NENC ICS Health Inequalities Summit

NENC ICS Health Inequalities Summit Reducing Health Inequalities in healthcare across the North East North Cumbria ICS

6th December 2021

Abstracts This e-book contains all case study abstracts received for the 2021 NENC ICS Health Inequalities Summit – they have been summarised to reduce length.

Please contact the authors if you require further information.

Table of contents Learning Disabilities and Autism ......................................................................... 4 Be Cancer Aware – a co-production project ...............................................................................................

Bridge Creative delivering Keeping People Connected...............................................................................

Cancer Screening Health Quality Checks by people with a learning disability ............................................

Keeping People Connected ........................................................................................................................

Learning Disabilities Annual Health Checks (AHCs) ...................................................................................

The Learning Disability Diamond Acute Care Pathways and E-Learning ....................................................

Mental Health .................................................................................................................... 7 Adult not brought to appointment ................................................................................................................

Healthy Happy Places ................................................................................................................................

NENC ICS Mental Health Programme review of offered financial support ..................................................

Parity of Esteem for Patients with severe mental illness in a forensic environment .....................................

Passport to my Health and Well-being: a co-produced solution to improve the experience of people living with a mental health condition and affected by cancer ................................................................................

Physical health checks for people with serious mental illness .....................................................................

Signpost NENC, creating an online hub of mental health and wellbeing resources for all across the NENC ...................................................................................................................................................................

Suicide and Self-Harm Resource Tins – improving access to information and resources project................

Trauma-informed Community of Action ......................................................................................................

Youth Mental Health First Aid .....................................................................................................................

Optimising Health Services……………………………………………………………………………..13 Addressing health inequalities through the Cancer workplan ......................................................................

DeApp ........................................................................................................................................................

Facts of Life for Children and Young People in the North East ...................................................................

Personalised care and support planning and health inequalities .................................................................

Poverty Proofing Health Settings Pilot ........................................................................................................

Reducing inequalities in maternity services ................................................................................................

STAR: South Tees Arts Project ..................................................................................................................

Tailoring lipid management interventions to reduce inequalities in cardiovascular risks and outcomes in deprived communities.................................................................................................................................

NENC Child Health and Wellbeing Network NHSE/I ...................................................................................

Population Health and Prevention…………………………………………………………..18 Alcohol Recovery Navigators......................................................................................................................

Better Health at Work Award: Primary Care Project....................................................................................

How a Population Health approach is helping tackle the Health Inequalities challenge ..............................

Improving the analytical capabilities to support the North Cumbria Population Health Management approach ....................................................................................................................................................

Integrated Community Rehabilitation "Rehub & Prehub" ............................................................................

NENC Deep End Network ..........................................................................................................................

Targeted Alcohol Identification and Brief Advice in Primary Care: A population health management approach to reducing alcohol harm.............................................................................................................

Treating Tobacco Dependency & Achieving Smokefree Vision by 2030 in NENC ICS ...............................

Digital Inclusion…………………………………………………………………………………22 Digital Care Homes ....................................................................................................................................

Reducing digital exclusion and inequalities in virtual outpatient services ....................................................

Silverline Memories Digital Inclusion for People with Dementia .................................................................

The COVID Oximetry @home (CO@h) ......................................................................................................

Understanding experiences of Digital Poverty across North Tyneside ........................................................

Our People……………………………………………………………………………………….25 An Introduction to the NHS – A BAME Initiative ..........................................................................................

Maximising the social and economic value of the NHS: Lessons from the Integrated COVID Hub North East Employment Outreach Programme ............................................................................................................

NENC ICS Mental Health Programme's Rapid Implementation of the Staff Wellbeing Hub ........................

Value Based Recruitment ...........................................................................................................................

Widening Participation ................................................................................................................................

Cross Cutting Themes…………………………………………………………………………28 Accessing GP services: community views in a deprived neighbourhood of Gateshead ..............................

Building the Trust with the Trust .................................................................................................................

Opportunities to develop health knowledge in relation to food using community assets ..............................

Place-based approach to improving health .................................................................................................

Care Point ..................................................................................................................................................

Celebrating pride and our LGBTQ+ community in secure services .............................................................

Embedding health inequalities considerations across clinical pathways and service reviews at an acute Foundation Trust ........................................................................................................................................

Establishing a Health Inequalities Programme Board to implement action to reduce inequalities in unmet need ...........................................................................................................................................................

Health Equity Assessment Tool ..................................................................................................................

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Holistic Support Programmes for Black and Minoritised Women Survivors .................................................

Learning from Ways to Wellness ................................................................................................................

Newcastle and Gateshead Social Impact Bond for people experiencing homelessness .............................

Reading Age...............................................................................................................................................

Reducing the health inequalities faced by substance users ........................................................................

Safe fasting messages at Ramadan ...........................................................................................................

Staying Steady ...........................................................................................................................................

The role of accessible health information in combating misinformation in ethnically diverse communities ...

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Learning Disabilities and Autism Be Cancer Aware – a co-production project Learning Disabilities and Autism Be Cancer Aware is a co-production project where 5 self-advocacy organisations from across the region came together to develop, deliver and evaluate a cancer awareness programme, delivered by and to people with a learning disability.

The training programme was developed by 5 self-advocacy organisations in 2018. Training was delivered throughout the region. Process and outcomes evaluation completed. In early 2020 an additional 3 groups trained to deliver Be Cancer Aware. During Covid we met online and delivered awareness messages using digital platforms to the learning disability community, including linking with Northern Cancer Alliance for their “Help us Help You” campaign and “reducing my cancer risk” campaign. Moving forward the teams are committed to delivering 5 training courses in the next year and supporting 2 campaigns.

Julie Tucker, North East and Cumbria Learning Disability Network, NHSE/I julie.tucker11@nhs.net

Presented at the HI Summit Conference on the 6/12/2021

Cancer Screening Health Quality Checks by people with a learning disability Learning Disabilities and Autism Skills for People and the North East and Cumbria Learning Disability Network aim to support breast and bowel cancer screening services by developing; a set of standards, a process, and tools for people with a learning disability to check how well breast and bowel screening services meet their needs using the health quality check process.

The breast screening quality check has been piloted at Newcastle Breast Screening and Gateshead Breast Screening programmes and the report shared; the Bowel Screening Hub quality check visit completed and report shared; the Bowel cancer screening quality check has been developed and is ready to pilot with North of Tyne Bowel Screening Programme.

Julie Tucker, North East and Cumbria Learning Disability Network, NHSE/I julie.tucker11@nhs.net

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Learning Disabilities Annual Health Checks (AHCs) Learning Disabilities and Autism Following the start of the pandemic where delivery of AHCs to those with a learning disability was significantly reduced, NGCCG has focused on the delivery of this agenda to subsequently integrate the voice of people with LD. The CCG achieved 77% uptake for patients on Learning Disabilities registers 2020/21, 82% in Gateshead and 74% in Newcastle. We continue to build on our progress throughout 21/22. More important than achieving targets is proactively providing care for people with additional needs, whose health risks and opportunities may otherwise be unrecognised. We feel we have achieved this and are ambitious to build on this success.

