From the Ground Up:

I am pleased to present the Hounslow Annual Public Health Report for 2023-24. This year we are sharing our experience of embedding the NHS England CORE20PLUS5 approach in Hounslow. We will show how, alongside the Council and the Borough-Based Partnership’s (BBP) prioritisation of equality, diversity, and inclusion (EDI), we used it to tackle health and wellbeing differences in our neighbourhoods and communities.  

Our collective ambition is to achieve a “Fairer, More Equal Hounslow” by reducing differences in health outcomes between people who live in the 20% of neighbourhoods and communities with the most deprivation (the CORE20 areas), and the rest of the population.  

We have started to address the five clinical ‘PLUS’ areas of CORE20PLUS5 using our population health management framework. We have extended our focus to include Hounslow-specific PLUS groups we know experience significant health and social inequality and for whom we have prioritised making a difference. The Hounslow PLUS groups we have prioritised are our homeless community, asylum seekers and young carers.  

The two approaches, the NHS CORE20PLUS5 and the EDI strategy of Hounslow Council and BBP, need to align. Improved health outcomes are not solely about access to clinical services. More importantly, people need the building blocks for sustained better health. These are the social, economic and environment health determinants into which people are born, grow, live, and age, and the relationships they have with those who are important in their lives.  

This report is a timely reminder that place-based inequality between neighbourhoods and communities is not acceptable. Despite changes to health and social care, and our collective commitment to reduce health inequality that pre-dates the work of the Marmot review, the gap between the most and least deprived areas and communities remain. For some it has even widened, especially among society’s most marginalised and vulnerable groups. The lack of progress despite investment could arguably be seen by some communities as an acceptance that change for them is not important. It is not surprising then that they sometimes lack trust and confidence in health services and are unwilling to engage with them. 

If taking the same approach repeatedly and expecting a different result is the definition of madness, we hold our hands up and admit this is a pattern we may have previously fallen into. But we hope our report demonstrates that we are committed to change and trying to do things differently by looking through a more informed lens, one that gives us a greater understanding of the health, social and economic needs in our most deprived, most vulnerable communities. The most important action we have taken is to engage with residents, to listen, understand, build trust and confidence, and start to act on what they told us could help them live healthier lives.   

We have shared a step-by-step methodology of what steps we took and warmly welcome your views on our approach. Even better, share your experiences. We want to learn, especially if it can help us.  

I acknowledge and thank the residents of Hounslow who gave their insight and the Hounslow VCSE groups who were the trusted people who gave residents the confidence to speak about their experiences. Thank you to my colleagues at Hounslow Council, our local NHS and my Public Health team for contributing to this report.  

Kelly O’Neill

Hounslow Director of Public Health

Hounslow's Annual Public Health Report 2023-24 report tells the story of Hounslow’s experience of embedding the NHS England CORE20PLUS5 approach to target action to reduce health inequalities. This report also brings together our population health approach and the Hounslow Partnership prioritisation of equality, diversity, inclusion (EDI), focusing on prevention and early intervention to tackle health and wellbeing differences in our neighbourhoods and communities.

Hounslow Borough Based Partnership was systematic in selecting the priority areas for CORE20PLUS5 in Hounslow. Not only have we focused on residents living in Hounslow’s CORE20 areas, but we also prioritise action to improve the health and wellbeing of three vulnerable groups: those experiencing homelessness, young carers, and asylum seekers. This work has been guided by the Borough’s population health management framework, integrating population health data analysis and community engagement to understand the lived experiences of our residents and their access to health and care service.

The 25,199 residents in CORE20 areas in Hounslow have weaker foundations upon which they can build healthy lives than the rest of Hounslow. In our most deprived communities, the social and economic experience of residents living in these areas includes lower incomes with fewer residents being employed in managerial roles and owning their own homes, food insecurity and greater exposure to unhealthy food and drink advertising. Residents in these areas also have longer travel times to access services, including health and wellbeing services compared to residents in the rest of the borough. This is especially important as this report shows there are inequalities in health indicators between residents living in CORE20 areas and the rest of Hounslow observed across all life stages. The data presented can be filtered by Primary Care Network to inform local work.

In our CORE20 communities we observed higher rates of childhood illness and long-term health conditions including asthma, diabetes, and obesity and uptake of primary immunisations was lower amongst children living in CORE20 areas compared to children living in the rest of Hounslow. We also observed that the attendance rate at A&E between April 2023 and March 2024 for children aged under 5 was higher in CORE20 areas than the rest of Hounslow.

