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Health Service Journal award win for Norfolk and Waveney’s Covid Protect

Covid Protect - a local NHS and social care initiative to protect Norfolk and Waveney’s most vulnerable patients at the onset of the pandemic – has won the 2021 Health Service Journal Award for Connecting Services and Information.

Covid Protect was launched by the Norfolk and Waveney Heath and Care Partnership in March 2020 and the pioneering project has been named as a finalist in six national awards so far this year.

The judges named the project as the worthy winner due to the inspirational and person-centred model of care provided in response to the Covid-19 crisis, which has since evolved into meeting the needs of the wider health and care system.

The HSJ Award judges praised the project and held it up as an example to other areas of the country: “The move from a standard medical model to encompassing all aspects of the care of a person was outstanding. The panel strongly recommend that other care systems study and adapt this approach in developing their own solutions to meet the needs of the local population.”

As the pandemic’s first wave hit the UK, NHS England provided ‘shielded patient’ lists and tasked local health and care systems with contacting those registered as clinically extremely vulnerable (CEV) to ensure their health and care needs were met during lockdown.

A collaboration of diverse organisations from across Norfolk & Waveney - in partnership with data technology specialists Prescribing Services Ltd - instigated a ground-breaking approach; maximising the use of Norfolk's population health management system (Eclipse) and GP-held patient information to identify, monitor and swiftly respond to the needs of those at high risk of serious complications from Covid 19.

A core Covid Protect team was established to drive the innovative use of data; expanding the list of patients identified nationally for shielding at home to include a wider group of individuals known by local GPs to be clinically vulnerable / at moderate risk. This meant an additional 12,000 patients were able to benefit from direct contact and support in addition to already identified shielding patients.

Targeted outreach focussed on those most susceptible to serious illness and hospitalisation, including many who now found themselves cut off from traditional routes into health and care services. More than 100 redeployed NHS and Voluntary Sector staff were part of a team of contact callers who regularly telephoned those who were deemed most vulnerable. This allowed Covid Protect to prioritise and escalate individual health and social care needs to both clinical and non-clinical teams across Norfolk and Waveney.

The remote monitoring of health conditions, ongoing contact with those most at risk of harm and the provision of early care and support interventions enabled people to stay safe and well at home. This approach allowed the health and care system, working collaboratively as a whole, to proactively reduce demand on ambulance and A&E services and avoid further increases in hospital admissions during the early months of the pandemic.  

Howard Martin, Director for Population Health Management and Health Inequalities at NHS Norfolk and Waveney Clinical Commissioning Group (CCG) and executive lead for Covid Protect said: “Our amazing team of over 100 people worked across more than 20 organisations to support upwards of 40,000 shielding patients with medication, social care, remote health reviews, domestic needs and preventing isolation. 

“One of the real advantages we have in Norfolk and Waveney is the strength of our primary care teams and their willingness to work with wider health and care colleagues to drive improvements in clinical care and patient wellbeing. Our talented clinicians and collaborative partners were not afraid to test the boundaries of what’s possible, working above and beyond their day-to-day roles to achieve the best possible outcomes.

“This national recognition puts Norfolk and Waveney firmly on the map for using data and technology to drive health and care innovations. Many congratulations to all involved and thank you for your ongoing professionalism and passion in this vital area of work.”

The pioneering innovation had been shortlisted as a finalist in both the Connecting Services and Information and the Primary Care Innovation of the Year categories of the 2021 Health Service Journal Awards. In September 2021, Covid Protect also reached the finals of British Medical Journal Awards.

Two Norfolk GPs, instrumental in leading key aspects of Covid Protect, have also been shortlisted as finalists for a national award. They are nominated separately for GP of the Year at the 2021 General Practice Awards for their individual contributions to the success of project.

These accolades - spanning a range of categories and disciplines - are recognised as the most significant and influential in heralding outstanding achievement across the sectors of medicine, health and care.

Dr Jeanine Smirl, GP at St Stephen's Gate Medical Practice in Norwich, provided clinical leadership to the Covid Protect team and Dr Julian Brown, GP Partner at Litcham Health Centre and Fleggburgh Surgery led on the coding of a digital platform that allowed patients to self-monitor their health and wellbeing from home.

Said Jeanine: “Partnership working across NHS, primary care, social care and voluntary support services meant the health and care system was able to gather information and mobilise its response more quickly and efficiently.

“We were screening shielded patients daily; assessing their risk and rapidly triaging them to make sure the right health and social care resources were in place to support them at home.  The pace we were working at was phenomenal and national guidance was changing all the time.  People were initially told to shield for 12 weeks but as virus transmission intensified this was extended into the summer. 

“Covid Protect provided a safety net for our most vulnerable patients whose needs may otherwise have been invisible because they were shielding at home.  Monitoring their health conditions – as well as checking they had food, medications, and the social support they needed – was crucial in them getting through the worst of the pandemic and letting them know we still cared.”

Said Julian: “Identifying our most vulnerable and at-risk patients using local GP practice data - in combination with the Council Data ​- was essential in expanding the care and support offered beyond the initial cohort of shielding patients.  GPs and local community health and care services hold essential information within their databases and patient records, based on the regular interactions they have with people at a local level.

“We were able to support the right patients at the right time to improve equality of care through creating a partnership between primary care, the Council and the patients themselves. We received more than 250,000 contact responses from patients enabling us to focus our clinical resources on those most at-risks.

“Using real-time data to inform clinical decision-making and care planning is fundamental in effective healthcare.  Harnessing technology and designing services in partnership with our patients to address the clinical and social needs of our population will be the future of sustainable health and social care services and help us ensure equality of care."   

Dr Clare Hambling, a GP at Bridge Street Surgery in Downham Market, also provided clinical leadership to the Covid Protect project and said: “Norfolk and Waveney is really leading the way in the use of primary care data.  The positive impact we were able to have at such a difficult time for these incredibly vulnerable people was just fantastic - and it was very rewarding professionally to be making such a tangible difference.” 

“We are now using similar approaches in our wider Protect Now programme of work; offering preventative health interventions and support to people at risk of developing long-term conditions. This national recognition is well deserved and a real testament to the commitment of my GP colleagues and local health and care partners in protecting people’s health and quality of life for the future.”

Protect Now – the wider programme of work that evolved from Covid Protect – sees similar digital risk stratification approaches to population health management and is currently focused of improving access to mental health wellbeing services (talking therapies), increasing uptake of cervical screening and preventing type 2 diabetes in those patients with increased risk factors.

In addition to the HSJ award win for Covid Protect, Norfolk and Waveney health services are enjoying wider recognition in the areas of dermatology and medicines management. The North Norfolk Primary Care team were an HSJ finalist for transforming dermatology through the use of diagnostic imaging and the One Norwich Primary Care Network pharmacy are also shortlisted in the Extended Practice Team Member of the Year category at the forthcoming 2021 General Practice Awards. Winners will be announced on 10 December 2021.

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