Integrated Health Awards 2023: most promising pilot

Here we have the finalists in the category of most promising pilot.

South London Partnership – Enhanced Treatment Team for Adult Eating Disorders across South London 

Overview. Clinicians working in the South London community adult eating disorders services identified the need to enhance their existing workforce, to enable individualised care for the service users and their carers – supporting earlier discharge from the ward. South London Partnership created a business case for a pilot Enhanced Treatment Team (ETT) and successfully secured funding for a 24-month pilot.

Why? The South London AED PC covers a population of 3.3 million – due to the scale of the demand, the partnership sought to create two ETT pathways which would cover 12 boroughs in the community. 

What happened? SLP recruited a number of staff, developed a clinical model and launched a family and friends intervention, alongside the two ETT teams in January 2023. They have so far managed to avoid admission for 3 individuals who would on average require an admission of 120 days, supported earlier discharge of 5 users and halved the admission time of one service user to only 60 days. 

Looking ahead. The ETT has a remit to support carers and family members and hopes to integrate peer support workers and Patient Carer Peet Support (PCPS) into the team. 

Yorkshire Health Partners Ltd 

nMABS Service Journey into Primary Care 

Overview. Yorkshire Health Partners (YHP) have mobilised a pilot service which identifies non-hospitalised patients’ eligibility for anti-viral therapy in line with COVID medicines in the primary care setting, across the ICS. 

Why? The main goal of the pilot was to support identified vulnerable non-hospitalised patients with access to antiviral therapy in line with COVID medicines within the primary care setting. 

What happened? The service was initially rolled out in secondary care in December 2021. Secondary care CMDU’s expressed they were overwhelmed with the service, so a decision was made to pilot the first triage in primary care. YHP led the first triage in March 2022, working with commissioners and secondary care to allow for a smooth transfer of services for the patients. The final phase of the pilot involved dispensing medication from the hospital to community pharmacies which was successfully achieved in March 2023. There is now a network of pharmacies across the ICS that can provide the covid antivirals to patients much closer to home. 

Looking ahead. YHP is currently working to further enhance the service by developing a self-referral platform for patients with a trusted digital provider. 

Healthwatch Essex Limited TAG Trauma Card 

Overview. Healthwatch Essex brought together their Trauma Ambassador Group to utilise their skills and lives experiences to better inform and shape health, care and wellbeing services for people affected by trauma. 

Why? Trauma is by nature unpredictable and affects many areas of life This can result in a person withdrawing and disengaging from health and care services, which leaves them in a position where they may not receive the level of care and support they need. The Trauma Ambassador Group aims to address these inequalities by: improving care providers understanding of trauma, raising awareness of the effects of trauma for both the public and professionals, encouraging those in similar situations to access support. 

What happened? The Ambassadors co produced the trauma card through every stage of its development. The front explains that the cardholder is living with the effects of trauma and has been triggered for some reason. The back gives three simple actions which the receiver of the card can take to help the person, along with a QR code which they can scan on their computer or smartphone. The card was adopted by many partner agencies in Essex, including domestic violence, sexual violence and abuse services, homelessness support, mental health, addiction, HIV services and GP surgeries. 

Looking ahead. Feedback has been overwhelmingly positive and Healthwatch hopes to extend the card’s services internationally, having made contacts with agencies in Eastern Europe and the USA. 

Nottingham and Nottinghamshire ICS 

Community Care Transformation Programme (CCTP) 

Overview. The Community Care Transformation Programme (CCTP) has been established to plan for and deliver a sustainable model of community care that aims to optimise people’s independence by addressing physical, mental health and social needs across the Nottingham and Nottinghamshire population. 

Why? When the CCTP was first established in April 2021, the standardised delivery models across the ICB did not reflect the varying needs of the demographic or address health inequalities. They found that there was limited integration between health, local authority and VCSE services as well as a focus on engagement rather than co-production. 

What happened? The CCP adopted a more collaborative approach -working with staff, partners, stakeholders, and the public to develop a new focus which aligned with health and social care resources. They aimed to deliver a more consistent model of care across the ICS whilst ensuring services were responsive to local population need. Since early 2023, the programme has completed multiple 100-day transformation cycles with 5 early adopter sites, generating successful service redesign initiatives. 

Looking ahead. The programme now aims to continue to spread their methodology across the entire ICS to create a far-reaching impact; ensuring people with multiple conditions receive a great service integration, more person-centred and holistic care. 


Overview. Cassius+ is Suffolk’s digitally enabled model for patients with chronic diseases who could benefit from closer monitoring than standard GP or outpatient processes allow. Identified patients receive a package of health devices which allows them to report key information such as heart rate, blood pressure and temperature from their own home. 