Claire Dovell, Planning & Performance Manager, NHS Newcastle Gateshead CCG claire.dovell@nhs.net

Keeping People Connected Learning Disabilities and Autism The Keeping People Connected project was co-designed and delivered by 9 voluntary & community sector organisations across Cumbria and the North East, in response to the pandemic. It aimed to help people with a learning disability or autism during this difficult time to: understand information from the Government; connect with others to avoid isolation and get the support needed for other things in their lives. During the initial 16 weeks the project ran for around 1600 people were supported. Much of this support was around anxiety, loneliness/isolation, and mental health concerns. The project evaluation report can be viewed here Judith Thompson, Network Manager, The North East & Cumbria Learning Disability Network: judith.thompson1@nhs.net Kellie Woodley, Regional Lead, Inclusion North: kellie.woodley@inclusionnorth.org Bridge Creative is a social enterprise based in Bishop Auckland and one of the 9 VCS delivery organisations for the Keeping People Connected project. It supported over 180 people across County Durham during the pandemic. The organisation employs people with learning disabilities, learning difficulties and autistic adults, and supports people to gain work experience so they can move on to finding a paid job.

The project supported people by phone, email, text and social media, including daily group video calls which allowed people to connect with friends safely from home.

Our long-standing links to people in our local communities meant we were best placed to develop and mobilise a rapid community response to address the issues highlighted by the pandemic, as they arose.

Ben Tinkler, Managing Director, Bridge Creative: bridgecreative@outlook.com 5

The Learning Disability Diamond Acute Care Pathways and E-Learning Learning Disabilities and Autism The North East and Cumbria Learning Disability Network co-ordinated the work which was led by our Learning Disability Acute Liaison Nurses from our Access to Acute (A2A) Network.

This was alongside input from people with a learning disability who discussed the care they would hope to receive when they come into hospital.

Development of Learning Disability Diamond Standard reasonably adjusted acute care pathways for: • planned admission • emergency admission • discharge Development of learning disability e-learning package for all staff clinical and non-clinical.

The training is underpinned by the Core Values and Principles of the pathway which include learning disability awareness, communication, reasonable adjustments, and Mental Capacity Act and Best Interest Decision Making. All trusts have now adopted the Acute Diamond Pathways and e-learning and are currently rolling out.

Julie Tucker, North East and Cumbria Learning Disability Network, NHSE/I julie.tucker11@nhs.net

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Mental Health Healthy Happy Places – From Healthy New Towns to Healthy Old Towns Mental Health This project seeks to outline the scope across the region for a greater understanding of the links between urban planning, design and mental health and wellbeing. Drawing on the legacy of previous work including the Darlington Healthy New Towns (HNT) NHS Pilot, and the learning that came from the experience, this project seeks to draw on the opportunities and barriers encountered in the challenge of transforming planning policy and practice to meet the current challenges of climate change and a just transition to net zero and widening economic and health equalities across the region. The Healthy Happy Places Programme is being led by the Academic Health Science Network for the North East and North Cumbria (AHSN NENC) on behalf of the mental health workstream of the NENC ICS. Timothy David Crawshaw, Planning and Development Consultant, Chair of Tees Valley Nature Partnership and Vice President of the Royal Town Planning Institute, Academic Health Science Network mail@crawshawurbandesign.com

NENC ICS Mental Health Programme review of offered financial support Mental Health Members of the ICS Mental Health Programme are working in collaboration with the Money & Pensions Service (MAPS), Rethink Mental Health and The Money and Mental Health Policy Institute. Evidence indicates that there is a significant link between financial stability and mental health and wellbeing. The NENC ICS agreed that the health inequalities experienced by people within the regional mental health system was a priority focus area and cross cutting issue within their mental health programme. A tool kit that includes a question framework for mental health practitioners has been developed to be used as part of the mental health assessment and care delivery. CNTW's Individual Placement Support service are piloting this questionnaire alongside other helpful resources provided by our partner organisations. Involve North East is carrying out the pilot and evaluation with IPS in Newcastle and Gateshead.

Vicky Donegan, Programme Manager, NECS – NENC ICS Mental Health Programme vicky.donegan@nhs.net

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Parity of Esteem for Patients with severe mental illness in a forensic environment Mental Health The aim of our parity of esteem work, is to ensure that those suffering from severe mental illness in secure in patient services have access to medical care, monitoring and the national screening programme that is equal to those without severe mental illness. We have partnered with our local acute trust, having regular discussions to allow smoother pathways for patients with high levels of anxiety and requiring large escorts to access acute services, or have treatment and investigations on site where possible. There was alongside this, a workstream providing education and support to our patients to encourage engagement with screening. A particular issue was cervical screening, as many of our female patients have suffered some kind of sexual abuse or trauma, they have been very resistant, understandably, to invasive screening. Following intensive work with patients, uptake has been much improved, and those requiring acute care do so with least restriction and most direct pathways.

Bernadette Johnson, Nurse Consultant Physical Health, Tees Esk and Wear Valleys NHS Foundation Trust bernadette.johnson5@nhs.net

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Passport to my Health and Well-being: A co-produced solution to improve the experience of people living with a mental health condition and affected by cancer Mental Health The NENC ICS - Mental Health supports the regional implementation of the co-produced Passport to my Health and Well-being in Mental Health, Cancer and Primary Care services.

The aims of the Passport are: a. To improve the experiences of people living with a mental health condition who are on a cancer pathway by: Providing space for people to record information about their health conditions, support networks and additional support needs, appointments, questions and concerns they may have and important information about their diagnosis and treatment. Providing people an opportunity to describe themselves when they are well. b. To improve the experiences of people living with a mental health condition who are supporting someone diagnosed with cancer by: Providing a tool to help them manage someone’s cancer pathway. c. To assist healthcare professionals supporting people on a cancer pathway by helping them: To gain greater understanding of the individual and their support needs. To support people to achieve the best possible outcomes of their treatment.

To share accurate information across the cancer pathway and other organisations / agencies involved in the individuals care and support.

Sarah Jane Ashcroft, Macmillan Mental Health Cancer Care Project Lead, Middlesbrough and Stockton Mind sarahjane.ashcroft@middlesbroughandstocktonmind.org.uk

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Physical health checks for people with serious mental illness Mental Health People with a serious mental illness have a reduced life expectancy of 15 – 20 years in comparison to the general population, and two thirds of premature deaths are due to a preventable illness. Annual physical health checks for people with serious mental illness should be an important part of their care plan to help identify early risk factors, however data shows that in many areas less than half of people with a serious mental illness have received all six physical health checks over the past year. The overall aim of the project is to increase the number of people with a serious mental illness who receive their physical health checks, reaching the national target of 60%, and recommend ways of best practice going forward. The first step towards achieving this is to understand the barriers experienced by people with a serious mental illness receiving these checks and to work with people with a serious mental illness to identify an initial strategy towards overcoming these barriers. All findings will be shared with GP surgeries across Tees Valley CCG and where possible GP surgeries will be supported to implement the recommended changes identified as being key to removing barriers for people with serious mental illness receiving their physical health checks Sinéad Murphy, Primary Care Network Development Lead, Middlesbrough and Stockton Mind sinead.murphy@middlesbroughandstocktonmind.org.uk

Signpost NENC, creating an online hub of mental health and wellbeing resources for all across the NENC Mental Health We worked alongside a social enterprise company, MediaSavvy that helps people with mental health issues back into work, to develop an accessible website that showcases mental health and wellbeing services and resources across the NENC. Our aim was to collate all the valuable and worthwhile wellbeing and mental health services and resources into one easy to use hub for everyone. Collaborating with many different groups, agencies and networks, Signpost NENC is a community hub with input from different partners and the voluntary sector, as well as key figures within marginalised groups such as the traveller community and those in prison. Usability and functionality of the site are essential, therefore the site is clear, concise and services are accessible through a variety of routes, dependent on user preferability, such as the search bar, map or dedicated pages based on locality or problem. We also worked closely with a sight loss charity to ensure that the site is compatible with screen readers, and the sight loss pages are easily accessible.