Our data shows that there was higher prevalence of all long-term conditions and smoking amongst working age adults in CORE20 areas compared to the rest of Hounslow. Through engagement, residents in CORE20 areas spoke about experiencing chronic pain, mental ill-health and long-term health conditions and how this impacted on their ability to gain and maintain employment. Uptake of breast and bowel cancer screening as well as flu vaccine uptake was lower in CORE20 areas than the rest of the borough. 

Inequalities also continue later in life. There was higher prevalence of smoking, chronic obstructive pulmonary disease (COPD), anxiety, depression, diabetes and obesity amongst people over the age of 65 years who live in our CORE20 areas. Hospital admission rates due to a fall for people aged 65 years and over, a key driver of frailty, were also higher in CORE20 areas.

How to improve health and wellbeing

Our engagement with residents in CORE20 areas showed that residents were not aware of the support services that are available. They asked for better dissemination of information in formats they understood available through trusted partners. Education to understand how they could improve their health, including more understanding of the social influences on health and wellbeing was also requested. Residents in CORE20 areas asked for improved access to services that could help them maintain physical and mental health and wellbeing.

This report demonstrates that it is possible to reduce the gap in inequalities between CORE20 areas and the rest of Hounslow. We present examples of work that demonstrate this.  

The approach we have taken to understand differences in health and wellbeing need between people living in CORE20 areas and the rest of the borough will enable system partners to better understand health and wellbeing need. They will be able to filter data at the Integrated Neighbourhood Team level, enabling professionals in these areas to access the necessary information to more effectively target neighbourhoods and communities with greater health needs. This will allow for the efficient allocation of resources and collective actions aimed at achieving better health outcomes for those with the greatest health and wellbeing needs, ultimately fostering a more informed approach to tackling health inequalities.

A health need audit of over 100 people in Hounslow experiencing homelessness was carried out in 2024. The audit found that:

• 75% of respondents reported having a physical health condition.
• 61% said the level of support they receive to manage their physical health does not meet their needs.
• 72% reported they had a mental health diagnosis with 51% of these people also managing comorbidities of mental and physical health need.
• 18% reported they had a learning disability. The proportion of homeless people with a learning disability is significantly higher compared to the 2% prevalence of learning disabilities in the general population.

There is limited data available that informs us of the health needs of young carers which makes it challenging to fully assess and understand their health needs. Data available from the North West London clinical systems shows that young carers experience higher rates of long-term physical and mental health conditions such as anxiety and asthma compared to the overall Hounslow child population aged 0-17.

Our report recognises that work is needed to better understand how many young carers there are in Hounslow, their health and wellbeing needs, and what they say will help them transition into adulthood, ensuring access to career and education opportunities.

The health and wellbeing of asylum seekers was the focus of the  Hounslow 2022-23 Annual Public Health Report . This year's report reviews the recommendations we made and the progress achieved, recognising that the scale and pace of improvement is directed by national policy and decisions made by Government. The latest data (September 2024) shows us that more Hounslow hotels are currently being used by the Home Office to house asylum seekers resulting in a increase in the number of asylum seekers in Hounslow; 1,900 people of whom 1,632 are living in contingency hotels. The challenge of tackling mental ill-health and improving nutrition through better food quality are two health needs that continue to be unmet due to that lack of additional funding and the continued need for Home Office action to make improvement.

This report sets out detailed understanding of the health inequalities of four groups in Hounslow aligned to the CORE20PLUS5 strategy. The findings demonstrate the complexity of addressing the wider public health determinants that influence health outcomes. The recommendations in the report show the vital role regional and local systems can play in reducing the health inequity gap. Change is possible. The findings should inform local policy, planning developments, strategies and services. This report calls for collective and collaborative action that unites residents, teams, and organisations to better understand the drivers of health needs. It emphasises the importance of focusing on prevention and early intervention, redesigning existing services, and improving communication about access to these services. Furthermore, it advocates for the use of place-based policies to enhance health and wellbeing.

Welcome to Hounslow's 2023-24 Annual Public Health Report. This year our report focuses on using the  NHS England CORE20PLUS5 approach  that aligns to the  EDI  strategy of the council and the BBP priority of population health improvement to tackle health inequalities in Hounslow. Our purpose is to raise awareness, assess population need, to identify unmet need, and recommend action that leads to positive health change focusing on residents with the greatest health need.  