Why? The health monitoring extension of Cassius, Cassius+, allows patients and clinicians to unobtrusively monitor their condition and intervene early if they are becoming unwell. This avoids the use of the NHS urgent care system and gives patients agency to take their care into their own hands. 

What happened? In the six months it has been operational, Cassius+ has proven a significant asset to Suffolk’s healthcare provision; it has made a huge difference to patients’ quality of life and has alleviated stress for many healthcare professionals. They also believe they are getting more accurate readings as patients measure their in-home pulse, blood pressure or respiration rate. Patients have reported that they feel they have an increased level of support, have greater contact with people and have less anxiety as a result of having Cassius+. 

Looking ahead. Cassius+ will continue to evaluate their progress and evolve their product around the needs of its patients, hoping to expand its usage across the UK. 

Chime Social Enterprise 

Overview. Chime Social Enterprise are a long-standing audiology service, offering practical ways to ‘future-proof’ this vital service across the UK and deliver high quality hearing care to more people – more efficiently. 

Why? Audiology services are under increasing pressure due to the growing needs of our aging population. When left without appropriate hearing care solutions, people are at higher risk of developing early onset dementia, loneliness, isolation, and depression as they struggle to stay engaged with the world around them. 

What happened? In 2020, Chime became the prime provider for the NHS audiology service negating the need for NHS money to exit to commercial providers such as Specsavers hearing. They have proven a commitment to empowering staff, patients and commissioners by delivering an innovative service model that has proven impact on patients’ lives. 

Looking ahead. Chime are currently in conversation with senior Scottish healthcare professionals, looking at ways to make Chime principles and practices work for Scotland. 


Digital cancer care: working with Nuffield Health to improve care for patients 

Overview. Careology is intelligent technology that empowers people living with cancer by enabling them to easily navigate key elements of their treatment in a digital-first way. Patients can use Careology to track symptoms such as pain, nausea and vomiting with the app or by connecting to a wearable device. 

Why? The pilot aimed to help tackle some of the main problems cancer services are currently struggling to deal with such as backlogs, workforce shortages, and escalating costs which are impacting cancer survival rates. Reports show that 25% of people diagnosed since 2020 have lacked specialist cancer nursing support during their treatment – Careology’s remote monitoring technology enabled nurses to proactively manage their patients in a safe and efficient manner. 

What happened? The pilot enabled cancer patients at Nuffield Health Derby Hospital to access an entirely digital care support solution, allowing them to feel connected and in control of their health. The pilot aimed to help tackle some of the main problems cancer services are currently struggling to deal with such as backlogs, workforce shortages, and escalating costs which are impacting cancer survival rates

Looking ahead. Following the success of the pilot roll out, Careology has been scheduled across 11 Nuffield Health sites. 

ShinyMind Ltd/ NHS Bedfordshire, Luton & Milton Keynes ICB 

Overview. The Shine ‘Wellbeing Prescription’ programme was co-created with NHS clinicians as a new psychological staff programme and digital patient resource – using digital solutions to simultaneously support the mental health of primary care staff and their patients. 

Why? Bedfordshire, Luton and Milton Keynes ICB urgently needed to address the growing demand on primary care services and staff to provide proactive and personalised care in order to prevent ill-health across patient populations. 

What happened? In 2022, ShinyMind and BLMK collaborated to co-create the Shine programme, providing personalised wellbeing prescriptions (including stress, coping with anxiety, sleep, resilience and more) responsive daily mental health support and many other interactive wellbeing resources. 60% of patients said they felt better after just 6 weeks and 83% said they would recommend the service to others.

Looking ahead. BLMK are rolling out the Shine programme to all GP practices and are currently working with the IAPT service to extend the programme for us with IAPT patients on the waiting lists.

Southwest London Local Pharmaceutical Committees and South West London ICB

Overview. The WinterFit MECC (Making Every Contact Count) intervention is a collaborative effort between Southwest London ICB, Dr Heffernan, Amit Patel and the Local Pharmaceutical Committees – delivering over 10,000 interventions across 70 pharmacies in just over 4 weeks.

Why? Prevention is key to reducing excess deaths and illnesses; WinterFit will be crucial in supporting patients aged over 65 in Southwest London during the winter months.

What happened? The intervention has increased awareness about winter health risk, promoted preventative measures and connected older individuals with relevant support services – including social prescribing options. Preliminary feedback from both pharmacy teams and participants has been overwhelmingly positive. 

Looking ahead. The WinterFit MECC intervention has proven to be a scalable and adaptable model that can be easily replicated in other regions and settings. There are plans to expand the WinterFit MECC to additional locations and exploring new areas in which community pharmacy teams can make a significant impact on public health.