Holly Fillingham, CNTW NHS Foundation Trust holly.fillingham1@nhs.net

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Suicide and Self-Harm Resource Tins – improving access to information and resources project Mental Health The Suicide Prevention and Self-harm Resource Tins have been developed as part of our system wide project to improve access to mental health information for everyone. These tins contain a range of self-harm and suicide prevention self-help resources, including safety plans and information for young people and parents, as well as links to a range of digital resources, free training, and signposting to support organisations. Our vision was to create a resource, similar to First Aid kits, as a way of getting evidence based information to places with wide community access (such as libraries, schools, foodbanks, GP surgeries) so that vulnerable people would have easy access. We also wanted to create a focus point for starting conversations about suicide and mental health, to help raise awareness and understanding in the general population and help reduce stigma.

Jenny Hicken, Network Delivery Lead, North East and North Cumbria Clinical Networks jennifer.hicken@nhs.net

Trauma-informed Community of Action Mental Health The Trauma-informed Community of Action (TiCA) emerged from the shared interest and advocacy of a core group of practitioners who provide care for people that have experienced trauma and/or who have themselves had direct or indirect experience of trauma in their own lives. TiCA has been established as a national resource for England funded by NHSE and hosted by the Northern England Mental Health Clinical Network. It has been established as England’s only open access resource consisting of documents forums and monthly webinars.

Angela Kennedy, Clinical Lead for national community of action for trauma informed care, NECN angela.kennedy@cntw.nhs.uk

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Youth Mental Health First Aid Optimising Health Services Outcomes of the Youth Mental Health First Aid project (across the Child Health and Wellbeing Network) include the qualification of the Network Development Manager as Youth Mental Health First Aid Instructor, 74 Network Members from a broad range of disciplines qualified as Youth Mental Health First Aiders with others booked in (demand for the training has been high). Participants, on average have seen their knowledge and confidence grow 40%, feedback overall was positive with 95% of respondents likely to recommend it to colleagues. Impacts of the programme on the local CYP population have included staff and professionals around them are more skilled and confident to recognise needs and signs of mental health issues, offer first aid and guide them towards the support they need. In doing so this supports their recovery and prevents mental health challenges from getting worse.

Emilia Soulsby, Network Development Manager, NENC Child Health and Wellbeing Network NHSE/I emilia.soulsby@nhs.net

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Optimising Health Services Addressing health inequalities through the Cancer workplan Optimising Health Services The Northern Cancer Alliance (NCA) cancer workstream of the Northeast and North Cumbria ICS considers health inequalities and the impact on cancer outcomes working across the cancer pathway, in primary and secondary care and working in partnership with voluntary sector organisations in the communities most affected by the inequalities.. A range of approaches have been used to ensure that at all cancer projects (current and future) include a focus on addressing health inequalities.

Sheron Robson, Programme Manager, Northern Cancer Alliance sheron.robson1@nhs.net

DeApp Optimising Health Services The Children and Young People’s Diabetes Networks were established in 2013 aiming to reduce inequalities in children and young people’s diabetes care across England and Wales. All children and young people with diabetes use device/s to manage their condition; blood glucose monitors, insulin pumps, continuous glucose monitors and flash glucose monitors are all commonplace. In order to optimise the benefits users download their data from the devices to share with their healthcare team and help them self-manage. Without the technology required to download, the gap in access to an equal level of support and care is widening, laptops, mobile phones and Wi-Fi are essential tools for someone living with diabetes and being able to provide these to low income families is a growing problem.

Together with NENC CHWN, The Health Foundation, Middlesbrough and Stockton MIND and T1Kidz project in Durham we have supported families across the region to acquire refurbished equipment and/or borrowed new equipment to ensure their level of care is not affected during the pandemic (and onwards). As the schemes grow, availability of equipment will increase across the region and become readily available for healthcare teams to access for families in need.

Jenny Foster, Project Lead, CYP NENC Diabetes Network Manager, NHSE/I jenny.foster5@nhs.net Louise Dauncey, Network Development Manager, NENC Child Health and Wellbeing Network NHSE/I louise.dauncey1@nhs.net

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Facts of Life for Children and Young People in the North East Optimising Health Services North East Quality Observatory Service were commissioned by CHWN to prepare a report which pulls together available data to provide a snapshot of children’s, young people’s and maternal health in the North East and North Cumbria (NENC). The resultant report provides a fantastic resource for agencies across the system which summarises the current position and trend over time for a wide range of indicators relating to pregnancy and CYP aged from birth to 25 years, including risk factors, outcomes, spend and healthcare usage which all combine to give us a view of how things vary across the region and compare nationally.

The aim of this report is to provide a meaningful baseline upon which impacts and developments can be measured against and will reduce the time spent searching for data, support with a regional picture and demonstrate the impact of COVID allowing an increased awareness of CYP needs across the region. Gaps and priority areas are identified and provides a single source of data to support integrated working.

Paul Collingwood, Project Lead, Senior Information Analyst, NEQOS Cumbria, Tyne and Wear NHS FT: paul.collingwood@cntw.nhs.net Louise Dauncey, Network Development Manager, NENC Child Health and Wellbeing Network NHSE/I: louise.dauncey1@nhs.net

Personalised care and support planning and health inequalities Optimising Health Services Year of Care Partnerships has a well-established method of supporting practice teams to implement personalised approaches to long term condition care. This involves putting in place a single care and support planning (CSP) process for people living with single and multiple long-term conditions, frailty, increasing physical/mental health or social complexity.

The aim of CSP is to increase people’s involvement in their care and ensure that identified need informs the provision of services locally. We aim to create a broader awareness of the approach and its many benefits sharing our accumulated learning to contribute to building a post-COVID health and social care economy that has individual and population engagement at its centre. Preparation and information sharing as part of the CSP process clarifies and promotes peoples understanding, supports their agency and makes for more patient-led conversations. CSP promotes a person-centred enabling and empathic consultation and evidence suggests that empathy and enablement have been harder to achieve in low income groups. ‘More than Medicine’ is a key outcome of CSP, identifying people’s needs and ensuring commissioning of community resource to meet them.