Our report provides a detailed analysis of the lived experiences as well as the health and social determinants of our four priority groups: CORE20 residents, asylum seekers, those experiencing homelessness, and young carers. It sets out recommended action to reduce inequalities and improve health for all.

A thriving, healthy community needs good "building blocks". These building blocks include, but are not limited to housing, access to good education, and employment, safe green spaces, and public transport.  ¹   When one or more of these building blocks is missing, there becomes a strain on our bodies and minds and can lead to stress, high blood pressure, a weaker immune system, ultimately reducing life expectancy and number of healthy years lived.

As a result, people in the most deprived neighbourhoods and communities in England die nearly a decade earlier than their neighbours in more affluent areas. For example, men in England's most deprived areas live 74.1 years on average, 9.4 years less than those in the least deprived areas.  ²  

Health inequalities are unjust and, avoidable differences in health status, that are also affected by the social conditions in which people are born, grow, live, work, and age. Health inequalities also refer to differences in access to, experience of and benefit from health and care services.  ³  

NHS England's CORE20PLUS5 framework provides a systematic approach to addressing healthcare inequalities.  ⁴   In Hounslow, we have consistently focused on reducing inequalities and improving health outcomes through the Borough-Based Partnership's (BBP) Prevention and Health Inequalities workstream. The Hounslow BBP brings together system partner organisations across health and social care to focus on shared health priorities that also contribute to the  Hounslow Joint Health and Wellbeing Strategy 2023-2026  which emphasises the need to deliver against the CORE20PLUS5 approach, utilising a Population Health Management (PHM) framework.

Many individuals face overlapping health conditions compounded by broader social and economic challenges that significantly influence their wellbeing. These inequalities cannot be tackled by health and care services alone, as factors such as poverty, housing, and employment play a critical role in shaping health outcomes.  ⁵  

In Hounslow, we have taken a more holistic approach to address not only the clinical priorities but also the wider determinants of health across social, economic, and environmental domains. By adopting this holistic perspective, we are working collaboratively with the Council and Borough Based Partnership to design targeted interventions that reduce inequalities and improve health outcomes for all residents.

The Council's  Equality, Diversity, and Inclusion (EDI) Strategy, "A Fairer, More Equal Hounslow,"  published in 2023, adopts a similar approach that goes beyond the seven factors that contribute to the Index of Multiple Deprivation by recognising equality by place, group, and employer. It utilises broader definitions of deprivation including community needs index score, and households with multiple deprivation characteristics. Working together, the local implementation of CORE20PLUS5 in this report has directly contributed to shaping the health aspects of the council's EDI strategy.

Over the past decade, there has been a growing focus on the wider and commercial determinants of health. The Health Foundation has researched effective ways to communicate these determinants.  ¹   The "building blocks" metaphor is a tool for illustrating the factors that shape health and guiding efforts to reduce inequalities.

The NHS CORE20PLUS5 approach guides Integrated Care Systems to deliver work to reduce healthcare inequalities.  ⁴   The approach directs who and what to focus on to address health inequalities, by focusing on key communities and key clinical areas that drive health inequity. It guides place-based integrated health and care systems to identify areas to prioritise ensuring resources are allocated collectively and effectively to reduce gaps in health and care outcomes.  ⁴  

The approach says that local health system should focus on the 20% of the national population living in the most deprived areas, the lowest deprivation quintile (levels 1 and 2 of the Index of Multiple Deprivation).

What is Index of Multiple Deprivation?

The Index of Multiple Deprivation (IMD) is the official measure of relative deprivation for small areas in England. It measures how deprived an area is by combining indicators under seven different domains of deprivation: Income, Employment, Education Skills and Training, Health and Disability, Crime, Barriers to Housing and Services, and the Living Environment. Areas are scored and grouped into deciles, with lower deciles (1 and 2) indicating the most deprived areas. We know that the IMD isn't perfect; some individuals living in affluent areas will have needs it does not capture, the IMD does help government and organisations target resources more effectively. By highlighting areas of greatest need, the IMD guides systematic efforts to improve outcomes, though we must also consider those not fully represented by this measure.

The CORE20PLUS5 approach also recognises that there are population groups who might not live in more deprived areas but are known to experience poorer health outcomes. It directs local health systems to select additional 'PLUS' priority groups based on local data and intelligence.

