Using Population Health Data to Address Health Inequalities

Case Study

Using Population Health Data to Address Health Inequalities

With NHS Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board (ICB)

 

The Challenge

Voluntary, Community, Faith and Social Enterprise (VCFSE) organisations often have invaluable relationships with communities but limited access to the data needed to evidence health inequalities and influence strategic decision-making. 

In 2024 Changing Suits hosted a series of community based Sahara Health Fairs to raise awareness about mental health within the South Asian community. With 2,000 attendees across all health fairs, the project allowed different parts of the community to access support services and attend awareness talks in South Asian languages by Mental Health Consultants and Psychiatrists. 

Changing Suits recognised that without access to population health data, it would be more difficult to demonstrate where inequalities existed and advocate for targeted interventions within South Asian communities.

Working in partnership with Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board (BSW ICB), we set out to overcome this barrier. 

Our Solution

Changing Suits worked collaboratively with BSW ICB to secure access to the Integrated Care Record (ICR) Population Health Management tools, becoming the first Voluntary, Community, Faith and Social Enterprise (VCFSE) organisation within BSW Integrated Care System to achieve this. 

Securing access required persistence, collaboration and a shared commitment to improving health outcomes. The result not only enabled Changing Suits to access valuable population health data but also demonstrated that meaningful partnerships between the NHS and community organisations can create new opportunities for addressing health inequalities.

The first project used the data to establish a baseline understanding of mental health needs within South Asian communities, providing evidence to inform future work and identify areas requiring targeted support.

Building on this, the next phase of work will focus on understanding the prevalence of cardiovascular disease within South Asian communities, helping to inform future interventions and improve population health outcomes.

Alongside this work, Changing Suits has continued to provide culturally informed advice and insight to support wider health initiatives. This has included contributing to discussions around the underrepresentation of South Asian women accessing Long-Acting Reversible Contraception (LARC), helping to explore potential barriers and identify opportunities to improve engagement.

The Results

Through this partnership, Changing Suits became the first VCFSE organisation within BSW Integrated Care System to gain access to the ICR Population Health Management tools, creating a pathway that has the potential to benefit many other community organisations in the future.

Access to population health data has enabled evidence-led work to better understand the health needs of South Asian communities, supporting more targeted interventions and contributing to the shared ambition of reducing health inequalities across the region.

The partnership has also strengthened collaboration between the NHS and the voluntary sector, demonstrating the value of combining population health data with community expertise to gain a better understanding of local needs.

As Lucy Heath, Swindon Health and Care Professional Director at NHS Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board, said…

“We have worked together to enable access to the ICB’s Integrated Care Record Population Health Management tools. Changing Suits is the first VCFSE organisation in BSW ICS to gain access to this. Their hard work has demonstrated both to the ICB and to other VCFSE organisations that it is possible, and we hope this will lead to many other organisations gaining access.”

She added

“I have also asked their advice on several projects and really appreciate access to their expertise… colleagues from Changing Suits were able to share useful insights based on their personal experiences and experience of working with this population. This has the potential to develop into a shared project to address this inequality.”

 

Project Outcomes

  • First VCFSE organisation within BSW ICS to gain access to the Integrated Care Record Population Health Management tools.
  • The data revealed very low baseline data for South Asians suffering with mental health issues which were seen as well below the national average. This further goes back to low diagnosis’ caused by several systemic factors including stigma around mental health, not seeking professional support and problems in diagnosis for patients who may not use English as their first language.
  • Supporting future work exploring cardiovascular disease prevalence.
  • Contributed cultural insight to emerging work addressing inequalities in sexual and reproductive health.
  • Demonstrated how NHS organisations and community organisations can work together to reduce health inequalities through evidence-informed practice.
  • More work needs to be done to join the bridges between NHS and VCFSEs. 

Work With Us

If you’re looking for ways to understand ethnic diverse communities better, or improve access to health and wellbeing services, Changing Suits can help.

Get in touch to learn how we can support your organisation in delivering meaningful, community-led impact.