Lindsay Oliver, National Director, Year of Care Partnerships: Lindsay.oliver@northumbria-healthcare.nhs.uk 14

Poverty Proofing Health Settings Pilot Optimising Health Services Together with the NHS Charities Together Fund, the Child Health and Wellbeing Network, the Diabetes Network, Gateshead NHS FT and Children North East we have been able to develop a pilot programme for Poverty Proofing© health settings. The project is grounded on the learning from the education settings work and wider Poverty Proofing delivery undertaken by Children North East over the last 5 years and will be influenced by the voice of families who are part of the Poverty Proofing© of Gateshead Paediatric Diabetes service.

The longer-term work will include the network working alongside Children North East in evaluating impact on children, Young People and families as well as developing some principles for wider implementation across health systems and services. This work is in its infancy but aims to support CYP and families access the services that they need at the time when they need them to effectively manage conditions and improve health and wellbeing.

Luke Bramhall, Project Lead, Poverty Proofing and Participation Manager, Children North East luke.bramhall@children-ne.org.uk Louise Dauncey, Network Development Manager, NENC Child Health and Wellbeing Network NHSE/I louise.dauncey1@nhs.net

Reducing inequalities in maternity services Optimising Health Services Women from ethnic backgrounds are disadvantaged in maternity services, with Black women 4 times more likely to die and Asian women twice as likely to die as White British women (MBRRACE, 2020). All women from non-white British groups will be offered an additional antenatal appointment (22 weeks) with their Community Midwife to assess their individual obstetric risk factors, and any social, cultural, and religious preferences which they would like considered. A face to face interpreter will be offered as standard practice at this appointment. Specific risks will be addressed, and an individualised plan of care agreed on in partnership with the woman. This project will be evaluated by our research and development team both quantitatively and qualitatively.

Carla Anderson, Public Health Midwife, NHFT Leila Swarbrick, Ward Manager, NHFT Carla.Anderson@northumbria-healthcare.nhs.uk

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STAR: South Tees Arts Project Optimising Health Services TINArts are working with NENC CHWN and multiple key regional partners to deliver an innovative locality-based dance and health project in South Tees. The project adopts a school and family-based approach, applying a social-ecological model to maximise outcomes for children, schools, and families.

The project includes active research that aims to understand better the benefits of taking part in dance and wider arts activities and how these support participants through creative and engaging ways to express themselves and develop self-awareness, identity, social and emotional learning skills. The three universities involved leading the research collectively offer a wealth of experience evaluating health and social care interventions and addressing health inequalities.

Martin Wilson, Project Lead, Executive Director, TIN Arts martin@tinarts.co.uk

Tailoring lipid management interventions to reduce inequalities in cardiovascular risks and outcomes in deprived communities Optimising Health Services This project aims to develop a tailored intervention aiming to optimise lipid management in primary care settings to help reduce inequalities in CVD risks and outcomes in deprived communities.

Objectives: 1) Synthesise the evidence on interventions for deprived populations with CVDs or those with high risks and understand the outcomes associated with these interventions 2) Establish the characteristics of current lipid management in primary care settings in deprived areas and identify clinical gaps and needs 3) Investigate the implementation and delivery of current interventions for patients with CVDs and those with high risks 4) Tailor and optimise the national prevention programme to suit context and needs of deprived communities.

Dr Yu Fu, Senior Research Fellow, Newcastle University yu.fu@newcastle.ac.uk

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NENC Child Health and Wellbeing Network NHSE/I Optimising Health Services Zone West is a social prescribing programme for children that has been operating in the West End of Newcastle for 2 years, using Link Workers to support vulnerable children to meet developmental goals. The programme has a blended approach to funding combining grant funding sources and is delivered through a collaboration between North East Wellbeing and Ways to Wellness.

Work is underway to replicate this project in the Tees Valley area and this is part of the work supported by the CHWN. The programme in Tees will be delivered across a number of schools and GP practices. Embedding Zone West will involve conversations with key stakeholders to identify cohorts of children who experience inequity of access to health (and other) services, for a variety of reasons, including socio-economic determinants. Link Workers will support children to identify developmental goals and will work toward these through engagement with community resources and health services, and supporting the child in the school and home. This integrated support and early intervention is an enabler in improving long term life chances and outcomes for the Young People as well as supporting to improve overall health and wellbeing.

Toby Quibell, Project Lead, Director, North East Wellbeing director@northeastwellbeing.co.uk

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Population Health & Prevention Alcohol Recovery Navigators

Population Health & Prevention The South Tyneside and Sunderland Alcohol Care Team steering group identified a need for enhanced support and a degree of assertive outreach for patients who are typically described as complex. These patients come into contact with a range of services across the system, regularly including the justice system, but often fail to engage. Local services report that this cohort of patients often have mental health issues, lead chaotic lifestyles and their access, experience and outcomes are substantially worse than others with similar level of alcohol dependence. This group is disproportionately made up of patients from more deprived communities. Building on local evaluations from other areas two ‘navigator’ roles were developed which will aim to bridge some of the potential gaps in between services and improve outcomes. The posts are employed by the two community substance misuse providers and have honorary contracts with STSFT as well as strong links with the third sector and other key stakeholders. The Alcohol Care Team have reported that the support provided so far by the navigators, who all have experience either volunteering/working with this cohort of patients or have personal lived experience, has been invaluable.

Ryan Swiers, Consultant in Public Health, STSFT ryan.swiers@nhs.net

Better Health at Work Award: Primary Care Project Population Health & Prevention In recognition of the importance of a focus on the health and wellbeing of the workforce, the Prevention Board secured funding from the NENC ICS Workforce Transformation Board for 1.6wte posts for dedicated workplace health practitioners to add capacity to the established Better Health at Work Award (BHAWA) programme. The project started in January 2021 in particularly challenging circumstances, when services were under severe pressure, but when staff wellbeing was a major concern. A huge amount of engagement has taken place, including with CCGs, Practice Managers, Healthwatch, Directors of Public Health, Local Pharmacy Committees and the ‘Deep End’ Programme Manager – to reach GP practices in the most socio-economically deprived areas. The delivery model had to adapt during COVID-19 and became a virtual offer of training and support and use of an e-portal developed by the TUC. An additional output has been the development of resources that can be used by the whole BHAWA programme, including a planned resource for Social Care organisations. The project is currently funded until end May 2022 and ongoing funding is being sought to further upscale the intervention across the NENC ICS footprint.

Denise Orange, Health & Wellbeing Programme Manager, OHID denise.orange@dhsc.gov.uk 18

How a Population Health approach is helping tackle the Health Inequalities challenge Population Health & Prevention The aim of the population health management (PHM) workstream across the NENC is to put PHM at the heart of everything that we do as an ICS, with Population Health Analytics being a key enabler in the public health cycle. Examples include: •

NUTH Diabetes Project - The aim is of the project is to understand the current scale of patients with uncontrolled diabetes awaiting surgery and plan for future interventions, and to do this by linking the current list of patients awaiting elective surgery at Newcastle upon Tyne NHS trust to their GP records.

•

Waiting Well - This model uses a population health management approach to identify and segment the patient groups by vulnerability (clinical and social) and ensure targeted and prioritised support is provided to those groups of people to ensure equity and not just equality of offer.

