WINNER: Sevenhills + Primary Care Network - Covid-19 Vulnerable Patient Visiting Service

Sevenhills Primary Care Network is based in a community which experiences ill-health due to its deprivation and diverse ethnicities. When the pandemic hit, patient presentations dramatically fell and the PCN introduced a new way of working to prevent a longer term widening of the health inequality gap.

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By visiting patients in their own homes, the practice-led service proactively identified vulnerable frail patients not otherwise self-identifying. This enabled uninterrupted continuation of long-term condition reviews and tackled isolation and vulnerability by linking into social support.

Patient management plans required change in 50 per cent of cases and the service evidenced detection and reduction in progression of illness.

Read more about this project on HSJ Solutions.


EQUIP (WEL CCGs) – Empowering All Primary Care Staff to Make Improvements Which Have a Tangible Impact on the Joy of Staff and the Experience of Citizens


  • Central and Thistlemoor Primary Care Network – Health, Wellbeing and Community Champions in inner-city Peterborough
  • Devon CCG – Devon Digital Accelerator Project
  • East Riding of Yorkshire CCG – High Impact Cross-System Innovations to Improve Musculoskeletal Care
  • Isle of Wight CCG, Isle of Wight Trust, Lighthouse Medical, Wessex Academic Health Science Network and Gnosco – Implementing Teledermatology Within Primary Care on the Isle of Wight
  • Northwest London Diabetes Programme, Carbs & Cals, ICS Health and Wellbeing – NWL Diabetes Programme, Carbs & Cals: Working Together to Address the Knowledge and Information Gap for HCPs and BAME Communities Living With, or at Risk of Developing, Diabetes
  • The AHSN Network – Atrial Fibrillation Programme