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A Population Health Approach

A population health approach aims to improve physical and mental health outcomes across the population, while reducing health inequalities. It takes into consideration the wider factors that influence these outcomes and recognises the need to work with communities and across partner agencies. An understanding of the complex interplay between these factors and joined-up action by partner agencies across the whole system is therefore required to effectively address inequalities.

Across Suffolk and North East Essex, different causes of death contribute to the difference in life expectancy between our most deprived and least deprived communities. Leading causes of death include circulatory conditions, cancer and respiratory conditions. Several underlying risk factors are implicated in their causation, e.g., tobacco, high body mass index (BMI), diabetes, dietary risks, high blood pressure, alcohol and high LDL (low-density lipoproteins or “bad” cholesterol). Focused action to tackle these risk factors will not only prevent people from developing these conditions but will also reduce health inequalities. A system-wide focus on prevention, targeting areas where we have the strongest evidence for inequalities, is therefore important

Core20PLUS5, a national NHS England and NHS Improvement (NHSEI) approach to reducing health inequalities, highlights areas for targeted prevention work. It asks for a focus on the target population of the 20% most deprived population as defined by the Index of Multiple Deprivation (the “Core 20” of the national population), ICS-determined groups experiencing poorer than average access, experience or outcomes from healthcare (the “PLUS”) and “5” clinical focus areas with the greatest opportunities to narrow the current gap in life expectancy due to health inequalities. These areas include the same conditions and underlying risk factors outlined above. Core20PLUS5 therefore offers a way of reducing inequalities by targeting prevention work using population health management data and approaches in ways which are responsive to the needs of our ICS population.

Population health management (PHM) data will help the system to identify areas of focus and individuals or communities for targeted interventions. Linked datasets will provide insight into current and future population needs, allow targeted action to prevent ill health and reduce health inequalities, enable the delivery of better coordinated care and better use of scarce resources. It will enable us to move from data to action and have much greater impact than could be achieved previously.

This was the focus of the Annual Director of Public Health Report for Suffolk 2022.

Effective action to address health inequalities in Suffolk and North East Essex will require a coordinated and whole-system approach, with targeted prevention work focusing on Core20PLUS5, and using PHM as an enabler. To facilitate this, we propose the establishment of a Health Inequalities and Prevention Committee (HIPC) reporting into the Integrated Care Board (ICB) and a system-wide Health Equity Network reporting into the Integrated Care Partnership (ICP).

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