For a local health system, these PLUS groups might be:

• ethnic minority communities
• people with a learning disability and autistic people
• people with multiple long-term health conditions
• people experiencing homelessness
• people experiencing drug and alcohol dependence
• vulnerable migrants
• Gypsy, Roma and Traveller communities
• sex workers
• people in contact with the justice system
• victims of modern slavery

The approach also sets out five clinical outcomes with significant inequalities and, for adults, emphasises smoking as the most modifiable risk factor affecting all five areas. By focusing effort on these clinical outcomes we can significantly achieve a reduction in health inequalities for children's and adults across England.

Hounslow Borough Based Partnership has been systematic in implementing the CORE20PLUS5 approach.

Hounslow’s BBP introduced a population health management framework in 2021. The framework is used to review, prioritise and develop the programme of public health activity, particularly to tackle differences in health risk and need. 

Using the framework helps the BBP identify and target those with the greatest health risk and directs the use of data and engagement to understand the needs of these residents to develop evidence-based interventions while prioritising evaluation to understand impact. The framework has guided our structure for implementing CORE20PLUS5.

As a Borough Based Partnership, workshops were held using local data and stakeholder intelligence to agree four priority groups: residents living in CORE20 areas, and three PLUS groups; asylum seekers, those experiencing homelessness, and young carers. While all PLUS groups need more support, it was recognised that these three PLUS groups face significant challenges in health outcomes and access to services locally that we needed to act on.

A range of sources have been utilised to measure the health needs of Hounslow's CORE20 population, asylum seekers, those experiencing homelessness, and young carers. Health care outcomes data for patients registered to a Hounslow General Practice has been extracted and analysed from North West London Integrated Care Board’s (ICB) clinical databases (Whole Systems Integrated Care (WSIC) and SystmOne). Other data sources include the National Child Measurement Programme (NCMP) and Homeless Link, as well as publicly available information from the 2021 Census, Transport for London (TfL), the Home Office, Urban Big Data Centre (UBDC), and Consumer Data Research Centre (CDRC). More detail is provided in the   Replicate this Approach  section.

For each priority group, we aimed to engage directly with residents to understand their lived experiences and stories.

As a result of this report, it is expected that the Borough Based Partnership will deliver interventions to reduce inequalities presented here and evaluate them to understand impact.

The report is set out in four sections, each presenting the findings on each priority CORE20 and PLUS group.

There are 25,199 residents living in CORE20 areas in Hounslow and registered with a Hounslow GP (as of August 2024). Understanding their experiences compared to those living in the rest of the borough allows for more targeted and supported interventions. For this report, we refer to the CORE20 as those registered with a Hounslow GP living in CORE20 areas and the 'rest of the borough' as those registered with a GP in Hounslow who live in other areas within Hounslow’s geographical area. The healthcare data is broken down by broad age groups: children and young people (0-17 years), working age adults (18-64 years), and older adults (65 years and over) that enables us to understand the challenges unique to each life course phase. 

We combined findings from analysing segmented health data from local clinical systems and other wider determinant datasets with insight from local resident engagement to examine how comparable the insight from residents was with the health and care data. This approach allowed us to provide evidence and explanations behind the stories shared and to compare CORE20 residents to the rest of the Hounslow population, measuring key differences in health outcomes. Beyond the five clinical outcomes outlined in the national approach, we explored additional determinants including health, socio-economic, and environmental factors to provide a more comprehensive understanding of health inequalities in Hounslow.

To understand what impacts health and wellbeing, we needed to speak to residents. We knew that these conversations are the most meaningful when led by trusted voices within the community. We partnered with nine (9) VCSE groups to facilitate discussion groups with our residents in April and May 2024.

We asked residents:

• What does health and wellbeing mean to you?
• What challenges affect health and wellbeing? 
• What activities, services and support could improve health and wellbeing? 
• What enablers and barriers exist in finding, accessing or benefitting from existing health and wellbeing services, and how do you suggest we overcome them? 

The community groups captured the insights of 340 individuals who live in CORE20 areas in Hounslow. Findings from this engagement were compared with the insights from the data analysis.

The funded VCSE groups who led engagement with residents in CORE20 areas were:

•  Acacia 
•  Autism Hounslow 
•  Brentford FC Community Sports Trust  
•  C-Change 
•  Fairer Housing 
•  Friends of Cathja 
•  Golden Opportunity Skills and Development (GOSAD) 
•  Hounslow Borough Respiratory Support Group 
•  SFIDA 

The findings from this report will guide the design of targeted interventions by the Borough-Based Partnership to improve the health and wellbeing outcomes for CORE20 residents. The PHM framework emphasises the importance of evaluation to understand what works in reducing inequalities. Evaluation is essential to ensure these interventions deliver measurable positive impacts, address gaps, and adapt to residents' needs for sustainable improvement.

