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proactive and preventative

Tackle inequalities in outcomes, experience and access to services

We want to focus on the wider determinants of health, listen to our communities and take action to tackle inequalities. Below you can find some of the work that has been happening to support this aim.


Covid vaccination programme community engagement across Coventry and Warwickshire

Health Care Partners across the system recognised the need to ensure that accurate vaccination information was available to seldom heard groups. Data showed that some groups and individuals were more disadvantaged or subject to the most harm from the pandemic.  It was crucial to reach out to our wider community and make sure that they had the facts available to make their own decisions about the benefits of getting the vaccination.
The Integrated Care System partners in Coventry and Warwickshire have been involving local communities and reaching out to seldom heard and vulnerable groups through many channels and approaches. 

All system organisations have collaborated to reach out to over 150 different local community and voluntary organisations, support services, groups and communities. Community groups have been participating confidently in vaccination Q&A sessions that were delivered by a GP/clinician from their culture/background and in their language and the ability to ask direct questions to NHS professionals has helped increase confidence in services across the board beyond the needs of Covid vaccinations and has built further trust in the NHS.

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Working together to increase life expectancy

Due to the impact of Covid-19 on health inequalities; the Marmot Partnership Group led on work to tackle increasing gaps in health outcomes.
They developed a ‘Call to Action’, which brought together input from all parts of the system – public, private and voluntary organisations. It recognised that there could be a significant impact on increasing life expectancy if everyone made a small difference.
The programme has just started but it will be a system-wide challenge to all businesses and organisations to take one or two actions which will benefit their workforce and the local community.

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Orbit Housing Association helping their tenants keep warm and well this winter

Recognising that many were struggle with rising energy bills this winter, Orbit commissioned National Energy Action to support their tenants and hold Winter Wellbeing events.

Key to Orbit’s engagement and support with tenants are Community Connectors and this team has recently expanded with two new Connectors starting in Nuneaton and Rugby and South Warwickshire this Spring.

The Community Connectors will have a regular presence across the community hubs and the team’s recent recruitment drive recognises a change in the way they engage with their tenants since the pandemic.

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Coventry and Warwickshire Hospices working together to put patients first

In order to provide equitable hospice care across Coventry and Warwickshire that both provided the best possible care to patients whilst respecting their end of life wishes, hospice providers and local NHS services came together to coordinate services and agree a joint vision.

This joint vision will form the basis of hospice care across our system and demonstrates a collaborative approach to hospice services.

This partnership working is already underway in South Warwickshire where healthcare and hospice providers are working together to create a single point of access to hospice and palliative care services. This new model will ensure patients are at the centre of their care and will access the right services, in the right place at the right time.

By working together NHS community teams and hospice providers are in a better position to meet the care needs and wishes of end-of-life patients.

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Addressing health inequalities in pulmonary rehabilitation

The number of patients accessing pulmonary rehabilitation health services after being discharged from hospital diagnosed with COPD was found to be lower in rural areas. Historically, pulmonary rehab was delivered in population hubs, which may have been difficult for these patients to access.

In order to address this health inequality, the physiotherapy team at SWFT have developed a new service model to improve access for patients living in rural areas.

The approach had two main elements. The first is that the teams go into GP practices and offer 1:1 consultations with those identified as requiring pulmonary rehab, where baseline tests can be carried out and patients can ask questions about the service. Second, the subsequent pulmonary rehab classes are delivered locally to the patients, either in GP surgeries or local community premises, bringing care directly to the patients.

The model will now be evaluated to determine the impact of uptake of pulmonary rehab and has the potential to be applied to other health and care services.

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Providing a Diabetes Foot Care service at George Eliot Hospital

The Multi-Disciplinary Foot Team (MDFT) have been commissioned and launched in March 2021 at George Eliot Hospital (GEH) for Warwickshire North patients with diabetes foot problems to be referred by Primary and Community Care who have urgent and complex active foot problems at extreme risk of amputation or loss of life. This team provide Diabetes Foot Care service in outpatient setting at GEH with active collaboration between acute and the community setting.

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Tackling tobacco dependency

Smoking remains one of the largest causes of preventable illness and premature death with 80,000 deaths per year from smoking related illness. In Coventry and Warwickshire, 13.8% of the population smoke, and smoking is associated with 7,188 hospital admissions and 2,954 premature deaths, per annum.

A system wide project group was established to determine how best to proceed with the mobilisation and implementation for acute inpatients and maternity pathways.

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Supporting patients with Type 2 Diabetes

Sowe Valley PCN are taking a Population Health Management (PHM) approach to support patients with Type 2 diabetes. They were among the four PCNs that participated in the national Population Health Development Programme in which they identified a population cohort to develop targeted interventions and evaluation plans.

The PCN has continued to build upon their progress from the programme to design a proactive, personalised and preventative model of care to support patients with Type 2 diabetes.

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