a practitioner checklist and also signposts to further culturally competent support and information available. Additionally, Good Thinking is in the process of co-producing six faith-based bereavement resources, with faith communities in London, that will provide more information about specific bereavement beliefs and rituals, religious specific support available and information that someone from outside the religion should know when supporting someone.

Link to content: How to guides

Impact/Outcome: To be determined, the guide was launched on 6th December 2021, with faith-based bereavement resources to follow in January 2021.

Theme: Healthy Minds

Project: Mind and Body Accreditation Scheme

Partners: King’s Health Partners

Location: London-wide when rolled out

Challenge: Integrating mind and body care to continually improve care integration through the accreditation network.

Response:

The scheme aims to deliver the parity of esteem agenda and improve outcomes for people with mental health (including SMI) and physical health conditions through better integration of care, initially within secondary care settings.  The scheme has been co-developed with people with lived experience and is currently being piloted within King’s Health Partners to refine the framework and approach ahead of launching the scheme nationally in 2022/23.

Impact/Outcome: Pilot findings will be shared in March 2022.

Theme: Healthy Minds

Project: End of Life Care

Partners: Barking, Havering and Redbridge University Hospital Trust - Spiritual and Pastoral Care Team

Location: Trust-wide

Challenge: New ways of supporting patients, their families and staff

Response:

The Spiritual and Pastoral Care Team made themselves more available to critical care and in some cases became the bridge between the patient and their family. They would sit with COVID-19 patients at the end of their life, contact families and discuss with them how their loved one was doing, using iPads and Skype. Almost all chaplaincy visits were to dying or struggling COVID-19 patients; they were able to relieve pressures on staff by sitting with patients. The Team also supported the Mortuary and Bereavement Team by telephoning families to inform them their loved one had been moved to a mortuary hub. The Team then telephoned them a few days later to see if they needed support and help in arranging the funeral.

Hospital staff were also supported, as the Team were available in staff rooms, rest rooms and wobble rooms during different times of the day. They contacted staff who were shielding or staying in hotels or other non-home accommodation to support them and checked in on staff at all levels from CEO to frontline, porters and paramedics. The Team offered to sit with staff as they telephoned families and informed them of the loss of their love one. The Team made sure to visit A&E most days to support patients and staff there.

Impact/Outcome:

We have learnt the importance of adapting quickly to different ways of working to support patients, their families and carers, as well as staff changes.

Theme: Healthy Minds

Project: South London Listens

Partners: South London NHS Trusts, charities, local authorities and 100+ community groups

Location: South London

Challenge: Tackling poor mental health due to social isolation, loneliness, and digital exclusion; work and wages;

Response:

South London Listens is a unique partnership between to help our communities recover from the significant mental health impacts of the Covid-19 pandemic.

We heard from over 6,000 people across south London, to co-create a programme of tailored and targeted mental health interventions to tackle four priorities: social isolation, loneliness, and digital exclusion; work and wages; children, young people, and parental mental health, and access to mental health services. These projects will be scalable, community-led partnerships that will form a blueprint for preventing mental ill-health across London and nationally.

https://www.slam.nhs.uk/about-us/get-involved/south-london-listens/

Impact/Outcome:

The commitment, buy-in, and engagement across South London communities has been unprecedented. We have created multiple communications toolkits with our partner organisations to ensure dissemination.

ICS systems in Kent and North London have taken on and adapted elements of the programme for their communities. Several national case studies have been published and the work is included in an NHS London Best Practice directory and will be taken forward as part of the London Anchor Institutions strategy.

Theme – Healthy Places

Project: Community Health Workers (CHW) pilot

Partners: Westminster City Council and Pimlico Health GP surgery with Imperial College London

Location: Churchill Gardens Estate, Westminster

Challenge: Targeting health inequalities by building a sustainable community approach that incorporates primary and social care and supports people based on their needs and circumstances.