A detailed summary of our methodology is provided in the  Replicate this Approach  section of this report.

We learnt that health and wellbeing have different definitions, meanings and interpretations for different people. The definition of ‘health’ used in this report is ‘a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’.  ⁶   Based on this definition, ‘health’ and ‘wellbeing’ are both included when using the term ‘health.’ Recognising that there are different views and understandings, we asked residents what health and wellbeing means to them.

Asking our CORE20 residents what health and wellbeing means to them is essential to ensure their insights included in this report are personally relevant and accurate, as well as culturally and contextually specific. Rather than making assumptions, this approach fosters trust by actively seeking and listening to their experiences and opinions before designing solutions.

Residents shared rich insights into what health and wellbeing means to them, demonstrating both supportive aspects and areas for improvement across services and the local environment. Their stories reveal that there are complex layers influencing their health and wellbeing from family, friends, and community beliefs to the broader, and at times confusing messages they encounter every day.

Our residents described being healthy as being free from mental and physical illness and pain. They discussed several elements, including eating healthy and balanced meals, being physically active, sleeping well, and managing stress and emotions.

When discussing social wellbeing, residents emphasised the importance of connections, community support, and a sense of belonging. Many shared that their health and wellbeing needs and what they value is shaped by family, friends and their local community. However, these personal influences often clash with the messages they encounter on social media or in advertising, where ideals of “health” can feel unrealistic or confusing. This creates uncertainty about whom to trust and what truly supports a healthy lifestyle.

They highlighted aspects of the local environment that make a difference in their daily life, such as accessible transport networks, access to green space, affordable, safe and warm homes, and convenient places to gather, like cafes and dining spots.

To better understand the factors affecting health and wellbeing in this community, we explored the challenges residents face. They shared their experiences related to physical and mental health, the wider social, economic, and environmental conditions, as well as accessing health and wellbeing support services.

These findings are explored in more detail with local data and evidence in the following sections comparing the differences between our CORE20 residents and the rest of Hounslow through:

• Supporting environment
• Housing and employment
• Access to services
• Health and wellbeing Indicators

We have split the sections of health data into three population groups: children and young people, working age adults, and older adults due to the specific health and wellbeing needs that impact these cohorts.

Like the solid foundation blocks that are essential to building strong structures, the same can be applied to health and wellbeing. In Hounslow’s CORE20 areas, some of the essential building blocks are either missing, or in need of repair. For example, many residents stated that they felt unable to participate in physical activity, not due to a lack of green spaces or motivation to be healthier, but rather because they considered these spaces as inaccessible due to poor maintenance and feeling unsafe.

Residents recognised the importance of healthy eating and access to nutritious food. However, they highlighted barriers such as the widespread promotion and accessibility of cheap, processed, unhealthy food compared to healthier options as factors influencing their choices.

Our team walked through several highstreets in Hounslow on a day in June 2024 to discover the density of unhealthy food advertising in different areas. They found that there were more unhealthy food adverts in CORE20 areas than the rest of the Hounslow.

In the CORE20 area of Bedfont, in just a 3 minute (0.2 mile) high street walk, there were 10 unhealthy adverts (Figure 10).

However, in non-CORE20 areas, for example, a 40 min (2.7 mile) walk along Chiswick high street there were 8 adverts for unhealthy food (Figure 11).

To strengthen these building blocks our CORE20 residents say we need to improve the use of food banks through advocacy campaigns that help to reduce any perceived stigma of needing to use them. Other recommendations include, support physical activity through improved community facilities such as green spaces, sports, leisure facilities, walking and bike trails to support physical activity, and to improve the use of parks through regular park maintenance, and the increased presence of enforcement services such as the police and drug reduction interventions.

Employment opportunities and access to safe and well-paid local jobs is essential to support other building blocks such as having a sufficient income for an affordable, safe and liveable home. When employment and income opportunities are missing, it restricts our options making it harder to keep healthy. In many of our conversations with CORE20 residents we learned more about how these building blocks are missing from their lives and how this affects our residents.

On average, men's healthy life expectancy increases by 5.1% for every 10-percentage-point increase in the area's employment rate.  ⁸   A higher proportion of CORE20 residents are employed in lower paid jobs compared to the rest of Hounslow. Financial stress impacts health behaviours such as levels of smoking and physical activity as well as mental and physical health.  ⁹  

There is a lower proportion of Hounslow's CORE20 residents employed in managerial and professional occupations, with higher proportions of CORE20 residents employed in roles such as plant and machine, caring, elementary, and sales roles that offer lower salaries (Figure 12).

