Newham Partnership Programme

UCLPartners and Newham Clinical Commissioning Group (CCG) are working in partnership, bringing together health, academic, education and improvement experts to drive health improvement for people in Newham.

This programme aims to accelerate understanding of how to improve the health of people in Newham and put ideas into practice to make a real, long-term difference. The programme has been running since 2013.

The programme has had multiple successes to date, including:

  • Implementing a gold standard peer mentoring programme in Newham secondary schools
  • Piloting a peer-supported diabetes self-management programme for young people resulting in a strong local network and on-going work to embed the model into routine clinical management
  • Providing support for GP development, including delivering a small scale Quality Improvement collaborative and NHS England’s Productive General Practice programme with a group of general practices in the borough

The work of this programme now focuses on five priority areas for Newham; Low birth weight babies, pre-diabetes, cardiovascular disease, tackling the challenges presented by Newham’s dynamic population and developing primary care staff.

Select one of the five priority areas below to read more about our achievements to date:

  1. Developing primary care staff
  2. Low birth weight babies
  3. Pre-diabetes
  4. Cardiovascular disease
  5. Dynamic populations

Developing primary care staff

In Newham there are only 53 GP surgeries to serve a growing population of over 300,000 patients. The borough is facing a huge challenge to deliver a high quality service with limited resources. In addition, many GPs in the area are nearing retirement age, meaning that the borough will need to provide an attractive offer to recruit new GPs in the near future.

To tackle this challenge we have launched a Quality Improvement Academy, aiming to equip primary care staff in the borough with the skills they need to work in new ways, maximising capacity and freeing up time for care. This robust training and development offer will also contribute to Newham’s appeal, helping to attract new GPs to the area.


  • We’ve supported nine general practices to complete an NHS England Productive Practice Programme where they ran quality improvement projects that focussed on back office functions to free up time for care. Results showed practices saved between 3 and 6 hours of admin time and between 4 and 5 hours of clinical time per week.
  • We’ve launched a Quality Improvement Academy following successful Quality Improvement (QI) training pilots which focussed on equipping primary care staff in the borough with skills in QI methodology.
  • We provided places for 16 primary care staff to attend an NHS England Fundamentals of Change and Improvement course as part of the academy in May 2017.

This work is led by Professor Martin Marshall, Newham GP, Professor of Healthcare Improvement at UCL and lead for Improvement Science London.

Low birth weight babies

Newham has one of the highest proportions of babies born with low birth weight in England, 3% above the national average. Low birth weight can negatively impact on baby’s long term development, therefore it is important that steps are taken to prevent it.

The Newham Partnership Programme aims to better understand the causes of low birth weight in Newham and use this information to design and test actions to prevent it and better support families.


  • We’ve produced a local situational analysis report, helping us to better understand the current evidence base and services that are provided in Newham.
  • We’ve worked closely with parents, midwives and health visitors to design a prevention and management programme. Activities within the programme include:
  • A pre-pregnancy care pilot where women who are planning a pregnancy are engaged in ‘Healthy Conversations’ with volunteer health buddies, with a good level of initial uptake.
  • A bank of case studies sharing existing local initiatives that promote healthy infant feeding with peer support that can be used to develop new services.
  • The production of a short film for the public that showcases the support services locally available.
  • We’ve launched a knowledge exchange student internship aiming to promote knowledge exchange for public health improvement with health and social care professionals and patient and public involvement groups.

This work is led by Angela Harden, Professor of Community and Family Health at University of East London and Professor Judith Stephenson, UCLPartners’ Maternal Health Programme Director lead this work.


The Newham population has a high prevalence of Type 2 diabetes. The prevalence of the condition is also on the rise amongst young people in the borough and a large number of women have gestational diabetes (meaning they are at high risk of developing subsequent diabetes).

In order to reduce the number of people in Newham developing Type 2 diabetes, the Newham Partnership Programme aims to identify areas at high risk of pre-diabetes, review screening and management measures currently in place and introduce evidence based interventions.


  • We have estimated the proportion of individuals at high risk of developing diabetes and mapped these by area to inform targeted locality-based interventions
  • We’ve reviewed and published the cost effectiveness of existing screening and management measures. Read our BMJ paper ‘Time to question the NHS diabetes prevention programme’
  • We’ve implemented evidence based interventions for pre-diabetes including:
  • A co-designed lifestyle intervention programme using the model developed for the ‘New Baby New You’ programme
  • The use of a linked data strategy to identify women registered with a Newham health centre that attended the local hospital with gestational diabetes over a ten year period, forming a risk register
  • Implementing an annual call back for women on the risk register so that their diabetes risk can be monitored and managed.
  • Offering at-risk women opportunistic blood glucose testing

These interventions are currently being piloted and there has already been a 31% increase in post-natal glucose tolerance testing uptake.

The work has helped successful bids for funding, including the first wave pilot of the National Diabetes Prevention Programme and the Diabetes Transformation Fund. We have recently submitted a proposal to the Health Foundation for their Innovating for Improvement award.

This works is led by Dr Shanti Vijayaraghavan, Consultant Physician at Barts Health NHS Trust and Dr Jim Lawrie, Newham CCG and Newham GP.

Cardiovascular disease

Early mortality rates from cardiovascular disease (CVD) and emergency admission rates for coronary heart disease and stroke in Newham are significantly higher than the national rate. Many of the Newham population are also at high risk of developing CVD due to high blood pressure prevalence, inactivity and obesity. The Newham Partnership Programme aims to tackle this problem by improving individual’s awareness of their CVD risk and their understanding of how to reduce it, improving information sharing between primary and secondary care providers to help reduce the number of unnecessary emergency admissions and improving referral procedures for patients with suspected CVD.


  • We’ve developed a personalised CVD ‘Risk Report’ that can be given to patients as part of an NHS Health Check. The ‘Risk Report’ is being piloted by six general practices in Newham and has received interest from four other boroughs keen to introduce it. Watch our short video to find out more.

  • We’ve created a primary care referral template for all GP practices in Newham to use, making it quicker and easier to refer a patient for testing or specialist consultation
  • We’ve improved information sharing by creating electronic forms and templates that work with existing systems, making it quicker and easier for clinicians in primary and secondary care to share information about a patient, joining up care and creating better patient experiences.

This work is led by Professor Adam Timmis, Professor of Clinical Cardiology at Barts Health NHS Trust and Dr Bhuphinder Kohli, Newham GP.

Dynamic populations

Newham borough has one of the most dynamic populations in England, with a 35-46 percent annual turnover in GP patient lists from 2014 – 2016. This highly mobile population are likely to experience inconsistencies in their care which can negatively impact their health and wellbeing. The Newham Partnership Programme aims to identify and implement interventions to help mitigate the impact of this high patient turnover.


  • We’ve conducted an in depth analysis of patient turnover, providing a much clearer picture of the nature of this challenge for Newham.
  • We’ve identified interventions that could help address the challenges including the development of literature and support tools for registering with a GP practice. These interventions are currently being implemented in GP surgeries across Newham

This work is led by Dr Ashwin Shah, Newham CCG and Gail Findlay, Director of Health Improvement at the Institute of Health and Human Development at the University of East London.


Programme Leadership

Mariana Wieske, Project Director,