Take a look at the active Population Health Management projects currently underway below. These projects currently focus on the areas of Norfolk and Waveney, and we are working to expand projects to Suffolk.
Purpose
We are supporting Great Yarmouth Borough Council’s Community Voices project to increase uptake of the NHS Lung Cancer Screening (LCS) programme. The project is aimed at communities who are disengaged in Great Yarmouth. It also aims to help people stop smoking through the Swap to Stop scheme – a national scheme that provides adults who smoke with a free vape kit to help them stop smoking.
Objective
The goal is to find lung cancer earlier, when treatment is easier and works better. The project will also help us understand why some people who can have screening have not taken part before.
The project offers friendly, personal support. It will help people understand what lung cancer screening is and support them to book and attend their appointments. People can also get help to connect with other services, such as stop smoking support and other health, lifestyle, or welfare services.
How it works
We look at information from GP records to find people who may be able to take part in the programme, and the Community Voices team from Great Yarmouth Borough Council will then contact these people. They will offer support to help them attend lung cancer screening and also help people find stop smoking support and other health or welfare services.
This project does not make referrals. It focuses on helping people understand the programme and supporting them to take part.
Purpose
The purpose of this project is to help people in Norfolk and Waveney understand Familial Hypercholesterolaemia (FH) and how to manage it.
FH is an inherited condition that causes very high cholesterol. Around 4,400 people in Norfolk and Waveney may have FH without knowing it. If untreated, it can greatly increase the risk of heart disease or stroke.
Objective
Our objective is to help people find out if they may have FH and make sure they receive the right care.
Early diagnosis and treatment can lower cholesterol, reduce the risk of heart attacks and strokes, and help people live longer, healthier lives.
How it works
- People who may be at risk will receive a letter inviting them to visit a dedicated webpage. The webpage explains FH in clear, simple language and allows people to book an appointment with a specialist nurse.
- People will also receive a text reminder. If there is no response, the Virtual Support Team may follow up with a phone call from 01603 257 299 to provide support.
- If someone sees the specialist nurse, they may be offered genetic testing. If treatment is needed, the patient’s GP will receive advice on the most appropriate care.
- The specialist nurse will also give guidance on speaking with family members who may also be affected.
Purpose
We are working with TIC Health Limited to increase uptake of the NHS Lung Cancer Screening (LCS) programme.
The project aims to find lung cancer earlier, especially among people aged 55–74 who smoke or used to smoke and may be at higher risk.
Objective
The Lung Cancer Screening programme aims to find lung cancer at an early stage, when treatment is simpler and works better.
People who are eligible will be invited by TIC Health for a Lung Health Check. After the check, patients may receive one of several outcomes. Some will be told no further action is needed, while others may be referred to their GP for help with lung or breathing problems. People at higher risk may be offered a low-dose CT scan.
By finding problems earlier, the programme aims to reduce late diagnosis and improve survival.
How it works
We use information from GP records to help identify people who may be eligible.
TIC Health then contacts these patients by text message, letter, or phone call to invite them for a Lung Health Check.
A trained nurse carries out the check, either by phone or in person. After the assessment, patients are told what will happen next. The outcome is also shared with their GP.
Purpose
We are working with Norfolk County Council Public Health, REED Wellbeing, and local GP practices to encourage more people to take part in the NHS Health Check.
The programme helps find early signs of stroke, kidney disease, heart disease, type 2 diabetes, and dementia.
Objective
The NHS Health Check helps lower the risk of heart and blood vessel conditions, including heart disease, stroke, dementia, and kidney disease.
Many risk factors, such as high blood pressure and high cholesterol, do not cause symptoms. The health check helps identify these risks early so people can take steps to improve their health, such as making lifestyle changes or starting treatment if needed.
How it works
People who are eligible will receive a text message reminding them that their NHS Health Check is due. If they do not respond, the Virtual Support Team may follow up with a phone call from 01603 257 010 to offer support.
The message will include a link to a webpage with clear information about the health check and why it is important.
From this page, people can book an appointment and choose a convenient location, date, and time. The appointment will be carried out by a trained health professional.
Purpose: The purpose of this project is to improve engagement of patients with Early Onset Type 2 Diabetes (EOT2D) with Type 2 Diabetes in the Young (T2DaY) reviews provided by their GP Practice.
Objective: Our objective is to contact all patients living with EOT2D to invite them to access a Protect NoW information zone webpage including engaging videos led by a Speciality Advisor. This webpage on our Knowledge NoW website explains why proactive diabetes management is important and what patients can expect from a T2DaY review. It also explains how to arrange a review with their GP practice.
How it works:
- Patients with EOT2D will be invited by text message or letter to visit the Protect NoW webpage.
- The T2Day webpage on our Knowledge NoW website provides clear information and videos from the Specialist Advisor. These explain why regular diabetes reviews are important and how T2DaY reviews support people with early onset diabetes.
- Patients can then contact their GP practice to arrange their review.
Purpose
This project aims to identify people who were invited to take part in the National Bowel Cancer Screening Programme but have not yet responded.
By contacting these people, the project aims to raise awareness and encourage them to take part in screening, especially those who may be at higher risk of bowel cancer.
Objective
To identify people who have not responded to their screening invitation and encourage them to use their existing test kit or request a new one.
Information will then be shared with the Bowel Cancer Screening Programme so requests can be checked and processed. The aim is to support more people to complete and return their bowel cancer screening test (FIT kit).
How it works
Eligible patients will receive a text message reminding them about bowel cancer screening.
The message will include a link where they can complete a short questionnaire, confirm they will use their existing test kit, or request a new one. They will also have the option to decline.
If a patient does not respond, the Protect NoW Support Team may follow up with a phone call from 01603 257 256 to provide information about the National Bowel Cancer Screening Programme and explain the importance of screening.
Purpose
Type 2 diabetes can often be prevented through healthy lifestyle changes. Around nine out of ten people with diabetes have type 2 diabetes. The condition can lead to serious health problems, including sight loss, kidney failure, heart attacks, and strokes.
Working with health consultancy service Xyla, this project aims to support people who may be at risk by encouraging them to join the NHS Diabetes Prevention Programme, especially in rural and more deprived areas where referral rates are low.
Objective
The NHS Diabetes Prevention Programme aims to reduce the number of people who develop type 2 diabetes.
The programme supports people to make healthy lifestyle changes. Completing the programme can reduce the risk of developing type 2 diabetes by more than one third.
Method
People who are eligible will receive a text message inviting them to join the programme.
They can follow a link to accept the offer or decline it. If a patient does not have a registered mobile number, they will receive a letter instead.
If there is no response, the Protect NoW Support Team may follow up with a phone call from 01603 257 232 to provide information about the NHS Diabetes Prevention Programme and offer support.
Purpose
This project aims to identify adults living with obesity who also have diabetes, high blood pressure, or both. It aims to increase awareness and uptake of the Digital Weight Management Programme (DWMP) in Norfolk and Waveney.
The programme supports people to manage their weight and improve their health. The Health Improvement and Support Team will focus on the most deprived areas and places where uptake of the programme is currently lowest.
Objective
The programme aims to reduce the health risks linked to being very overweight. These include type 2 diabetes, heart and blood vessel disease, joint problems, mental health problems, and some cancers.
It also aims to help prevent early illness, disability, and premature death, while improving access for people in more deprived communities who may be less likely to use other weight management services.
How it works
Eligible patients will receive a text message inviting them to register their interest online or decline the offer.
If a patient does not have a registered mobile number, they will receive a letter instead.
If there is no response, the Protect NoW Virtual Support Team may follow up with a phone call from 01603 257 034 to offer further information and support.