Only 25% of our CORE20 households own their homes compared to almost 50% of the rest of Hounslow households (Figure 13). Almost 40% of residents in CORE20 areas are living in socially rented homes owned by the council. Residents stated their experiences of overcrowding, due to adult children being unable to afford to move out of their family home. Residents also stated issues of damp, mould and condensation that contributed to the crumbling of this building block and the adverse impacts poor housing has on health and wellbeing.

To strengthen the housing and employment building blocks, residents suggest more advocacy support is needed for better housing, job creation and fair treatment. They also want more education on how to manage their existing income as well as managing stress.

Improving health and wellbeing in our CORE20 areas is not only about identifying and analysing data, but also about understanding and listening to the insights from our residents and working with them to make access to services work for them. Residents shared key actions which can help improve awareness and experience of available services including health services, leisure centres, parks, and community hub locations. They told us it is important to:

Provide access to trustworthy information through community-trusted messengers using a variety of communication channels to ensure inclusivity. They told us we needed to offer translated materials to reach residents with diverse language and reading needs.

Support residents in attending existing community events, ensuring these spaces are inclusive and health focused. They said we need to increase the number of health and care workers to meet demand and offer more flexible appointment options, this is especially important for families where adults are shift workers which is common amongst CORE20 residents in Hounslow due to our proximity to Heathrow airport and the travel and logistic business infrastructure that supports this. We need to reduce barriers such as long waiting times, administrative complexities, and rigid scheduling.

Provide free or discounted access to sports, arts, and wellness activities, helping residents maintain physical and mental health. Foster environments that build trust, enabling personalised care. Ensure digital and face-to-face services are user-friendly and accessible to all, reducing digital exclusion. Ensure culturally appropriate services with trained staff who are culturally aware.

Adopt a comprehensive, holistic approach to care that addresses multiple health concerns in one visit when possible. Encourage a multidisciplinary team approach, shared health records, and streamlined referral processes to reduce fragmentation in care provision.

Residents would like to see psychosocial education that recognises how social factors influence an individual's health and wellbeing and their behaviours. Specifically, education on mental health, stress management and financial skills as well as community activities targeting social isolation. The most popular way of delivering these activities was in a format that fosters community participation and networks such as through community groups, clubs and/or events.

Many VCSE groups in Hounslow support residents living with long term conditions such as asthma, COPD, and autism. However, CORE20 residents told us they were often unaware of these organisations and the services available locally. Through the engagement process with CORE20 residents, many VCSE groups realised that residents in CORE20 areas are not accessing their events or support groups due to this limited awareness. Better communication is needed to ensure our CORE20 residents know about the existing service offers from VCSE groups available to support their health and wellbeing.

Improving access to NHS Health Checks and increasing the uptake by eligible people in CORE20 areas is an example of targeted action in Hounslow that aims to reduce health risk through early detection and intervention.

Uptake of NHS Health Checks in CORE20 areas was significantly lower than the rest of Hounslow in April 2022. A partnership between public health, primary care and residents led to increased community engagement and telephone calls from primary care to residents which provided education on the importance of NHS Health Checks and the invite to attend. This partnership resulted in an increased uptake in NHS Health Checks in CORE20 areas from 6% to 32% in one year (Figure 29) .

Fifteen recommendations were made and directed at national and local public sector organisations. The main recommendations for the UK Government and Home Office are stated below. The pace of change improve conditions has been outside local control and has been disappointing given that numbers of people living in hotels has increased and basic food and mental health needs are not being met, putting their health and wellbeing at risk. We therefore reinforce our recommendations to the UK Government and Home Office to make the changes needed. A reminder to them is the repeated in the recommendations below.  

The report recommended that the UK government works with local areas as equal partners to deliver more collaborative approaches, reduces fragmented working between central government, provides sufficient funding to local areas to meet the demand and need, and takes immediate action to hold accountable the organisations commissioned to provide accommodation, welfare support and food, to asylum seekers.

