Population Health and Equity projects

Our vision is for all south east London residents to have the same opportunity to lead a healthy life, no matter where they live or who they are, through equitable, convenient and effective access to prevention and wellbeing services and support. 

We recognise that it will take time to fully realise this vision across south east London. During 2024/25 we are therefore putting in place building blocks for longer-term delivery and impact by:

1. Co-designing a systematic approach to prevention focused on early detection and intervention and addressing health inequalities; underpinned by population health management;
2. Establishing a multi-year partnership to build trust and confidence in prevention and wellbeing services for our diverse SEL communities;
3. Embedding health equity in our care pathways and enhancing our focus on prevention across the system;
4. Embedding the Core20Plus5 Framework for adults and children and young people across our local care partnerships and care pathway programmes;
   • Driving improvements in the uptake of vaccinations and immunisations across the life course;
   • Continuing to develop and embed Vital 5 interventions for adults and children and young people, with a holistic approach to care through primary and secondary prevention that takes into account the wider determinants of health;
   • Parity for mental health through levelling up investment in mental health services across the system to meet population need in prevention and access to secondary/tertiary care services;
   • Addressing health inequalities for women and girls’ , including co-designing and launching at least one networked women’s and girl’s health ‘hub’ in SEL ICS by December 2024.

Population Health Management is an approach aimed at improving the health of an entire population through data and insight-driven planning and the delivery of proactive care to optimise health outcomes. It is essentially about shifting from a largely reactive system (that is responding only when someone becomes unwell) to a more proactive system (that is focusing on interventions to prevent illness, reduce the risk of hospitalisation, and address inequalities in the provision of healthcare).

Population Health Management should enable services to act as early as possible to keep people well, targeting support where it will have the greatest impact and ultimately helping to address these changing health and care needs.

We want to ensure that all health and care staff in south east London have access to the information they need to make the best possible decisions for the people they care for and to support people to get more involved in their own care. The Coalition will do this by: 

• Raising awareness of population health management as a new way of working across south east London and its successes to date, including lessons learnt from the Wave 2 NHS England and Improvement (NHS E & I) Population Health Management Development Programme;
• Highlighting the benefits of population health management and why population health management should be adopted as a way to work;
• Producing content that tells the story of establishing population health management as a core way of working for the south east London operating model;
• Promote services and tools being developed to enable population health management as a way of working.

To continue to provide the amazing services it does, the NHS must both treat people who are unwell as well as play a key role in helping people from becoming unwell in the first place. We call this prevention of ill-health.

Our work to prevent ill-health includes tackling the root causes of illness. These are sometimes termed ‘the wider determinants of health’ and focus on the social, environmental, and economic factors that affect a person’s overall health and wellbeing.

Through the Integrated Care System (ICS) we are committed to work together as partners across south east London (SEL) on this important agenda. By working in partnership as anchor institutions – large employers with strong local roots – we aim to maximise the impact of our work in this area, developing a collective view of what we need to do differently to address these issues and then acting.

Following a successful community listening campaign run in partnership with the charity Citizens UK at the end of 2023, during which we heard from thousands of people, we have pledged to take forward action in four key areas including understanding how we can address the impact of poor quality housing on health, improving access to good work and improving support for those with English as a second language, paying a living wage, and opening up our NHS estates for the community to use.

We are finding ways to work differently with local people and communities and deliver changes alongside them, including identifying ways we can work in strategic partnership with the voluntary, community and social enterprise sector. This is being delivered in part through our work with the charity Impact on Urban Health to build trust and address health inequalities for Black communities, and our work with the SEL VCSE Alliance to deliver the commitments as set out in the SEL VCSE Charter.

This work takes place alongside the major community led programme of South London Listens which helps to deliver on the priorities that our communities have told us are important to them including improving access to services for migrant and refugee communities and tackling social isolation and loneliness.

King’s Health Partners clinical academics, including Prof John Moxham, developed a system-wide approach to ‘The Vital 5’. This focuses on five risk factors - blood pressure, mental health, obesity, smoking and alcohol intake - which if identified and managed early, will make a big difference to our population’s health and help to reduce inequalities by preventing the onset of ill-health.

The south east London Vital 5 Check is a new, standardised prevention health and wellbeing screening intervention that seeks to better detect Vital 5 risk factors and facilitate preventative support in a way that meets the needs of communities who are more likely to experience health inequalities.

The Vital 5 Check has been designed with healthcare staff and local communities and is focused on the things that residents have said are important to them.  It is currently being piloted in community pharmacies across south east London, community pop-ups and outreach (e.g. in Bromley and Southwark), and in some outpatient services at Guys’ and St Thomas’ NHS Foundation Trust.