•

A dashboard has been developed within their RAIDR BI tool which links primary care and waiting list datasets to enable stratification/segmentation of the P4 patients. This includes the use of Population view of IMD and Ethnicity to ensure the effective targeting of interventions to more vulnerable and disadvantaged groups and will be provided at scale across the ICS from the learning from the NUTH Diabetes project.

Professor Edward Kunonga, Public Health Consultant, CDDFT edward.kunonga1@nhs.net

Improving the analytical capabilities to support the North Cumbria Population Health Management approach Population Health & Prevention This project was funded between September 2019 and November 2020 as a Health Foundation Applied Analytics funded project and was run by North Cumbria Integrated Care NHS Trust, in partnership with Cumbria County Council, Cumbria Partnership Foundation Trust, and Cumbria Learning and Improvement Collaborative (CLIC). The aim was to help clinicians and managers in North Cumbria use the wealth of available health data to improve patient care in the region. A comprehensive training and support programme was developed and delivered on how to access and use population health intelligence to deliver better outcomes for patients and make a difference to communities.

Tommy Davies, Head of Strategy and Planning, North Cumbria integrated Care Trust tommy.davies@ncic.nhs.uk

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Integrated Community Rehabilitation "Rehub & Prehub" Population Health & Prevention The NHS Long Term Plan makes several commitments to improve availability of personalised, community-based support and rehabilitation for people to manage long term conditions. The CCG long term conditions team and South Tyneside and Sunderland FT rehab teams believe the rehab hub "rehub" will provide our patients with access to professional support, advice and intervention at a level they need in order to achieve their personal rehabilitation goals, maximise their independence and exercise control over their lives. The rehub will achieve this by focusing on the impact that the health condition has on the person’s life, rather than focusing just on their diagnosis. A person-centred approach is fundamental to ensure that rehabilitation is as an active and enabling process for each individual. It ensures that support is built around a person’s own circumstances and responds to the diversity of needs that will be present. The key objectives of the integrated rehabilitation hub will be to improve access, uptake, and completion of long-term conditions rehabilitation, to support patient self-management and to reduce disease burden to the patient and the system.

Simone Rowlands, Cardiology Nurse Practitioner, South Tyneside, and Sunderland Foundation Trust simone.rowlands@nhs.net

NENC Deep End Network Population Health & Prevention Deep End GP networks are formed of primary care practitioners in areas of high blanket socioeconomic deprivation with a common goal to mitigate health inequalities and champion the cause of primary care. The NENC network priorities fall into 4 key areas Workforce, Education, Advocacy and Research. The advocacy work has produced some interesting data suggesting that the pattern of healthcare utilisation is driven by the characteristics of patients, rather than by practices care pathways or services. This data supports the network in advocating for a different approach in addressing health inequalities for the Deep End patients including the potential for additional support and resource allocation for equity to be achieved. Network pilots currently include projects on psychology input into practices, GP fellowship focused on deprivation and reviewing opioid and gabapentin prescribing.

Donna Bradbury, Commissioning Delivery Manager, NECS donnabradbury@nhs.net

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Targeted Alcohol Identification and Brief Advice in Primary Care: A population health management approach to reducing alcohol harm Population Health & Prevention A process has been developed and implemented using RAIDR data to identify PCN patient cohorts with priority conditions where there are low levels of alcohol consumption recorded.

Objectives: 1. Use RAIDR to identify patient cohort/s with priority alcohol related health conditions and low rates of alcohol IBA 2. Support PCNs to develop effective systems to implement targeted IBA to identified cohorts 3. Evaluate the effectiveness of this approach Sarah Hulse, Alcohol Strategic Manager, North East & North Cumbria ICS sarah.hulse1@nhs.net

Treating Tobacco Dependency & Achieving Smokefree Vision by 2030 in NENC ICS Population Health & Prevention The ICS Smokefree NHS Taskforce has developed a collaborative programme to oversee establishment of Acute Tobacco Dependency Services (ATDS) across maternity, acute, and mental health services (as per NHS Long term Plan). The programme benefits from regional wide tobacco control, a place-based approach, national advocacy, and connections to research consortia and government advisory groups. Regional evidencebased partnership approaches have halved adult smoking prevalence since 2005 (29% 15.3% 2021) and Smoking at Time of Delivery fell from 21% (2010/11) to 13% (2020/21), narrowing the gap to England.

Rachel McIlvenna, Smokefree NHS Strategic Manager, NENC ICS rachel.mcilvenna@nhs.net

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Digital Inclusion Digital Care Homes Digital Inclusion Aims to empower care home staff with digital tools and skills to enable the ability to carry out routine observations and refer electronically to clinical teams, with the overall aim of reducing digital inequalities within care homes to improve patient care and safety. Care home staff will continue to be provided with access the HCDCH solution and the necessary tablet devices, kit and be supported with training to bridge any skills gaps that exist.

From the outset, various benefits have been achieved from the programme (1) Reduction in time to make referrals, enabling care home staff to spend more time providing care to residents (2) Referrals made earlier in the day enabling improved case management by nursing teams (3) Better quality of referrals.

Catherine McShane, Clinical Lead, Health Call robin.blythe@nhs.net

Reducing digital exclusion and inequalities in virtual outpatient services Digital Inclusion NHCT Public Health Team has worked with Northumberland County Council and North Tyneside Council to support eight community settings to establish themselves as community hubs. The aim of the hubs is to improve health outcomes for local populations by reducing inequalities in digital access, and support people who do not have the means or confidence to access virtual outpatient appointments independently. The Ashington hub have supported 70 virtual appointments since the start of 2021 and also provided further support with other issues impacting on emotional and financial wellbeing. Further settings have expressed interest in offering support with virtual outpatient appointments and we are focussing on providing the service in areas with high non-attendance rates for outpatient appointments.

Jill Harland, Consultant in Public Health, Northumbria Health Care NHS Foundation Trust jill.harland2@northumbria-healthcare.nhs.uk

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Silverline Memories Digital Inclusion for People with Dementia Digital Inclusion To continue to fulfil our charitable aims and objectives during the Covid-19 Pandemic and beyond. Our purpose is to provide social opportunities, advocacy services and wellbeing support to families affected by Dementia in the local community, and prior to the Pandemic all our provision was delivered face to face.

Silverline Memories undertook a complete digital transformation of all services and service provision. A recent evaluation has highlighted the success of our Pandemic response, with 75% of our users saying they would like the online provision to continue alongside face to face activities in the future. We are now looking towards a hybrid model of service delivery.

Our work has been recognised nationally and we have been named in the #DL100 list for 2021 and have been shortlisted for the Craig Macdonald Memorial Prize for our work in closing the digital divide in the local community.