The report recommended that the Home Office share information with local areas to better understand the health risks of the asylum seeker communities accommodated locally. Additionally, to ensure that their commissioned provider of services for asylum seekers provides training for hotel staff that increases their understanding and empathy towards the needs of asylum seekers. Also recommended was the need to improve continuity of care processes for asylum seekers, achieved through improvement in health data records that leads to timely communication between services in the areas where an asylum seeker is located. We also recommended that the Home Office improve communication, including translation services, to help orientate new asylum seekers as well as commission an independent advocacy organisation on each local area to advocate for the voices of asylum seekers.

The report recommended that the local authority, local NHS and voluntary sector organisations are enabled with adequate central government funding to:

While significant progress has been made to support asylum seekers in Hounslow locally, there is more to do in ensuring better health and wellbeing of this population. The progress outlined here provides a foundation for building on last year’s recommendations this year and next.

Our Annual Public Health Report 2023-24 set out to understand the inequalities experienced by four groups: those living in CORE20 areas in Hounslow, those experiencing homelessness, young carers, and asylum seekers. Our report highlights the health inequalities faced by over 25,000 residents who encounter systemic, environmental, and structural barriers that undermine their ability to live healthy and fulfilling lives.

Reducing the inequalities presented in this year's report requires a shift from focusing solely on individual lifestyle choices or using language that places blame on residents.

Instead, we must take concrete action to address the systemic building blocks that make it easier for people to live healthier lives.

Change is already underway. Initiatives such as increasing the uptake of NHS Health Checks demonstrates how altering the behaviours of trusted community messengers, rather than placing the responsibility on residents alone, can lead to meaningful improvements.

Our findings show that that our residents understand what is needed to achieve health and wellbeing but often find their efforts blocked by structural challenges.

While national reforms remain critical, regional and local systems have a vital role to play. From influencing policies and designing accessible services to improving communication methods, local action can create tangible benefits for residents.

By focusing on our CORE20 population and the three PLUS groups, we can drive strategic, collaborative efforts across the BBP. A population health management approach that acknowledges the wider determinants of health provides a clear process and pathway for change.

Whether through small interventions or systemic shifts we must work together to narrow the gap in health outcomes.

The recommendations that follow outline a roadmap to achieve this vision and together rebuild the missing blocks, reduce health inequalities, and support all residents in leading healthier, more equitable lives.

We recognise that our recommendations are many and complex. We know that action is already underway that can progress improvement in health and wellbeing of these communities, however the importance of ensuring that health takes primacy and there is an effective policy of the public’s health being central to all decisions is the foundation of our ability to deliver improved health outcomes.

It is possible to replicate this approach in other local authorities or integrated care partnerships using similar methods to:

1. Agree priorities
2. Conduct community engagement
3. Conduct data analysis.
4. Combine the engagement with the data insights

In 2023, we held a workshop to agree Hounslow's CORE20PLUS5 priority groups. Stakeholders from various health and care organisations were invited to attend the workshop. During the workshop, residents were asked to consider each potential PLUS group against the following criteria:

• Population size
• Known health inequalities that exist amongst this group locally
• Degree to which current services are meeting their needs
• How well are services engaging with them currently
• Potential impact of future interventions

Through this exercise, four priority groups were selected: CORE20 residents, those experiencing homelessness, asylum seekers, and young carers.

To assess and compare health, socio-economic, and environmental inequalities within Hounslow, we conducted a structured data analysis focusing on two cohorts:

1. Residents living in the most deprived areas (CORE20 cohort) – defined as those living in areas within the lowest two deciles (IMD Deciles 1 and 2) of the Index of Multiple Deprivation (IMD 2019).
2. Residents living in all other areas – representing the remainder of Hounslow (Rest of Hounslow cohort).

Our analysis used anonymised patient health records from local clinical systems and commissioned services, and external socio-economic and environmental datasets to identify disparities between these two cohorts. These results were then integrated with the engagement findings to validate and contextualise the results.

2.1.1. Health-Related Datasets and Processing

To examine differences in health outcomes and healthcare activity across our cohorts, we utilised de-identified patient health records and hospital episode data from North West London’s Clinical Systems (WSIC, SystmOne, ERNI), as well as data from commissioned services.

North West London’s Clinical Systems host a wealth of clinical information drawn from primary care, emergency care, acute hospitals, community trusts and mental health trusts.

These systems provided access to structured datasets, including:

Patient Index Table – demographic and geographic attributes (age, sex, ethnicity, deprivation status, postcode sector, LSOA, ward, GP practice, and Primary Care Network).

Long-Term Condition Table – prevalence and patterns of chronic illnesses and frailty.

GP Events Table – interventions such as screening and immunisations activity.

