Neighbourhood and Wellbeing Delivery Alliance Progress Report 2023-24
Strategic Priority 3: Living well for longer
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Our priority outcome: living well for longer
We aim to better support residents with long-term health conditions by improving our approach to person-centred care. This means better collaboration behind the scenes. It means reducing the need for people to repeatedly share their story. And it means addressing multiple needs in a single appointment.
Context and key challenges
Long-term conditions refer to health issues that persist over an extended period and often require ongoing management1. These conditions can significantly impact a person’s quality of life and the need for regular medical attention.
More than one in five people in Lambeth live with at least one long-term condition1. Three specific long-term conditions the NWDA focused on in 2024 were:
High blood pressure (hypertension)
Diabetes
Cancer
We know that there are inequalities for people living with these conditions in Lambeth.
34%
adults with higher than average blood pressure
19,000
adults living with type 2 diabetes
30%
higher incidence of cancer in Lambeth than the rest of the UK
High blood pressure
Over 34% of Lambeth adults have higher than average blood pressure. High blood pressure affects some groups within our community much more than others.
Managing blood pressure is crucial because low blood pressure reduces the risks of stroke, heart attack, dementia, kidney disease, and impotence. This is particularly important for Black African and Caribbean communities in southeast London, who often face higher blood pressure risks.
Diabetes
Approximately 19,000 adults in Lambeth are living with type 2 diabetes, with an estimated 4,500 more undiagnosed, highlighting a gap in detection and care (SEL ICS).
Cancer
Lambeth has a higher incidence of cancer than the rest of the UK, especially lung and prostate (which is nearly 30% higher than the UK average) and there are significant differences in cancer outcomes (OHID). For example, almost four in ten adults (37%) in Coldharbour Ward die from cancer earlier than the national average. This stands in stark contrast to Clapham Common, where only 2% fall below the national trend.
What we offer
High blood pressure (hypertension)
Our approach focuses on promoting healthy lifestyles and using medication when necessary. We aim to improve access to healthcare and build trust within Black communities. By working closely with GPs, we support Black and multiethnic people in Lambeth to manage their blood pressure effectively.
To reach more people, in 2024 we joined up with national health campaigns – Know your Numbers Week and Heart Month – to offer free blood pressure checks across Lambeth. We partnered with the Lambeth Together Health and Wellbeing Bus Team as well as specialist and community pharmacists.
Diabetes
Our aim is to support people to manage their diabetes and avoid complications of the disease. One of those complications can be diabetic eye disease.
People diagnosed with diabetes are invited to an annual eye (retinal) screening to help detect diabetic eye disease. People who do not attend their screening appointments are at highest risk of developing diabetic retinopathy, which is a complication of diabetes, where high blood sugar levels damage the back of the eye (known as the retina) which can lead to vision loss if left undiagnosed and untreated.
Our data shows us that people who live in more deprived areas are less likely to attend their screening which puts them at greater risk of sight-threatening eye disease not being detected in time. In the last year we have worked to improve the uptake of screening for diabetic eye disease in patients who have not attended eye screening for three or more years.
GPs reviewed patient records to understand the reasons why people were not attending and to identify what additional support they might need. Seven pop-up clinics were held at GP practices and patients within the practice who had not attended screening for three years or more were invited to attend. This provided the opportunity for patients to visit a familiar setting and time to talk about the importance of eye screening.
Cancer
We focused on several initiatives with local partners to improve cancer screening and awareness. This included funding General Practice to run early cancer diagnosis events aimed at reducing health inequalities.
Additionally, the Catch 22 Lambeth Bowel Cancer Screening Project employed multilingual staff to reach out to people who haven’t taken up their screening invitation, providing personalised support and information. We also funded key events for Hills Brook & Dale Primary Care Network (HBD PCN) to promote cancer screening awareness, highlighted at the end of this page.
Through our collaborative local approach in Lambeth, and working closely with our colleagues in Southwark, we were able to undertake engagement and joint working with primary, secondary, voluntary and social care providers to help support people with long-term conditions.