Sandra Coulter, Chief Executive Officer, Silverline Memories sandra@silverlinememories.com

The COVID Oximetry @home (CO@h) Digital Inclusion The COVID Oximetry @home (CO@h) service delivered by NHS Tees Valley CCG as one of three national pilot sites for the NHS, has mobilised rapid adoption of an innovative programme, digitally enabling COVID patients at risk of silent hypoxia to self-monitor their condition from home, using a Pulse Oximeter device and app with continuous monitoring from nursing staff, improving safety, with early intervention for better outcome. In addition, a ‘virtual ward’ system enabled hospitalised COVID patients to be discharged early to selfmonitor from home with ongoing care and support from respiratory nurses, again improving safety and releasing hospital beds.

Tony Roberts, Patient Safety Lead, Academic Health Science Network - North East and North Cumbria, (AHSN NENC) / South Tees NHS FT t.roberts@nhs.net

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Understanding experiences of Digital Poverty across North Tyneside Digital Inclusion Covid-19 has had an unprecedented societal impact, with many turning to technology to remain connected. Inequality surrounding digital use is two-fold; those suffering inequalities are most likely to experience digital exclusion, and as a result of digital exclusion, are in turn likely to experience heighted inequalities.

This research commissioned by NTCCG in collaboration with Northumbria and Newcastle universities aims to provide an in-depth understanding of digital poverty across North Tyneside by 1) identifying reasons for non-access to technology 2) understand facilitators or barriers to using technology and 3) map solutions to improving digital access / digital skills which will inform the digital strategy for North Tyneside.

Holly De Luca, Improvement and Development Officer, North Tyneside CCG holly.deluca1@nhs.net

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Our People An Introduction to the NHS – A BAME Initiative Our People This is a multi-agency piece of work that was seeking to address inequalities in mental health by utilising interested local community groups to develop the BAME workforce within the TEWV Inpatient areas. Tees Mental Health Services for Older People (MHSOP) originally started working with Shazia Noor and her company NurFitness back in 2013/14.

Our trust data previously demonstrated that this community group very rarely accessed our memory services and as a result people where not getting the help and support required.

The plan was to develop a 5 week course that could be delivered jointly by TEWV, Shazia Noor and Middlesbrough community learning services. The overall aim was for the Asian ladies to partake in the course, completing all 5 weeks and then become a volunteer for our inpatient unit, with a view to them becoming a paid member of staff through the temporary staffing team.

The reason we wanted to do this is because we saw it as a huge opportunity to change the staffing demographics within older people’s services, ensuring that it is reflective of the communities that we serve. This in turn would help us to break down the barriers about mental ill health, spreading the word within the community that mental health services are accessible to everyone.

Allison Cook, Locality Manager, Tees Esk Wear Valley FT NHS allisoncook1@nhs.net

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Maximising the social and economic value of the NHS: Lessons from the Integrated COVID Hub North East Employment Outreach Programme Our People As part of our region's COVID-19 pandemic response, Newcastle Hospitals Trust (NUTH) and Newcastle City Council (NCC) established the Integrated COVID Hub North East (ICHNE) to expand COVID testing capacity and collect and use data to develop the science around COVID-19. Built into the ICHNE model is a focus on maximising local social and economic value, with a key aspect being the creation of up to 1000 new entry-level NHS jobs with a diverse staffing model focused on working with local authorities and the voluntary, community and social enterprise sectors on proactive recruitment from disadvantaged communities. This study aims to assess the impact of providing high-quality NHS jobs, which pay living wage rates and provide training, support, skills development, qualifications and career opportunities, on the health and well-being, including any financial and social benefits, of people from disadvantaged communities. Preliminary findings indicate that attempts to diversify the ICHNE workforce have been largely successful.

Valuable new partnerships and ways of working have been developed that will be used to continue to increase the diversity of NHS staff in our region.

Jayne Jeffries, Research Associate, Newcastle University, Population Health Sciences Institute jayne.jeffries@ncl.ac.uk

NENC ICS Mental Health Programme's Rapid Implementation of the Staff Wellbeing Hub

Our People NHSE funded the set up and delivery of a North East and North Cumbria infrastructure for staff wellbeing. The Staff Wellbeing Hub was set up by the NENC ICS, using secondments to rapidly deploy staff with the range of skills needed and a wide range of support offers.

There is evidence to suggest that particular staff groups may be disproportionately affected

by Covid-19 and are particularly vulnerable to the effects of the pandemic. One in five NHS staff come from BAME backgrounds, a population which has been particularly adversely affected by the Covid-19 pandemic and this will have placed additional stress on the workforce, with many having been exposed to the virus or experiencing bereavement as a result of the illness. The Hub does not replace other services. Instead, the Hub helps staff to navigate the offers and find what is best for them in a confidential and expert way.

Vicky Donegan, Programme Manager, NECS – NENC ICS Mental Health Programme vicky.donegan@nhs.net

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Value Based Recruitment

Our People Skills for Care over the past five years have been working with social care providers to encourage the use of value-based recruitment as a tool in recruiting the right workforce to meet the organisations and service users’ needs. Employers were most positive about the approach enabling them to identify attitudes and attributes which they believed could not be taught or learnt. Value based interviewing by reducing reliance on agency staff, reducing vacancies, reducing staff turnover lead to more stable and reliable staff teams which offered greater support to team colleagues and in turn provided greater consistency of care and support; thereby reducing health inequalities for those people who need care and support.

Peter Northrop and Wendy Adams, Locality Managers at Skills for Care peter.northrop@skillsforcare.org.uk & wendy.adams@skillsforcare.org.uk

Widening Participation

Our People Widening Participation (WP) is a government strategy to address systemic inequalities of participation in both education and employment. Areas of focus include young people, individuals from lower income families, people with disabilities, people from a Black, Asian and minority ethnic heritage, people facing redundancy and people with a criminal record.

The WP strategy has direct links with the key priorities for the North East North Cumbria ICS both in terms of workforce and health inequalities. It is one of a number of practical interventions to ensure that we address systemic barriers and ensure that our staff population reflects our local population and the people who we provide care for.

It is our aim to agree a sustainable, meaningful strategy to better support those who are not successful for opportunities but who may benefit from support available to be successful on a subsequent occasion. Working together we will better engage with our population and address systemic barriers which may prevent them being able to achieve and succeed in a health and social care setting.

Sarah Kilner, Workforce Lead, NENC ICS & North ICP sarah.kilner1@nhs.net

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Cross Cutting Themes Accessing GP services: community views in a deprived neighbourhood of Gateshead Cross Cutting Themes The Gateshead Outer West PCN includes the communities of Chopwell, Rowlands Gill and Blaydon: areas that are within the 20% most deprived areas in England, according to the Index of Multiple Deprivation. Between 2019 and 2020, NGCCG undertook research to establish how these communities accessed their local GP services. We also asked the communities how they would prefer to access local GP services. The findings and recommendations were collated into a report: " Exploring patients views of using digital solutions in GP practices". 244 patients shared their views alongside 13 stakeholder organisations who work with BAME, Carers, Children and Young People, Disabled People, Families, LGBTQ+ People, Older People, People requiring support around drugs and alcohol and people requiring support around emotional wellbeing.

