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Reducing health inequalities

What are our overall aims by 2028?

All partners in the Coventry and Warwickshire ICS will work to identify and tackle the inequalities faced by our local population to ensure that Coventry and Warwickshire is a place where everyone starts, lives and ages well.  

Action to tackle health inequalities will be embedded strategically and operationally across all organisations within our health and care system and will be a golden thread running throughout this plan.

We will build a culture and data architecture that supports us to prioritise those in greatest need – reducing inequalities will be a core consideration in the prioritisation and allocation of resources. 

Service delivery and preventative activities will be driven by data around both existing health inequalities and the wider determinants of health.   

Services will be planned and delivered in an inclusive way through co-production with people and communities.  

Work programmes and services will systematically be assessed for their contribution to the health of our population.


What’s our starting point?

Our Health Inequalities Strategic Plan 2022-2027 provides a strong framework for our work in this area, setting out the programmes that we are implementing to tackle health inequalities and the action that we are taking to improve the capacity and capability of our system in this area. The plan establishes a number of key principles, that include ensuring addressing inequalities is core to our work and that interventions to address inequalities are evidence-based, with meaningful prospects for measurable success.

The Directors of Public Health for Coventry City Council and Warwickshire County Council, alongside ICB and partner NHS Trust Executive Leads for tackling inequalities, play key leadership roles across our system. We also have two Core20PLUS Ambassadors working in the system. We have a Health Inequalities Delivery Group driving delivery of our Strategic Plan, while our Population Health, Prevention and Inequalities Board strategically aligns health inequalities and wider determinants work across health and care system partners. 

We have also established a local Health Inequalities Innovation Fund to drive and encourage innovative thinking and approaches.


What are some of the key links to other parts of the plan?

Collaboration and Integration – joining up care and services at a local level will be critical to our success in reducing heath inequalities.  A range of initiatives are already being delivered through our Places and PCNs. 

Population Health Management – embedding Population Health Management will enable us to better understand health inequalities and how to address them effectively.

Children and Young People – delivery of the Core20Plus5 will be embedded within the new system Children and Young People Health and Wellbeing Strategy. 

Quality – the health inequalities agenda is closely aligned to the quality and safety agenda.

Improving Access to Services and Personalised Care – tackling inequalities in access to services and developing more personalised models of care that respond to people’s different needs and characteristics will be important areas of focus.


What will we be focusing on in the next 2 years?

Working with wider partners across our Integrated Care System to strategically align our efforts on health inequalities improvement through the Integrated Care Partnership and the two local Health and Wellbeing Boards.

Delivering the five strategic priority areas for health inequalities improvement identified by NHS England as reflected in our Strategic Plan.

Refreshing and then monitoring delivery of our Core20PLUS5 and other key workstream delivery plans as reflected in our Strategic Plan, including a focus on our five clinical priority areas and our plus groups such as transient communities.

Developing Children and Young People Core20PLUS5 workstreams and aligned delivery plans.

Completing development of and implementing our Health Inequalities Strategic Plan Maturity Matrix to provide a mechanism to self-assess and provide assurance on our progress in delivering the Strategic Plan.

Driving innovation through our Health Inequalities Innovation Fund, transitioning to a Place based funding allocation and engaging our Care Collaboratives to be part of decision making. 

Evaluating projects funded via the Health Inequalities Innovation Fund to demonstrate impact by population group and/or Place, sharing learning and assessing scalability.

Building a shared understanding across partners of what health inequalities are, how they relate to their work on a day-to-day basis and how to address them by embedding use of the Health Equity Assessment Tool (HEAT). 

Delivering ‘data deep dive’ briefings to support detailed exploration of inequalities in relation to defined service areas.

Delivering projects and initiatives within the system Diabetes Transformation Programme Plan.  

Delivering a hypertension, Atrial Fibrillation and lipid case finding and optimal management pathway project in Warwickshire North Place.  

Continuing to progress the development of the Heath Determinants Research Collaboration in Coventry, boosting local capacity and capability to conduct high-quality research to tackle health inequalities. 

Continuing to deliver the NHS inpatient and maternity smoking cessation programme, increasing coverage from 5 days a week to 7 days a week across all NHS Trusts.

CWPT to work in partnership with NHS Confederation through “Delivering Equity: Stop Describing and Start Delivering” – learning to be shared across system partners.


Key Challenges

Financial resource to deliver the data architecture required to deliver PHM.

Shifting financial resource to align to prevention and health inequalities.

Delivery and programme management workforce constraints.

System alignment and development i.e. formation and integration of Care Collaboratives. 

Managing the variance of socio-economic challenges across the system.

Significant pressure on acute services.

Obtaining robust and accurate data to support evidence-driven approaches.

Clinical and care professional leadership aligned to health inequalities. 


Key Metrics and Deliverables

Overarching Metric: 
- Reduce the gap in life expectancy between people living in our most deprived communities compared with the least deprived by 5% by 2028.

5 Clinical Areas:

Chronic Respiratory Disease:
- Reduction in the under 75 mortality rate from respiratory disease considered preventable.
- Reduced hospital admissions and exacerbations.
- Increase Covid, Flu and Pneumonia vaccination uptake levels for those with a diagnosis of COPD. 
- Reduce overall smoking prevalence in adults. 

- Proportion of women living in the most deprived areas being placed onto a continuity of carer pathway at 29 weeks.
- Improve continuity of carer for 75% of women from BAME communities and from the most deprived groups. 

Early Cancer Diagnosis:
- 75% of cancer cases diagnosed at Stage 1 or 2 by 2028. 

Severe Mental Illness:
- Ensure annual health checks for 75% of those living with a Severe Mental Illness. 

Hypertension case-finding:
- Increase hypertension detection (reported prevalence as a percentage of estimate prevalence). 

Plus Groups:
- Increase in percentage of asylum seekers and other transient communities registered with GP practice.

- Reduction of inequalities in access to elective care and services, through prioritisation of waiting lists.
- Reduction in differential waiting times in A&E for Core20 populations and non-Core20.

Coventry and Warwickshire Health Inequalities Innovation Fund Projects:
- Milestones/Key Performance Indicators as per individual Health Inequalities Innovation Fund project plans – 16 projects funded to date.