By Dr Nadia Saeed, GP & Health Inequalities Lead, Operose Health

At Operose Health, tackling health inequalities isn’t an afterthought or tick box, it’s central to delivering on our values: Caring, Ambitious, Resourceful, and being committed to Excellence.

That’s why I am delighted to introduce our new Health Inequalities Champion Working Group. Each of our practices has nominated a dedicated Health Inequalities Champion to help identify and address the unmet needs of vulnerable and underserved populations within our neighbourhoods and communities. This initiative not only allows us to scale up our efforts to reduce disparities but also fosters shared learning and collaboration across our organisation.

Why this work matters

We are aligning our work with the NHS Core20PLUS5 framework, which sets out a clear path:

• Focus on the most deprived 20% of the population (Core20).
• Add local PLUS groups who face barriers to access, experience or outcomes (for us, this includes people experiencing homelessness, asylum seekers, and migrant communities).
• Accelerate progress in five clinical priorities: maternity, severe mental illness (SMI), chronic respiratory disease, early cancer diagnosis, and hypertension (including optimal lipid and blood pressure management).

For children and young people, Core20PLUS5 also emphasises asthma, diabetes, epilepsy, oral health and mental health. This helps us ensure equity from infancy and beyond, helping people to start well and live well.

What we heard from our Champions

At our recent Health Inequalities Champion meeting, we shared inspiring examples of improvement projects already underway:

• Digital inclusion: enhancing accessibility of online platforms and providing support to those unfamiliar with digital tools.
• Outreach for vulnerable groups: targeted approaches to improve healthcare access for people experiencing homelessness, asylum seekers, and migrant communities.
• SMI health checks: improving the physical health of individuals living with serious mental illness through consistent recall systems and holistic reviews.
• Addressing barriers in long-term conditions: understanding cultural and systemic challenges that some ethnic minority communities face when managing health conditions.
• Community partnerships: forging strong relationships with local voluntary and community sector organisations; partnerships that are vital for improving health and wellbeing.

What’s next

Together, through this working group, we are laying the foundation for meaningful, sustained progress in reducing health inequalities. Over the next 90 days, our Champions will be focusing on:

• Expanding SMI physical health checks across our Core20 and PLUS populations.
• Embedding hypertension case-finding into everyday practice.
• Piloting community-based clinics for vaccinations, screening, and long-term condition reviews.
• Strengthening culturally competent pathways in partnership with local communities.

Bringing our values to life

• Caring: keeping people at the heart of everything we do, particularly those least likely to reach us.
• Ambitious: setting bold, measurable targets to close the gap.
• Resourceful: harnessing data, partnerships, and innovative approaches to deliver change.
• Excellence: ensuring every patient, in every practice, receives consistent and equitable care.

Looking ahead

It was particularly encouraging to hear about the strong local partnerships our practices are building with community groups and the voluntary sector. These relationships will help us extend our reach beyond clinic walls, into the heart of the communities we serve.

This is just the beginning. By working together as Champions, and guided by the Core20PLUS5 framework, we can achieve real, lasting change.

Our commitment is simple: to make sure great primary care is not only available, but truly equitable for everyone.