Sameena Hassan, Clinical Director, Gateshead Outer West PCN, Newcastle Gateshead CCG sameenahassan@nhs.net

Building the Trust with the Trust Cross Cutting Themes The Bright Charity is working in partnership with the Being-Women Community in Ashington (A Charity focused upon supporting diversity, inclusion, and education). It was decided to set up a focus group with the support of group members. Minority groups can experience barriers to accessing health and care services and we were keen to reach out and hear about their experiences, issues, and ideas to inform the way we communicate and deliver services and build relationships.

Participants shared their views on issues with healthcare services, which included language barriers and length of time for appointments, they also shared their experiences of Covid-19 Testing, GP Appointments, the ambulance service, and Outpatients. This group is there to give the members a voice so they can discuss any issues/concerns they have when using their local NHS service. We are planning some sessions focused upon confidence building with the group. The group have also commented upon the Religion, Belief and Culture Guide for staff. The group decided to call themselves: Building Trust with the Trust Lynn McCormack, Operational Services Manager for Volunteering, Northumbria Healthcare NHS Foundation Trust: lynn.mccormack@northumbria-healthcare.nhs.uk Brenda Longstaff, Head of Bright Charity 28

Opportunities to develop health knowledge in relation to food using community assets Cross Cutting Themes This Call for Projects aims to encourage agencies to work together to build on community assets which support the healthy weight agenda, to build confidence and motivation in relation to healthy weight and explore opportunities to develop knowledge and skills in relation to food, cooking, growing and physical activity. In Sunderland, we have adopted a whole systems approach to Healthy Weight, reducing child and adult obesity is a key action within the Healthy City Plan, the Healthy city Implementation Plan and in our response to the Sunderland COVID-19 Health Inequalities Strategy - Sunderland City Council. The whole systems approach will be key to improving access to healthy food options, increasing use of greenspace and community assets and reducing health inequalities associated with the maintaining a healthy weight agenda by contributing to improving the social determinants of health and strengthening resilient communities and services. As furlough comes to an end and unemployment continues to be a concern, evidence highlights the detrimental effect on health, including distress, anxiety, depression, sedentary and risktaking behaviours, as well as sustained access to food that is nutritious.

Wendy Mitchell, Public Health Lead, Sunderland City Council wendy.mitchell@sunderland.gov.uk

Place-based approach to improving health Cross Cutting Themes Aims to strengthen a place-based approach to improving the health of the most disadvantaged communities and enable projects which aim to build on community assets to support good health and independence, improving insight into our most at risk communities shaping the planning of services to meet local needs.

Objectives: 1. Maximise the use of data, intelligence, and evidence to systematically understand the impact and consequences of Covid19 on health inequalities.

2. To strengthen a place-based approach to improving the health of the most disadvantaged communities.

3. To build on community assets to support good health and independence, recognising individual and community strengths that can be built upon.

Wendy Mitchell, Public Health Lead, Sunderland City Council wendy.mitchell@sunderland.gov.uk

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Care Point Cross Cutting Themes Our aim is to address frailty, health, and wellbeing in older people, promote independence and help patients remain in their own homes for longer. We hope to reduce social isolation by linking patients to our and other partner community activities whilst we set appropriate short-term goals and work together with the patient until they are met. We educate patients as well as ourselves and deliver high quality, holistic care, tailored to patients’ needs and work with our patients and their families to avoid the need for an unnecessary trip to the hospital.

Our Vision A world where everyone enjoys later life Our Mission To help people make more of life Our Values Caring, Empowering, Inclusive, Influential, Optimistic, Responsive, Realistic, Respectful Yvonne Probert, Head of Charity Services, Age UK North Tyneside yvonne.probert@ageuknorthtyneside.org.uk

Celebrating pride and our LGBTQ+ community in secure services Cross Cutting Themes At Ridgeway, Roseberry Park hospital an LGBTQ+ group has been set up fortnightly, which is an opportunity for people from the community and its allies to meet to discuss the issues closest to them and offer peer support. The group has quickly become one of the most attended groups we have at Ridgeway. The group has links with community organisation Hart Gables who provide resources, support, and a community link for those who are discharged and wish to continue to benefit from the support these links can provide.

Feedback from service users has been overwhelmingly positive with some stating they have never felt so accepted and supported.

Nichola Dunn, Senior Forensic Recovery Lead, Tees Esk and Wear Valley NHS Trust nichola.dunn@nhs.net

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Embedding health inequalities considerations across clinical pathways and service reviews at an acute Foundation Trust Cross Cutting Themes CDDFT has an ambitious programme to embed health inequalities. The trust has been working with a range of partners on the following key programmes: •

Transforming outpatient services – using data analysis to understand inequalities and to identify areas for further work across different clinical pathways

•

County Durham and Darlington Integrated Diabetes review – taking forward recommendations

•

RSV and acute respiratory infections – applying an inequalities lens

Professor Edward Kunonga, Public Health Consultant, CDDFT Morven Smith, Inequalities Executive Lead, CDDFT edward.kunonga1@nhs.net

Establishing a Health Inequalities Programme Board to implement action to reduce inequalities in unmet need Cross Cutting Themes The Northumbria Healthcare NHS Foundation Trust Health Inequalities Programme Board (HIPB) was established in July 2021 with the aim of reducing inequalities in health and the drivers of health across the patient population. Initial objectives: 1. To transparently, systematically, and objectively quantify, characterise and report on inequalities in the Trust’s population’s health according to access, outcomes, experience, and drivers of health 2. To bring together all existing initiatives regarding health inequalities and to identify, enable and support priority areas for interventions 3. To work with local partners to drive coordinated approaches to reducing health inequalities including through development of data-driven collaborative approaches Initial work initial priority areas have been identified as smoking, waiting lists, lung cancer and staff health and wellbeing.

Jonathan Pearson-Stuttard, Chair of the Health Inequalities Programme Board, NHFT Jonathan.Pearson-Stuttard@northumbria-healthcare.nhs.uk Co-authors: Chris Wilcockson, Alistair Blair, Jill Harland

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Health Equity Assessment Tool Cross Cutting Themes The Trust Public Health Consultant developed a revised version of the PHE Health Equity Assessment Tool (HEAT) which, following engagement with key staff groups and piloting, was adopted into the business case template. Training has also been provided to support its implementation. To support this work STSFT have improved their data quality in relation to ethnicity and have added indices of multiple deprivation (IMD) data to all patient records which allows services to consider access, outputs, and outcomes in relation to equity. The process has been used to challenge and improve business cases and there is an expectation that when approved cases are reviewed (typically at 12 months) progress against stated ambitions can be assessed. Furthermore the process has helped ensure discussions around health inequalities happen at various levels of the Trust, in relation to a wide range of activity, on a regular basis. Examples of progress on health inequalities identified at review will be shared via the Trust health inequalities group.

Ryan Swiers, Consultant in Public Health, STSFT ryan.swiers@nhs.net

Holistic Support Programmes for Black and Minoritised Women Survivors – Thrive, Ma Simba & Young Women’s Network Cross Cutting Themes Women empowered to achieve their full potential free from inequality, discrimination, violence, and abuse is at the heart of our work. Tackling a range of barriers to fulfilling their potential, we work with women in relation to VAWG, Capacity Building and Strategic Advocacy by providing: front line advocacy, information and advice; employability support resources; training; social/recreational activities and events; accommodation; counselling and therapeutic support. Through facilitated emerging support groups for survivors of abuse, mothers and young women peer support spaces, learning and development as well as social action projects, we aim to share our findings of the last 18 months of working with women engaged with these programmes, focussing on heightened disadvantages so that we can all learn from women’s lived experience of health poverty.

