Health Inequalities

Cambridgeshire & Peterborough ICB is committed to increasing the number of years people spend in good health. To do this, we are aware of the need to address the variances and disparities that exist in terms of access to healthcare services, the experiences people have of using our services, and the outcomes our population receive.

To oversee the ICB’s approach to addressing such inequalities, the Strategic Commissioning Unit has established and manages the following:

• Population Health Improvement (PHI) Board:

  • The Board provides strategic leadership to improve health outcomes and reduce inequalities across Cambridgeshire and Peterborough. Chaired jointly by the Deputy Chief Executive of the ICB and the Executive Director of Public Health, it brings together partners from across the health and care system, including NHS providers, public health, VCSE, and academic stakeholders.
  • The Board ensures system-wide alignment, evidence-led planning, integration of research, and targeted interventions based on population needs.

• Healthcare Inequalities Strategic Oversight Group (HISOG):

  • The Group has representation from NHS providers, local authority, public health, and the Voluntary, Community and Social Enterprise (VCSE) sector.
  • The Group is responsible for developing insights about existing healthcare inequalities across Cambridgeshire and Peterborough and providing; sharing best practice; collaborating with system partners to identify opportunities to address healthcare inequalities; and monitoring progress against the commitments in the Joint Forward Plan

• NHS Provider Sub-Group

  • This group ensures health inequality priorities are embedded within provider contracts and operational plans. It promotes shared learning, supports alignment across provider organisations, and strengthens accountability in service delivery. The group identifies opportunities to scale effective practice and ensures consistency across different settings and geographies.

• Inclusion Health Network

  • The Inclusion Health Network focuses on improving care for socially excluded groups, including people experiencing homelessness, asylum seekers, refugees, sex workers, Gypsy, Roma and Traveller communities, and individuals in contact with the justice system. It supports the implementation of the NHS England Inclusion Health Framework, fosters co-production with affected communities, and promotes service design that removes barriers to access and enhances equity.

• Primary Care Network

  • This collaborative network connects health inequality leads across PCNs to share learning and drive local action. It enables peer support and strengthens primary care’s role in reducing inequalities through targeted initiatives, including continuity of care, outreach, and improved access for underserved populations.

• Data & Insights Group

  • This group supports the Healthcare Inequalities Strategic Oversight Board by generating analytical reports and insights that inform system strategy and local priorities. It leads on the development and use of the Health Inequalities Improvement Dashboard, Core20PLUS analysis, and population segmentation. Its work ensures data-driven decision-making and supports resource allocation based on need and impact.

The Strategic Commissioning Unit has aligned the health inequalities programme to NHS England’s five strategic priorities. These are as follows:

1. Restore services inclusively
2. Mitigate against digital exclusion
3. Ensure data sets are complete and timely
4. Accelerate Preventative Programmes
5. Strengthening leadership and accountability 

In Autumn 2022, NHS England launched the Core20PLUS5 approach to support the reduction of health inequalities at both national and system level.

The approach defines a target population – the ‘Core20PLUS’ – and identifies ‘5’ clinical areas requiring accelerated improvement.

Core20: The most deprived 20% of the national population as identified by the national Index of Multiple Deprivation (IMD).

The IMD is the official measure of relative deprivation for small areas (or neighbourhoods) in England. The IMD ranks every small area (Lower Super Output Area) in England from 1 (most deprived) to 32,844 (least deprived).

There is a wide body of evidence that underlines the relationship between deprivation and health outcomes. There are many health-related indicators, such as number of preventable deaths, that increase as deprivation increases as well as many health-related indicators, including life expectancy and access to primary care services, which decrease as deprivation increases.

For Cambridgeshire and Peterborough:

• Although not considered to be a system with a high-level of deprivation across England as a whole, deprivation within Cambridgeshire & Peterborough is spatially concentrated predominantly within Peterborough and Fenland.
• The average IMD score for the ICB footprint is 16.8 (this is less deprived than the national average of 21.7).
• 13.6% of our population (approx. 112,000) reside within the 20% most deprived quintile nationally. Approximately 107,000 (95%) of these live in the North of the system, with relatively small pockets of high deprivation in the South, concentrated within Cambridge City and Royston. 

PLUS: ICS-determined population groups experiencing poorer than average health access, experience and outcomes, but not captured in the ‘Core20’ alone. This should be based on population health data at a local ICS-level. For Cambridgeshire & Peterborough, examples of PLUS groups include:

• Gypsy, Roma, and Travellers (GRT) are one of the largest ethnic minority groups, with approximately 7000+ living within the ICS footprint.
• There are approximately between 1,500-1,700 people who are homeless within Cambridgeshire & Peterborough. Population growth, combined with increasing housing costs and lack of affordable housing is one of the possible reasons for increasing homelessness issues.
• Cambridgeshire & Peterborough has a large transient migrant population, with influxes of migrant workers predominantly from Eastern Europe, most markedly in the Fenland and Peterborough areas.

 

Core20PLUS5 (adults) – an approach to reducing healthcare inequalities

 

Core20PLUS5 – An approach to reducing health inequalities for children and young people

In November 2023, NHS England published new guidance on how NHS bodies discharge their responsibility to report information on health inequalities:

NHS England » NHS England’s statement on information on health inequalities (duty under section 13SA of the National Health Service Act 2006)

The guidance reflects a proportionate and phased approach to gathering and making use of available information on health inequalities and recognises that this will evolve over time.

NHSE also provided a list of indicators that NHS bodies should collect, analyse and publish on health inequalities.

NHS England’s Statement on Information on Health Inequalities (duty under section 13SA of the National Health Service Act 2006)

The Health Inequalities Information Statement Data Pack is supplementary to NHS Cambridgeshire & Peterborough ICB’s annual report and should be read in conjunction with this.

The pack has been created to highlight how Cambridgeshire & Peterborough ICB is delivering against NHS England’s priorities and discharging its statutory duty to tackle inequalities in outcomes, experience and access.

Cambridgeshire & Peterborough ICB’s Health Inequalities Information Statement for 2024/25 can be found here: Health Inequalities Information Statement

Inclusion health is an umbrella term used to describe people who are socially excluded, who typically experience multiple interacting risk factors for poor health, such as stigma, discrimination, poverty, violence, and complex trauma. People in inclusion health groups tend to have poor experiences of healthcare services because of barriers created by service design.

These negative experiences can lead to people in inclusion health groups avoiding future contact with NHS services and being least likely to receive healthcare despite having high needs. This can result in significantly poorer health outcomes and earlier death among people in inclusion health groups compared with the general population.

This includes people who experience homelessness, drug and alcohol dependence, vulnerable migrants, Gypsy, Roma and Traveller communities, sex workers, people in contact with the justice system and victims of modern slavery.

The ICB continues to work with system partners to embed NHSE's Inclusion Health Framework to support those within inclusion health groups overcome barriers to accessing healthcare services; to be more visible in data sets; to ensure services are not designed to exclude inclusion health groups; to help overcome digital exclusion; and to empower people to look after their health and wellbeing though personalised care and peer support approaches.

NHSE’s Inclusion Health Framework can be found here:

NHSE's Inclusion Health Framework

For further information on how Cambridgeshire & Peterborough ICB is working to deliver the inclusion health framework, with examples of specific actions being taken, please refer to the Health Inequalities Information Statement for 2024/25.