High blood pressure (hypertension)
23,549
People from Black and minority ethnic communities diagnosed with high blood pressure in December 2023
24,437
People from Black and minority ethnic communities diagnosed with high blood pressure in December 2024
We work to improve how high blood pressure is identified and managed, with a focus on reducing health inequalities. It’s making a big difference—previously there were high estimations of undetected blood pressure but this year, more people from Black and minority ethnic backgrounds have been diagnosed with high blood pressure than last year—23,549 in December 2023 and 24,437 in December 2024. This means that we’re able to better treat and support these patients to reduce their blood pressure
We also held a successful event where 142 staff had their blood pressure checked. 35 people were found to have high blood pressure and needing follow-up action, and an additional 28 were outside the normal range so were advised on lifestyle changes.
Diabetes
264
People had an eye screening
695
People on the register (down from 1460)
• The Lambeth register of people who have not attended diabetic eye screening for three years or more reduced from 1460 to 695 people by April 2024
• The non-attendance rate reduced to pre-pandemic levels
• 264 people who had not attended eye screening for three or more years attended eye screening because of joint working
Cancer
706
Bowel cancer screening tests in 2024
22-22%
Completion rate among South American, Arab, Indian, and Chinese
Between February 2023 and February 2024, 8,339 people who hadn’t responded to a bowel cancer screening invitation were contacted again. They managed to speak to 4,439 people, of which 706 successfully completed the test. Completion rates were higher among South American, Arab, Indian, and Chinese groups (22-27%) compared to others.
Our next steps
High blood pressure (hypertension)
We will continue to regularly work with local pharmacy leaders to encourage and support blood pressure checks at community pharmacies.
At the upcoming Lambeth Country Show, we will set up a stall to engage with our local community. We will share tips on how to maintain healthy blood pressure and offer free blood pressure checks for anyone interested. It will be a great opportunity to talk with our partners on neighbouring stalls about their health while enjoying the festivities.
There will be a continued focus to reduce health inequalities amongst different communities in Lambeth when it comes to blood pressure.
Diabetes
We will continue to work with people with diabetes to share the importance of the diabetes care processes in managing their diabetes well. We will also continue work with the Lambeth community to improve the number of people having their diabetes care processes measured and jointly develop care plans, to minimise the complications of diabetes.
Additionally, we plan to set up temporary health clinics at local GP surgeries and team up with South London and Maudsley NHS Trust to run short-term clinics for patients and find better ways to support them.
Cancer
We will continue to fund more community groups such as the Indoamerican Refugee and Migrant Association (IMRO) and the Lambeth Somali Community Association (LAMSOM) to address barriers to cancer screening. They will be running targeted education, workshops and one-to-one support on cancer screening.
We also continue to support community events such as an upcoming screening awareness event at the Clapham Park Cube organised by Clapham and Brixton PCN. (check with Mark anymore)
Case studies: Hills, Brook & Dale Primary Care Network cancer screening awareness events
Brixton Library cancer screening event
In September 2024 Hills, Brook & Dale PCN used their patient records to find people who’d missed screening appointments or hadn’t responded to invites and invited them to a special cancer screening awareness event. It encouraged open, honest conversations about health and addressed concerns our community had. It was a great chance for people to get their health questions answered and learn more about cancer screening and prevention.
105 people attended and, alongside chats about the different cancer screenings, and the chance to talk with various cancer charities and support groups, were also able to get:
Free health checks by trained volunteers from Carers4carers.
The Lambeth Wellbeing Bus was there to offer advice and health checks.
Information on stopping smoking and other health services.
West Norwood womb cancer awareness event
South East London Cancer Alliance (SELCA), The Eve Appeal (Womb cancer – The Eve Appeal), and HBD PCN hosted a workshop on womb cancer at Goodwin Hall in West Norwood in January 2025. The event, part of a series promoting cancer screenings, attracted over 30 participants and fostered connections among local residents with shared experiences. A talk took place explaining the key causes and symptoms of womb cancer, including abnormal bleeding, and dispelling myths such as the occurrence of one-off periods after menopause.
One participant commented that workshops like these felt like a ‘broken cycle’ of silence around these issues. She also felt she could speak openly about symptoms like abnormal bleeding with her daughters and granddaughters. Marie, another workshop participant, agreed, stating how good it was to see the way services had changed between the time she and her daughter experienced the menopause.