Kainat Javed, Training and Wellbeing Services Manager, The Angelou Centre kainat@angelou-centre.org.uk

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Learning from Ways to Wellness Cross Cutting Themes Ways to Wellness, launched in April 2015, was set up with the aim of delivering a social prescribing service to people aged 40-74 with defined long term physical conditions across 18 relatively disadvantaged general practices in West Newcastle. The objectives within the outcomes contract were improvements in the quality of life on the Triangle Wellbeing Star and savings in secondary care compared with a matched cohort. During the first six years the service received 7,700 referrals. 5,800 engaged with the service. 86% of clients improved their wellbeing and secondary care costs per patients were 27% lower. The Newcastle University NIHR evaluation of patients of the service with Type 2 Diabetes has also demonstrated a small but statistically significant improvement in HbAic. Learning from the project includes the benefits of a rigorous and targeted place-based population health management approach to link worker social prescribing, the importance of longterm contracts in demonstrating benefits and the important role of the VCSE in the effective employment and management of link workers. The model has clear benefits and the ICS should actively explore how it can be best spread while taking account of different local contexts and the need for local ownership across the ICS footprint. The full six year report is available at https://waystowellness.org.uk/shared-learning-consultancy/ways-towellness-the-first-six-years Professor Chris Drinkwater, Chair of the Ways to Wellness Foundation chris.drinkwater@gofo2.co.uk Newcastle University researchers have conducted a number of studies into 'Ways to Wellness', The studies aimed to explore patient and provider experiences of social prescribing and the intervention's effect on a range of clinical outcomes, with a particular focus on patients living with the greatest deprivation. Findings from qualitative studies show that patients value the opportunity to develop trusting relationships with their link worker over time. Link workers identified high caseloads and a lack of appropriate VSCE services for onward referral as barriers to effective social prescribing.

Josephine Wildman, Research Fellow, Newcastle University, NIHR ARC NENC josephine.wildman@ncl.ac.uk

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Newcastle and Gateshead Social Impact Bond for people experiencing homelessness Cross Cutting Themes Changing Lives recently led on the delivery of a Social Impact Bond (SIB) in Newcastle and Gateshead to support people who are rough sleeping or entrenched in the homeless system. The project gave us a unique opportunity to re-think how we support people who are amongst the most socially excluded and have often experienced years of deprivation, trauma, and discrimination - and subsequent health inequalities. For this project we used a multi-disciplinary team approach, which included an outreach team often with lived experience of homelessness working in a person’s own environment and community, alongside specialist practitioners such as a dedicated CPN. A refer and accompany approach was used to improve engagement with services, especially health care. This way of working that evolved led to great outcomes – 70% of the 141 people we supported were safely accommodated and 51% have sustained long term tenancies; 31% engaged in drug and alcohol treatment and 100% were successfully registered with a GP. Laura Seebohm, Executive Director for External Affairs, Changing Lives laura.seebohm@changing-lives.org.uk Presented at the HI Summit Conference on the 6/12/2021

Reading age Cross Cutting Themes STSFT has an aspiration to only send material (leaflets, letters) to patients which corresponds to the local reading age.

This is not about meeting the accessible information standard nor is it about producing material for people with ‘additional needs’ but rather an attempt to change an aspect of ‘business as usual’ which may have a positive impact on health inequalities. A random sample of patient leaflets and letters has shown that there is a disconnect between the reading age of patients and the reading age of information sent to them. Given that we have a high degree of control over this material it may be considered as an example of an intervention generated inequality.

Ryan Swiers, Consultant in Public Health, STSFT ryan.swiers@nhs.net

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Reducing the health inequalities faced by substance users Cross Cutting Themes Foundations is a specialist GP practice in Middlesbrough .The service supports vulnerable populations including substance users and people seeking asylum. The practice adopts a health focused harm reduction approach to care utilising a make every contact count approach. The service has been able to demonstrate a correlation between its care provision and a reduction in drug related deaths. Patient data shows that those receiving care via the service were 80% more likely to survive than patients who were not. The innovative practice also includes England’s only heroin assisted treatment programme, recently published research has shown the treatment intervention has dramatically increased health, mental health, social wellbeing and reduced criminal activity in a previously untreatable patient population. The programme has been highlighted as an example of good practice locally, nationally and in a recent HMIP inspection.

Daniel Ahmed, Clinical Partner, Foundations daniel.ahmed@nhs.net Presented at the HI Summit Conference on the 6/12/2021

Safe fasting messages at Ramadan Cross Cutting Themes Haref works with ethnically minoritised communities to identify key issues around health and improve the health information available to them. Our Ramadan prayer calendars are an example of providing relevant health information in a format and context that is useful and requested by our local communities. We have been designing and distributing these calendars with our local mosques for over 10 years. Our calendars show the prayer times for different mosques across Newcastle, Gateshead, and North Tyneside (each mosque has different prayer times according to their orientation and position to the sun). We include important health messages alongside the timetable to help people to fast safely.

This year we also included information about COVID-19 vaccines and fasting and completed an evaluation with the mosques about the calendars, to find out how they worked in a digital format, and how the health information was used.

Vicki Harris, Haref Coordinator, Connected Voice Haref vicki.harris@connectedvoice.org.uk

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Staying Steady Cross Cutting Themes Staying Steady is a 20-week strength and balance programme funded by the Newcastle and Gateshead CCG. The programme is specifically designed to reduce the number of incidents of falls suffered by people aged over 50 in Gateshead. The course is delivered by a Level 4 qualified Postural Stability Instructor. Staying Steady comprises a series of evidence-based exercises to improve strength and balance and is recognised as a falls prevention activity by the National Institute for Health and Care Excellence (NICE). Overall, the Staying Steady course has demonstrated a significant improvement in all areas for its beneficiaries, and in its most recent course, 91% of the participants progressed to taking part in regular community exercise (such as Yoga, Tai Chi or keep fit classes).

Nicola Bruce, Health and Wellbeing Manager, Gateshead Older People’s Assembly nicola@gatesheadopa.org.uk

The role of accessible health information in combating misinformation in ethnically diverse communities Cross Cutting Themes “We’re not just fighting a pandemic; we’re fighting an infodemic”.

The UK’s COVID-19 experience highlighted pre-existing health inequalities in an acute manner. Particularly in ethnically diverse communities, a vacuum of accessible information was noted to be a contributing factor to the disproportionate impact faced in the public health response. In its absence, misinformation began taking a hold, weakening efforts to combat the virus. Our initiative aimed to keep ethnically diverse communities informed in a bid to tackle misinformation.

Venughanan Manikavasagar, Foundation Year 2 Doctor at Queen Elizabeth Hospital in Gateshead; Co-Founder of the COVID-19 Infographics Initiative venughanan.manikavasagar1@nhs.net Presented at the HI Summit Conference on the 6/12/2021

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