Health Inequalities Improvement Programme: Redbridge Place
In 2023, the NHS Confederation and AstraZeneca announced a collaboration agreement to support and enhance patient care through population health-focused solutions to address health inequalities. The first programme under this collaboration is taking place in Redbridge, North East London.
NHS North East London serves one of the most deprived populations in the country, where poverty and health inequalities are stark. With over 53% of this health system’s two million people being from ethnic minority backgrounds[1]; system leaders here recognise that a ‘one size fits all’ approach to services does not work for the people and communities that it serves.
The Challenge:
In Redbridge place, almost one-third of the population lives with Cardiovascular Disease (CVD). CVD is one of the main causes of death across the borough in the last 5 years and, before this programme commenced in October 2023, the Integrated Care Board had identified that BME individuals across Redbridge were twice as likely to present at A&E with a CVD condition than their white British counterparts[2]. While the reasons for this are complex and varied, we know that people who don’t or can’t access support quickly enough require greater intervention, resulting in worse outcomes.
The NHS Confederation model:
The NHS Confederation has developed a 5-step collaboration model for health inequality improvement as part of its commitment to support health systems meeting their statutory responsibilities by tackling particular health inequality challenges.
The model aligns with Core20PLUS5 and the Major Conditions Strategy by integrating the original NHS principles into a collective practice of service redesign, supporting improvement within health systems for populations experiencing inequality of access, experience and outcomes.
Through clinical leadership and community ownership, enabled by engaged commissioners, the model strengthens understanding of the critical challenges to be addressed and the co-development of sustainable solutions, ensuring that the service user and community voice is heard.
The model has been applied in Redbridge place to reduce health inequalities for BME individuals living with cardiovascular disease.
The Intervention:
Working in the newly established Redbridge Place Partnership with health system partners from across the ICB, Barking Havering and Redbridge University Hospital Trust, Redbridge community organisations and residents, Primary Care teams and Redbridge Council, a Health Inequality programme was developed to address the inequalities experienced by Black and Asian communities and improve outcomes for residents living with cardiovascular diseases.
The following three objectives were agreed:
- Ensure all individuals already known to primary care with CVD and on disease registers are consistently well controlled and supported.
- Engage with communities to understand existing barriers and challenges across access, experience, and outcomes.
- Using the insights gained, work with communities to co-design practical solutions for sustainable, long-lasting change (primary prevention).
Achievements to date:
As of June 2024, the project has:
- Facilitated collaboration across organisational boundaries and shared decision-making (including VCSE) through robust governance structure and programme management
- Identified patients not receiving optimum control and management of CVD – ICB and clinicians co-produced a practice support plan to ensure locally agreed CVD guidelines are consistently applied
- Used existing resources for better efficiency: upskilling the workforce and optimising use of technology for an improved model of care
- Connected Primary and secondary care clinicians to facilitate multidisciplinary management of patients’ interconnected CVD conditions through development of an integrated pathway
- Uncovered a range of challenges being experienced by the Black and Asian communities in relation to CVD, from communication, knowledge and understanding of the disease and associated risks; and barriers to access for support from existing services
- Co-designed innovative and sustainable solutions to improve the health and wellbeing of residents between public Health, the community and the ICB.
What our members say:
“The striking ethnic differences in cardiovascular disease (CVD) risk have long been acknowledged in primary care, where disease presentation may differ, challenging both diagnostic skills and therapeutic requirements. We recognize that addressing CVD inequalities in primary care at a time of primary care transformation can be challenging. However, through this partnership-initiated project, we are able to deliver culturally competent care through multidisciplinary team working at Practice, PCN, and Place level. This community-driven approach strengthened by data insights will deliver personalized care where it is most needed.
As we get ahead of the curve to lower CVD mortality in Redbridge, there is a renewed commitment towards empowering our diverse communities and promote equitable access to prevention and management strategies.”
Dr Shabana Ali
GP and Clinical Pathways lead for Long Term Conditions – Redbridge Place.
“NHS North East London’s focus on CVD ethnic inequalities is not only crucial for improving life expectancy for all, but it has significant economic impact, potentially reversing costs relating to CVD across both health and social care. At Redbridge Place, addressing inequalities is not linear but requires a multi-faceted approach involving various stakeholders including statutory groups, providers, community organisations, private organisations, and individuals. This programme is one example of how we are striving to deliver for patients, residents, carers: taking early steps to strengthen CVD end-to-end pathways and blur organisational boundaries, delivering care in the Right Place and by the Right People.”
Tracy Rubery
Director of Partnership, Impact and Delivery: Redbridge (Place Director)
NHS North East London
“The Trust’s purpose is to deliver care that we are proud of, and our patients are happy with, by listening to local residents to better understand their needs. We are delighted to co-sponsor this project with the NHS Confederation and system partners, working smarter with patients and partners to manage care in a better way that meets those needs, reduces health inequalities and reduces avoidable attendances in our hospitals. The focus this project brings will deliver results and create a different relationship with patients; the learning can also be applied to other conditions.”
Ann Hepworth
Director of Strategy and Partnerships
Barking, Havering & Redbridge University Hospitals NHS Trust
“This programme is tackling a number of key areas which traditional NHS systems have not systematically addressed, such as: clinical management of multimorbidity; a tailored approach to clinical and self-management; racial bias in health information and advice; and the value added from communities themselves. This programme will also powerfully demonstrate the importance of a Population Health Management approach to embed the learning from this work, shifting focus away from hospital care to primary and community services to reduce inequalities in health outcomes in a sustainable way.”
Sue Matthews
Public Health Consultant
London Borough of Redbridge
