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Core20PLUS5 is a national NHS England and NHS Improvement approach to support the reduction of health inequalities at both national and system level between 2021-2024. It was the theme for the Annual Director of Public Health Report for Suffolk in 2022. Click here to see report

The approach defines a target population cohort:

  • The Core20 most deprived population in the area
  • PLUS ICS chosen cohorts that experience worse than average health experiences, outcomes and/or access
  • 5 nationally defined focus clinical areas requiring accelerated improvement, with the addition of smoking cessation as a thread running through the 5 areas.
Image of Core20Plus5 Reducing Healthcare Inequalities

Core20PLUS5 is designed as the NHS contribution to a wider system effort by Local Authorities, communities and the Voluntary, Community , Faith and Social Enterprise (VCFSE) sector to tackling healthcare inequalities –and aims to complement and enhance existing work in this area.

The aim is that Core20PLUS5 will support ICSs to effectively prioritise energy, attention and resources enabling the biggest possible impact.

Core20PLUS5 is not designed to be a new set of priorities but should refine existing NHS Long Term Plan commitments on tackling health inequalities into clear and focused areas which have the biggest opportunities to narrow the health inequality gap

The Core20 in Suffolk and North East Essex

  • 80,068 people in Suffolk live in the 20% most deprived Lower Super Output Areas (LSOAs) in England. This is approximately 10% of Suffolk’s residents.
  • Pockets of greater relative deprivation can be found in more built-up areas such as Beccles, Bury St Edmunds, Felixstowe, Ipswich, Lowestoft, and Stowmarket.
  • Ipswich is the most deprived local authority in Suffolk and has 28 LSOAs that are in the 20% most deprived nationally –1/3 of all the Ipswich LSOAs.
  • East Suffolk is the next most deprived local authority in Suffolk, the most deprived areas within East Suffolk are in the Lowestoft area. 20 LSOAs in East Suffolk are in the 20% most deprived nationally.90% (18 of the 20) most deprived LSOAs are located in the Lowestoft and surrounding area.


[Data for North East Essex to be added here]

PLUS Populations in Suffolk and North East Essex

We also need to consider local population groups who may be experiencing poorer than average health access, experience and/or outcomes, but who may not be included within the CORE20 or 5 groups

These groups need to be decided locally and at different levels across the health and care system. Consideration should also be given to local PLUS groups at Alliance, Locality Level, Integrated Neighbourhood Team (INT) or Primary Care Network (PCN) level – collectively these groups form the ‘PLUS’ populations in the CORE20PLUS5 framework.

For example, the Annual Director of Public Health Report for Suffolk 2022 recommends that at the level of Suffolk as a whole, based on data and evidence, the following should be the Suffolk PLUS Populations:

  • People from minority ethnic communities
  • Coastal communities
  • Rural communities
  • People and groups facing the sharpest health inequalities (such as groups at risk of disadvantage)

Groups at Risk of Disadvantage

The ‘5’ in Suffolk and North East Essex

There are five clinical areas of focus. Governance for these five focus areas sits with national programmes; national and regional teams coordinate local systems to achieve national aims.

  1. Maternity: ensuring continuity of care for 75% of women from Black, Asian and minority ethnic communities and from the most deprived groups.
  2. Severe mental illness (SMI): ensuring annual health checks for 60% of those living with SMI (bringing SMI in line with the success seen in learning disabilities).
  3. Chronic respiratory disease: a clear focus on Chronic Obstructive Pulmonary Disease (COPD) driving up uptake of COVID, flu and pneumonia vaccines to reduce infective exacerbations and emergency hospital admissions due to those exacerbations.
  4. Early cancer diagnosis: 75% of cases to be diagnosed at stage 1 or 2 by 2028.
  5. Hypertension case-finding and optimal management and lipid optimal management: to allow for interventions to optimise blood pressure and minimise the risk of myocardial infarction and stroke.

Whilst not included in the 5, smoking cessation is also included at this level of Core20PLUS5 as a cross cutting theme.  This is because stopping smoking has a positive impact in all of the five clinical areas of focus.

Infographic data reducing healthcare inequalities for children and young people

The ‘5’ in Suffolk and North East Essex for Children

There are five clinical areas of focus. Governance for these five focus areas sits with national programmes; national and regional teams coordinate local systems to achieve national aims.

  1. Asthma: Address over reliance on reliever medications and decrease the number of asthma attacks.
  2. Diabetes: Increase access to real-time continuous glucose monitors and insulin pumps in the most deprived quintiles and from ethnic minority backgrounds and increase proportion of children and young people with Type 2 diabetes receiving annual health checks.
  3. Epilepsy: Increase access to epilepsy specialist nurses and ensure access in the first year of care for those with a learning disability or autism.
  4. Oral health: Address the backlog for tooth extractions in hospital for the under 10s.
  5. Mental health: Improve access rates to children and young people’s mental health services for 0-17 year olds, for certain ethnic groups, age, gender and deprivation.


 CORE20PLUS5 is a new approach aimed at reducing inequalities

  • While some elements of it are clinical, realising the full potential of this approach will require effort and commitment by all partners in our health and care systems.
  • CORE20PLUS5 highlights the need for ongoing prevention work; and if driven by Population Health Management data and approaches, this activity may be more effective than ever before
  • Within Suffolk and North East Essex there are clear opportunities to improve the identified conditions, care pathways and health behaviours within CORE20PLUS5which would increase the likelihood of good health outcomes for many thousands of people
  • We propose that coastal communities; rural communities; people from minority ethnic communities; and populations facing the sharpest health inequalities should be our chosen PLUS populations at Suffolk and North East Essex level. Alliance and teams will also define their own PLUS populations over time, some of which will overlap with these larger communities, and some of which will rightly reflect very local need.
  • The more recently published CORE20Plus5 for Children provides us with the opportunity to focus more specifically on the priority conditions specifically experienced by children.

Last Updated on 3 January 2023

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