Innovation for Healthcare Inequalities Programme (InHIP)

Atrial fibrillation (AF) is one of the most common forms of abnormal heart rhythm (arrhythmia) and a major cause of stroke. Around 1.5 million people in the UK have been diagnosed with AF. It is estimated that there are significant numbers of people (at least 270,000) over 65 with undiagnosed (or silent) AF in the UK and around 1 in 8 people are not treated effectively (1).  Once diagnosed, most people will be treated with blood-thinning medication to prevent clots (anticoagulants), which reduces the risk of stroke by two thirds (2) and avoid other health care complications. This stroke risk is why it is so important that AF is detected as early as possible. Suffolk and North East Essex ICB and Hertfordshire and West Essex ICB focussed on AF detection in our Core20PLUS 5 populations. 

Suffolk and North East Essex  

In partnership with Suffolk GP Federation, Suffolk and North East Essex ICB targeted a small number of practices to further refine the process of identifying, effectively engaging with and optimising treatment for people who had already been diagnosed with AF.  The focus was on clinically reviewing and supporting those with a diagnosis who were not currently receiving optimised treatment, alongside further understanding the reasons why patients where not accessing appropriate care.   

Hertfordshire and West Essex 

Hertfordshire and West Essex ICS worked with primary care networks (PCNs) located in areas defined by the Index of Multiple Deprivation (IMD) as deprived. They engaged with local voluntary, community, faith and social enterprise organisations (VCFSE’s) to co-develop a community outreach approach to raise awareness of AF in black, Asian and other ethnic groups through in primary care settings to improve detection and subsequent management with direct oral anticoagulants (DOAC’s) where appropriate. 

Lipid managment refers to the management of fats in the blood (cholesterol and triglycerides) (3,4).  A high level of cholesterol is one of the most significant risk factors for cardiovascular disease (CVD). Around 43% of adults have raised cholesterol in the UK which can be reduced with appropriate management, saving lives (5). 

Cambridgeshire and Peterborough 

Cambridgeshire and Peterborough ICS  worked with practices in some of their most deprived areas (see IMD above) to identify and optimise patients with poorly managed lipids, enabling access to novel treatments in line with the NICE AAC lipid management pathway. 

Nearly 43,000 people are diagnosed with bowel cancer every year in the UK (6). Screening aims to find cancer, or changes in the bowel that could lead to cancer, early when treatment is more likely to work. A FIT (faecal immunochemical test) is used to screen for tiny traces of blood in poo that may be an early indication of cancer.

Norfolk and Waveney 

Norfolk and Waveney ICS focused on improving bowel cancer screening. They worked with community champions and connectors in voluntary, community, faith, and social enterprise groups to screen for bowel cancer in higher risk people within Core20Plus groups.  A targeted community outreach programme took place to engage people who have not responded to the national screening programme and looked to provide advice about accessing healthcare and cancer screening tests, specifically the FIT, as appropriate.

Norfolk and Waveney 

Following the success of Wave 1, Norfolk and Waveney ICS has expanded its cancer detection project to focus on women’s health. This initiative addresses healthcare inequalities among women in higher-need areas, particularly those from underserved communities who often face barriers to accessing traditional services. 

Partnering with local system leaders, Community Voices champions and VCFSE organisations, the project promotes cancer screening (for breast, cervical, and bowel cancer) as part of a wider conversation within menopause, menstrual, and sexual health services. Engaging women aged 40-60 in Core20 areas, it builds on previous work with faecal immunochemical testing (FIT) to tackle barriers to access and improve health outcomes. 

Bedfordshire, Luton, and Milton Keynes 

Bedford, Luton, and Milton Keynes (BLMK) ICS are working with practices in their most deprived areas (see IMD above) to address healthcare inequalities. The initiative focuses on underserved populations by improving care and treatment for patients with heart failure with preserved ejection fraction (HFpEF) in five key GP practices. 

The project emphasises clinician education, patient engagement and comprehensive monitoring to enhance care delivery. Using NICE guidance TA929 and TA902, the goal is to identify all patients with a confirmed HFpEF diagnosis and optimise their treatment using oral antidiabetic medications, Dapagliflozin or Empagliflozin, to ensure better health outcomes for these vulnerable groups.

Suffolk and North East Essex 

Suffolk and North East Essex will be working with selected GP practices across Suffolk to implement FeNO testing in primary care, aiding in the diagnosis of asthma in children and young people (CYP). By increasing access to FeNO testing and new diagnostic tools, the project aims to improve asthma diagnosis, provide appropriate management, and enhance patient outcomes and experiences. 

The initiative seeks to reduce asthma exacerbations and hospital admissions, particularly targeting CYP living in areas defined by the Index of Multiple Deprivation (IMD) as being in the most deprived 20%. Through early and accurate diagnosis, the project aspires to lower hospital admission rates and address healthcare inequalities in children and young people. 

NHS England- East of England 

NHS England- East of England regional InHIP project aims to address local healthcare inequalities by implementing a virtual regional multidisciplinary team (MDT). Facilitated by Royal Papworth Hospital with support from the East of England Respiratory Clinical Network’s Interstitial Lung Disease (ILD) steering group, the project will pilot twelve monthly MDT meetings. 

The project will address the urgent need for prompt referral and diagnosis for patients with ILD, alongside integrated ongoing support. The MDT approach seeks to deliver comprehensive, joined-up care, enhancing patient outcomes while identifying and addressing potential challenges and to proving proof of concept.