ICS respiratory review successes - health inequalities

Integrated Care Systems are working in innovative ways to reduce inequalities, ranging from initiatives to work with homeless people to finding new ways to increase vaccine uptake in under-served populations.

Buckinghamshire, Oxfordshire + Berkshire West

Most impactful intervention: CYP Asthma – identifying and focusing on priorities via the CYP Asthma Care Bundle: setting up BOB CYP Asthma Network. Inclusion of CYP within the BOB ICB Spirometry and FeNO LCS 2024-27. CORE20PLUS5 CYP – has been a key driver of inequalities work relating to CYP Asthma.

Cold and unsafe homes referral pathway – enabling home improvements and grants for those whose poor/cold housing is impacting their health condition.

COPD Winter Planning Guidance – guidance for primary care and patients on COPD management leading up to and during winter.

CORE20PLUS5 – Winter 2023/24 project increased uptake of Covid-19 vaccination in immunocompromised and at-risk populations in BOB, inclusive of people with COPD and learning disabilities. An additional 270 people received Covid-19 vaccination over a period of six weeks. It included working with refugee centres, food banks and drug and alcohol addiction clinics, as well as vaccinating several housebound patients in their home.

CYP Asthma: a service developed to meet the needs of a Core20PLUS5 or seldom heard group. 1) Acute asthma pilot to address the variation in care across BOB ICS in access to specialist CYP asthma nurses. 2) PCN level pilot using a social prescriber model to review high risk CYP with asthma and offer holistic interventions where appropriate. 

Cheshire + Merseyside

Fuel poverty programme aligning with respiratory services in Mid Mersey.

Frimley

Started Nepalese group – to engage in PR also screen for diagnostics COPD.

Just about to start homeless project for PR access and COPD.

Talking with Broadmoor re: specialised clinics for respiratory and establishing a form of PR.

NHS Hampshire and Isle of Wight

Warm homes on prescription. Portsmouth County Council and the NHS ran a successful pilot in Autumn 2023 which is being expanded for winter 2024. The project identified people aged 65 and over living with a respiratory condition, who were living in cold homes. This was achieved by combining NHS and low Energy Performance Certificate (EPC) rating data from the local authority. People were sent a text offering them advice on increasing the warmth of their home, including where to get help on energy use, bills and what financial support was available. 

CORE20PLUS5 supporting uptake of COVID-19 vaccinations in deprived areas using a vaccination bus. Hampshire and Isle of Wight Integrated Care System had the highest uptake in the spring 2024 COVID-19 vaccine programme of anywhere in the South East. More than 180,000 eligible people had the vaccine, the third highest number of vaccines delivered nationally. Our uptake level was over 65 per cent which was the highest in the South East Region and fifth highest for population uptake in the country. We promoted and delivered the vaccines through a Hampshire roving vaccination and health vehicle. Specific initiatives to reduce health inequalities in vaccine uptake included specialist clinics in GP practices, pop-up services, supporting people who are homeless, and ethnic minority community champions.

Northamptonshire

Breathlessness pathway in a certain part of Northampton, with link between voluntary sector, primary care, public health. Working with disadvantaged patients in that area with COPD. Awaiting the impact of this.

Somerset

We have had projects to reduce COPD health inequalities and asthma inequalities across our county.

Surrey Heartlands

Most impactful intervention: CYP Asthma Team established - their work includes: providing updates and teaching for primary and secondary care, improving communication between primary and secondary care, developing discharge pathways to improve a safer discharge process, promoting asthma friendly schools, liaising with housing services to decrease incidence of damp and mould in homes, working with Surrey Air Alliance to increase awareness of pollution and asthma, and working with prescribing leads to find ways to decrease SABA prescribing in CYP asthma. Evidence of impact of the role-modelling clinics for CYP asthma, undertaken by the team, can be seen in reduction of the number of CYP at high risk of asthma attack/death (reducing by more than 40% in one practice, and c. 60% in another).