Response: A one-year Community Health Worker pilot in Churchill Gardens estate. The four CHW were recruited from the local area, and each looks after around 140 households.  They visit each household once a month and provide advice and practical support with health matters. This includes helping residents manage chronic conditions, increase the uptake of screening and immunisations, supporting them with their mental health and connecting them with other services.

Impact/Outcome: The pilot has shown the approach to be safe and viable, with immediate outcomes being achieved across low- and high-level health needs. Several data gathering methods have and are being established to monitor longer term indicators and outcomes.

Theme: Healthy Places

Project: Wellbeing Garden

Partners: University Hospital Lewisham in collaboration with The Royal Horticultural Society (RHS).

Location: Lewisham

Challenge: Improving patient, staff and community wellbeing

Response:

After engaging with staff and stakeholders from our local community we will soon be starting work on a new wellbeing garden at University Hospital Lewisham. Working in collaboration with The Royal Horticultural Society (RHS), the garden will not only help staff, patients and visitors combat stress, fatigue, anxiety and depression it will also help to improve air quality in our local area. The space will be open to community groups and local people to use as part of wellbeing activities. There will also be a memorial to the NHS staff and local people we sadly lost during the Covid-19 pandemic. The RHS are bringing a wealth of experience and passion to the project which will benefit Lewisham for many years.

Impact/Outcome: Garden opens in 2022.

Theme: Healthy Places

Project: The pandemic impact on people living with disabilities

Partners: Tower Hamlets Council, Healthwatch and three disability organisations

Location: Tower Hamlets

Challenge: Tackle the disproportionate impact of Covid-19 on people living with disabilities to improve access to, prevention and protection.

Response:

Public Health in Tower Hamlets Council commissioned a community outreach, engagement, and Covid-19 messaging programme. The collaboration involved three disability led organisations and Health Watch Tower Hamlets over 6 months. It co-produced a wide range of recommendations through numerous disability specific workshops, surveys, videos.

Impact/Outcome:

Over 400 disabled people were engaged and 14 stakeholder organisations. The recommendations were prioritised and formed the basis of a further commission for implementation. This includes 5 strands of actions:

- strategic improvements, (key role of GPs, accessible and acceptable vaccination clinics, corporate communications)

- disability awareness training for health and social care staff

- co-design and development of comms assets

- a good practice guide for the Council communications using insight gained

- a feasibility study for opensource access for adjusted assets.

Theme: Healthy Places

Project: Specialist Alcohol Care Team

Partners: Hounslow ICP, West Middlesex University Hospital

Location: Hounslow

Challenge: Lack of effective care for those misusing alcohol in the acute setting and substantial unmet need for those who would benefit from alcohol treatment.

Response:

In August 2021, Hounslow ICP formerly agreed to fund a specialist Alcohol Care Team to be primarily based within West Middlesex University Hospital. A seven day a week service has been developed which, through a skill mix model employing five staff. The service will provide optimal care within the hospital and will seek to engage people into community treatment through assertive outreach.

Impact/Outcome: No details yet as service has just begun.

Theme: Healthy Places

Project: Social Welfare Alliance

Partners: Newham Council, PCN and VCS

Location: Newham

Challenge: To pre-empt residents most pressing social welfare issues by equipping frontline staff with understanding of the issue, immediate advice and referral information.

Response:

High quality social welfare training was provided for all frontline staff across public and FVCS sector to reduce impact of financial hardship for residents. Topics included Finance and Employability, Housing and Homelessness, Early Help and Family Support, Immigration for non-immigration advisers. The training is open to frontline workers from all sectors for example, social prescribers, advisors on money and debt, family support workers, and volunteers.

Impact/Outcome:

Building on initial piloting and feedback training is being offered across 8 themes and 28 training sessions have taken place with 1,383 attendees.

Theme: Healthy Places

Project: Collaborative action as anchor institutions in NEL

Partners: NHS and local authority partners

Location: North East London ICS

Challenge: Health inequalities have been exposed and exacerbated by the Covid-19 pandemic and our NEL population is facing stark economic challenges. NEL has a relatively young and diverse population with high levels of deprivation.