Emergency Care Dataset (ECDS) – hospital visits, A&E attendances, and emergency admissions.

In addition, we incorporated commissioned services data, including findings from the National Child Measurement Programme (NCMP), and the Homeless Health Needs Assessment by Homeless Link.

We extracted, cleaned, manipulated, and validated relevant data using SQL, Snowflake, and RStudio, to ensure consistency and accuracy, standardising it for cohort comparison.

We utilised SNOMED codes (for clinical conditions, treatments, and interventions) and ICD-10 codes (for hospital diagnoses and procedures) to classify and segment health data.

We structured data as patient-level records (one patient per row) or hospital spell-level records (one hospital spell per row) to facilitate meaningful analysis.

To analyse the broader determinants of health, we sourced external datasets that provided insights into socio-economic and environmental factors at small-area geographies (LSOA level). These datasets enabled us to classify and compare CORE20 vs non-CORE20 areas. Key datasets included:

Occupation and Accommodation Type – assessing housing and employment disparities.

Public Transport Accessibility Levels (PTAL) – evaluating transport access differences.

Food Insecurity Data – measures disparities in access, proximity and accessibility to supermarket facilities and online deliveries, proximity to non-supermarket food provision, socio-economic barriers, food support, and fuel poverty.

Travel Times to Essential Services – measuring accessibility to GPs, pharmacies, parks, and supermarkets.

Data Processing:

LSOA-level data was aligned with IMD 2019 deciles to categorise areas into CORE20 or non-CORE20 groups using 2011 boundaries.

Comparisons were made between the two cohorts to determine disparities in socio-economic and environmental exposures.

A cross-sectional analysis was conducted, using descriptive statistics to assess differences in health outcomes, healthcare utilisation, and socio-economic conditions between the two cohorts.

The findings were visualised using Microsoft Power BI, chosen for its interactive and user-friendly features, enabling stakeholders to explore segmented data at different levels (by condition, area, demographic, etc.).

Replicable SQL and R scripts were created to ensure that these analyses can be reproduced, updated, and expanded upon by other teams.

The quantitative findings were further contextualised through engagement and qualitative research, allowing us to validate observed disparities against resident experiences, explore root causes behind specific inequalities, and shape intervention strategies based on both data-driven evidence and community feedback.

This methodology is designed to be replicable and scalable for similar analyses in other regions. If teams or organisations wish to replicate, adapt, or expand upon our approach, we welcome discussions and can provide further technical details on data processing, analytical methods, and visualisation strategies.

For the purposes of this report, we aimed to understand the effects of wider factors on CORE20 areas' residents’ ability to live healthy lives. To this objective, the Hounslow Borough Based Partnership collaborated with nine local non-profit community organisations who have established links with various local communities within Hounslow including within CORE20 areas. The collaboration included local organisations carrying out meaningful engagement, using a range of engagement methods and activities with residents, to gain insight into their needs and experiences around health and wellbeing and healthcare.

We developed three key areas of exploration which aimed to explore people’s direct experience of health and wellbeing in relation to their immediate environment including the social, built and natural environment. In specific, the key research questions were:

Thinking about your immediate community/your neighbourhood, 

• what contributes to health & wellbeing and what challenges affect health & wellbeing?
• what activities, services and support could improve health & wellbeing?
• what enablers and barriers exist in finding or accessing or benefitting from existing health & wellbeing services, and how to overcome them?

Interested local community organisations went through an application process. The successful applicants were offered training, resources and ongoing guidance on:

• deciding which research and engagement methods are appropriate
• further information on the insights we were looking for including suggested sub-questions
• recruiting participants
• our expectations on data gathering and reporting
• how to facilitate focus groups or interviews and run surveys.

To create a summary of the individual reports we received, template analysis was used. Template analysis is a style of thematic analysis (TA) with a deductive (theory-driven) orientation to coding data. This includes two core processes: defining codes and organising them into wider conceptual entities called themes and sub-themes. Template Analysis includes the creation of a codebook which includes pre-defined themes but is also responsive to the data by adding new codes when necessary. The codebook of themes and sub-themes was based on the figure below.

A key part of the Population Health Management is triangulating quantitative data analysis with findings from rich community engagement. To do this we used the insights from the community engagement to ask questions of the data. This enabled us to provide concrete data behind the issues and solutions that were most relevant to what was said during the engagement. For example, people talked about issues accessing key services. Using available public transport data, we could evidence this issue highlighting the differences in travel times for CORE20 residents and the rest of the borough.

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