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Driving health equity with the Locality Improvement Framework
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Serving a population of 1.13 million, Staffordshire and Stoke-on-Trent Integrated Care Board (ICB) set out to tackle health inequalities guided by NHS England’s Core20PLUS5 framework. While the national model provides a clear mandate, the ICB faced a critical challenge: limited guidance and fragmented data made it difficult to accurately identify and segment priority populations at a local level. This created barriers to translating national priorities into meaningful, targeted interventions.
What is Core20PLUS5?
Core20PLUS5 is an NHS England framework for reducing health inequalities. ‘Core20’ refers to the most deprived 20% of the population, ‘PLUS’ covers locally identified groups who face poorer access or outcomes, and the ‘5’ highlights five clinical priority areas: maternity, severe mental illness, chronic respiratory disease, early cancer diagnosis, and hypertension case‑finding. It helps systems focus support where it’s needed most.
To tackle health inequalities, the ICB partnered with Optum to use PHM Pathfinder Analytics for clinical risk stratification and segmentation. This enabled all 14 localities to gain insights on their specific populations and build robust, data-backed business cases that would support them in securing ICB funding for interventions targeting those most in need.
The ICB united organisations into coalition teams and, through workshops facilitated by Optum, helped local authorities, primary care networks and the voluntary sector collaborate effectively around a shared goal: reducing health inequality.
Through these workshops, teams used PHM Pathfinder Analytics to help identify their ‘Core20’ (the most deprived 20% of the population), their locally selected ‘PLUS’ groups at greater risk of inequalities, and the ‘5’ national clinical priority areas (maternity, chronic respiratory disease, early cancer diagnosis, severe mental illness and hypertension case‑finding). By defining their own local ‘PLUS’ groups and aligning to these priorities, localities were able to make the Core20PLUS5 model tangible and relevant to real‑world need.
Introducing the Locality Improvement Framework
To put their strategy into action, the ICB launched the Locality Improvement Framework (LIF), a structured approach to drive collaboration and meaningful change across the system. Each locality worked with Optum during a 8-week cycle to:
- Present clear, evidence-based insights to stakeholders
- Build a business case for change, aligned with Core20PLUS5 priorities
- Design interventions tailored to local needs
- Access funding to support delivery plans and interventions
This structured approach enabled each locality to align priorities, share insights and co‑develop a compelling business case to reduce inequality, helping the ICB make informed strategic commissioning decisions.
Zooming in on one locality: Tamworth
Tamworth entered the LIF programme with a strong foundation: a well-established delivery group and long-standing local partnerships. This meant the locality could collaborate effectively and move quickly from insight to action, helping them build a robust business case and secure funding within a six‑week window.
We were able to draw on the strengths of each organisation, which helped us build trust quickly and establish clear roles across the group. Our regular meetings built momentum. The consistency brought structure, accountability and a shared sense of progress.”
Using risk stratification, the team identified that obesity levels in Tamworth were significantly higher than the national average and that the locality held a ‘red‑red status’ across several indicators. A red‑red status shows a locality is performing worse than both the England average and the average of its statistical neighbours. These insights made obesity and related long‑term conditions — including diabetes, cardiovascular disease (CVD), hypertension and depression a clear priority for the programme.
When we realised how much higher obesity rates are in Tamworth compared with the national average, it reframed the urgency for us. It’s not just about individuals, the impact spans whole households, comorbidities and wider deprivation.”
Reviewing the population health management data together sparked a turning point for the coalition team. Sonia Senior, PCN Operations Manager, Mercian Primary Care Network said:
The data in Pathfinder really opened the conversation. It helped us see the scale of the challenge and prompted a much deeper, more focused discussion than we’d had before.”
Working through the data collectively helped them align on the areas of greatest need, where to target efforts and shape a clear, evidence‑based plan.
The debate was genuinely constructive. Walking through the data together was incredibly helpful in aligning us around the same goal.”
Digging into the local stats, especially around childhood obesity and the geographic spread, gave us real clarity on where we needed to target our efforts.”
The team segmented the data by practice and identified Belgrave, Glascote Heath, and Stonydelph as the areas of highest deprivation. They then focused on an initial cohort of 38 patients from Heathview Medical Practice within these areas. This cohort had obesity alongside hypertension and either diabetes or cardiovascular disease and demonstrated lower levels of engagement with their GP surgery. Further analysis of the data in Pathfinder helped the team estimate that the cost for obesity for patients in Heathview’s geographical area costs £5.6 million annually with an average of £2,500 per person. Individuals living with obesity cost an additional £1,300 per year compared with those without obesity, reinforcing how health behaviours and social factors are closely linked.
They agreed to prioritise prevention and support for lifestyle change, developing a delivery plan targeting this cohort that included wellness checks, community engagement and tailored interventions. Collectively, these interventions could deliver annual savings of £49,400 per year.
Tamworth’s coalition team went on to develop a compelling business case and secured funding to deliver targeted interventions to tackle obesity. The locality is now implementing these plans, including wellness checks, community outreach and prevention programmes in schools.
Potential annual savings over £49K
A scalable model for tackling health inequalities
Tamworth’s experience demonstrates how strong foundations, clear priorities and data-driven insight can create a scalable model for tackling health inequalities across other localities.
As these interventions continue to roll out, we will work closely with Tamworth and other localities across Staffordshire Stoke-on-Trent to evaluate their effectiveness using Pathfinders evaluation toolkit. This will ensure consistent monitoring, shared learning across the system and ongoing refinement of the approach. The case study will be updated as further insights and outcomes emerge.
Staffordshire Stoke-on-Trent ICB leverages a comprehensive suite of Optum solutions to deliver integrated, efficient care. From Pathfinder for advanced analytics and clinical decision support, to Apex for demand and capacity planning and EMIS-X® for primary care coordination, these tools enable the ICB to streamline workflows, enhance patient outcomes and maintain data accuracy across the system.