Response:

We are collaborating as an ‘anchor system’ to use our assets for social, economic and environmental benefit – sharing local learning to accelerate progress more widely and grasping opportunities to collaborate where helpful, also with wider local partners such as primary care and local educational institutions. Our joint priorities, within which a range of activity is taking place, are:

-Widening access to employment, training and a better working experience

-Procurement for social value

-Maximising the social value of our buildings and land

-Supporting a greener and healthier future

-All local authority and NHS trust chief executives have signed up to a set of shared principles outlined in our NEL anchor charter.

Impact/Outcome: Progress will be monitored over coming years and success celebrated and shared across NEL and London.

Theme: Healthy Places

Project: Eligible exemptions from NHS maternity charging

Partners: Homerton University Hospital Foundation Trust

Location: Trust-wide

Challenge: Correctly identifying eligible women and discharging our legal duty in a compassionate and trauma-informed way as possible.

Response:

A document produced Maternity Action was the basis for identifying four areas of focus:

• Appropriately identifying those who are chargeable or have exemptions

• Payment planning

• Complications (i.e. stillbirths etc)

We developed:

-Payment options for those who are chargeable and the amount of flexibility the Trust can offer are being explored.

-Two sessions of Maternity Action training delivered to midwives at the Trust and one was recorded so further staff can access this.

-Trauma-informed training for the Overseas Visitor team to aid their discussions with women, particularly in relation to exemption reasons (which should not be necessary to discuss at all if confirmed by midwife).

Impact/Outcome:

Developed strong relationships with the Overseas Visitor team, who are now in contact as soon as they identify a chargeable family and they work together to support them.

Data has been provided on how many women were identified as charged/ chargeable in the last two years and an audit of engagement and outcomes is in progress.

So far results include successfully prevented three women being charged by identifying and confirming that they met exemption criteria and advocating to get charges rescinded for a further family.

Theme: Healthy Places

Project: Occupational risk assessment for COVID-19

Partners: Barking, Havering and Redbridge University Hospital Trust

Location: Trust-wide

Challenge: COVID-19 pandemic disproportionate impact on BAME staff

Response:

We set up a BAME Task and Finish Group who undertook work involving: data collection; absence review; staff testing; review of previous risk assessments; further round of risk assessments with a focus on BAME vulnerability complementary to early staff risk assessment of those who were potentially vulnerable. We monitored risk assessments and actions to encourage BAME colleagues to undertake these. A letter from the Chief Executive was sent to all BAME colleagues encouraging risk assessment.

Our communications approach included blogs by BAME colleagues stressing the importance of risk assessments. These also included reflections on the death of George Floyd and Black Lives Matter and promotion of our BAME Network.

We conducted an evaluation of our staff by ethnicity who tested COVID-19 positive; self-isolated; and had been redeployed.

Impact/Outcome:

100% of our BAME colleagues completed a risk assessment.

Theme: Healthy Places

Project: Health summer work placements

Partners: Barking, Havering and Redbridge University Hospital Trust - Voluntary Services Team, New City College (Havering College of Further & Higher Education and Havering Sixth Form College)

Location: Havering

Challenge: COVID-19 pandemic and lockdown impact on young peoples’ ability to access education

Response:

A summer programme for vulnerable students to meet some of the gaps in their education, as well as provide a consistent and safe place for them to access support during this time. 12 students were identified by the colleges and they went through an expression of interest process to join the programme. All students were studying health and social care, and were aged 17-18 years old. The programme informed students of the career opportunities and pathways available in the NHS.

Impact/Outcome:

-8 of the 12 students successfully completed the course

-2 students have tentatively accepted an apprenticeship course with the Trust - once they finish the second year of studies

-4 students have undertaken further volunteering with the hospital

Overall, feedback from the programme by students and staff was incredibly positive, it was felt that it allowed young people to experience NHS life and help consider the choices available in a professional capacity.