Partner by

NorvatisNHS England

The Innovation and Improvement in Reducing Healthcare Inequalities Award, partnered by Novartis, has been our most popular category since its inception last year. This year, we received 148 submissions for this category, highlighting the great work within the sector around tackling health inequalities. Meet our finalists:

Organisation : Advancing Quality Alliance and Salford City Council 

Project Title : Using asset-based community development to increase uptake of COVID-19 vaccine in Salford

Synopsis : Working in partnership, Salford City Council Public Health, Salford’s five primary care networks, Aqua, and local community organisations, collected and used community insight to rapidly design and deliver drop-in COVID-19 and flu vaccination clinics, targeted to communities with high levels of vaccine hesitancy.

This project evidenced:

  • An increase in COVID-19 and flu vaccination in targeted communities.
  • Easily replicable new ways of working through co-design and delivery with targeted communities, which led to providing warm, welcoming drop-in services offering a range of health and care screening, vaccination, and welfare advice.
  • Strengthened partnership working between primary care, public health, and local communities

Organisation : City and Hackney PBP, NHS North East London, Hackney CVS, ELFT, London Borough of Hackney and Corporation of City of London

Project Title : Peer Led Tree of Life in Schools for African and Caribbean Heritage Young People

Synopsis : Our project focused on addressing inequalities experienced by African and Caribbean Heritage (ACH) students in accessing the right mental health support at the right time.

Our partnership between the NHS, schools and VCSEs, adapted the Tree of Life model and pioneered its use in schools as an ACH peer led and ACH focused approach embedded in the whole school system. Developed in Zimbabwe, the Tree of Life allows culture to be reframed as a strength.

The high voluntary access rates and enthusiasm from students and the improvements in mental wellbeing demonstrate the value of providing peer led culturally attuned support.


Organisation : Coventry & Warwickshire Partnership Trust

Project Title : Midlands Op Courage

Synopsis : Midlands OpCourage is a mental health service providing specialist care for British Armed Forces’ veterans and their families.

It is a highly responsive service tuned into military culture and aligns with the CORE20PLUS5 approach of the NHS in targeting those veterans facing severe and complex mental health needs and co-morbid issues such as addiction.

Midlands OpCourage is a collaborative programme built up from local partnerships between statutory, mental health and veteran specific services.


Organisation : Hertsmere Borough Council

Project Title : Hertsmere Cancer Screening Project

Synopsis : The Hertsmere Cancer Screening Project is identifying patients who have not responded to cancer screening invites and those with increased risk of cancer and taking away the barriers to booking patients often experience by proactively contacting them to arrange the appointments during a phone call.

The project has also launched a Hertsmere against cancer campaign to raise awareness of risks, symptoms and screening services.


Organisation : Improvement Academy

Project Title : Yorkshire Community Health Checks

Synopsis : The Connected Bradford Community Health Checks is a co-produced initiative to provide at risk communities cardiovascular health checks in community settings.

The health checks additionally facilitate connections to primary care services and supported lifestyle interventions to address risk factors for cardiovascular disease (CVD). Interventions include risk-lowering medications, such as statins, and social prescribing to address the wider determinants of cardiovascular health.

The project developed from clinical evidence at Bradford Royal Infirmary regarding the increased mortality observed from specific sub-populations in parallel with conversations with community members that highlighted experience of poor outcomes from CVD.


Organisation : Medway Public Health, Kent and Medway ICB, OHID, Kent Community Health FT, EK360 and BHF

Project Title : Kent and Medway Hypertension Heroes

Synopsis : A multiagency collaboration between voluntary and statutory bodies including Kent and Medway ICB, developed a personalised approach to improving hypertension awareness, detection and management.

Working with community volunteers, complimenting initiatives in primary care and community pharmacies, EK360 lead co-design and co-delivery with community groups to reach populations who may be at risk, but unaware of having hypertension and/or not accessing services or support to help identify and manage their blood pressure. Trained volunteers engage their communities to overcome barriers to self-management, take their own blood pressure readings and manage risks through lifestyle change; self-monitoring; treatment and accessing primary care support.


Organisation : Midlands & Lancashire CSU, NHS England and Specialist Pharmacy Services

Project Title : Learning Disabilities and or Autism: Developing a Community of Practice

Synopsis : This national project upskilled, motivated, and inspired primary care network pharmacists to undertake structured medication reviews in people with a learning disability to help reduce inequalities. Pharmacists are well-placed to deliver holistic lifestyle and medicines expertise to help these patients get the most from their medicines and live a fulfilling life.

Strongly co-produced by a range of stakeholders, the project identified pharmacists’ learning and development needs; scoped and delivered a model of support; collected data to demonstrate success; and made recommendations for uptake across the system. Participant and user feedback was positive, and the model is available for wider implementation.


Organisation : Modality Partnership Hull

Project Title : Modality Partnership Hull: A PCN approach to core 20 plus 5

Synopsis : Core20plus5 offers a unified approach to population health management for organisations of any size within the NHS. Our PCN approach examined how we could implement and tailor national approaches to the benefit of our local population and patient needs. Using data, local intelligence, and feedback we have designed quality improvement initiatives that will benefit the patient populations who need our support the most. We focus on comprehensive models of care that offer continuity, coordination and proactive engagement, drawing on best practice to improve quality of care. Each service is designed to improve access, experience and outcomes for its target patients.


Organisation : University College London Hospitals FT

Project Title : RESPOND: an Integrated Asylum-seeker and Refugee Health Service

Synopsis : RESPOND is an integrated, co-designed health system providing services for asylum-seekers and refugees (ASR).

Our Outreach Assessment Service has seen more than 1400 asylum-seekers in initial accommodation centres in North Central London (NCL), exploring physical, mental, sexual, dental and social health needs (aligned to CORE20PLUS5), using a holistic care-planning framework to promote service access.

A specialist multidisciplinary team (MDT) facilitates partnership-working, and a comprehensive patient-held health plan is created for service-users. RESPOND addresses health inequality in a vulnerable population, and has demonstrated improved access to health services, identification of health needs and patient / stakeholder experience.