Health inequalities can prevent many people from accessing the healthcare they need. Factors such as deprivation, ethnicity, disability, mental health, and digital access can determine who can access key services and who is being missed.

Health data can help highlight how many people interact with health services and where outcomes differ. But traditional data analytics often struggles to reflect people who are underrepresented in services or missing from care altogether. If they’re not using the services in the first place, there’s no data for them.

The risk then becomes that services are designed around those already visible and using that service, while people facing the greatest barriers remain unseen.

When data does not represent the full population, it reinforces gaps rather than reducing them. To address this, Integrated Care Systems (ICSs) need to move beyond reporting inequalities and start using data to design services that actively close gaps.

CIPHA (Combined Intelligence for Population Health Action) supports this shift by enabling inclusive population health action at scale.

 

CIPHA’s Role in Supporting Health Equity

CIPHA is a system-wide population health platform currently operating across Cheshire and Merseyside, built using Graphnet software.

It securely brings together data from across health and care, including GP practices, hospitals, mental health services, community services, and local authorities, into a single, shared view.

By linking data from across organisations, CIPHA provides a more complete picture of population need. This is important because health inequalities often span multiple services rather than sitting within a single dataset.

CIPHA enables ICSs to:

• Identify underserved populations at a local level
• See where outcomes differ across population groups
• Understand where people are not accessing care

This helps systems focus effort where it can make the greatest difference.

 

Supporting Core20PLUS5 Targeting

Core20PLUS5 is the NHS’s approach to reducing healthcare inequalities. It focuses on the most deprived 20% of the population, plus additional groups experiencing poorer outcomes, across five national clinical priority areas.

CIPHA supports Core20PLUS5 by enabling ICSs to:

• Identify the most deprived 20% of their population at the place and neighbourhood level
• Overlay PLUS groups, such as ethnic minority populations and inclusion health groups
• Stratify populations across the five national clinical focus areas

This level of granularity allows ICSs to move beyond broad averages and tailor interventions to local need rather than applying a single approach across an entire system.

 

Using Inclusive Data to Reach Underrepresented Groups

CIPHA supports the use of inclusive data to help ICSs better understand and respond to the needs of underrepresented groups.

This includes analysis across:

• Ethnicity – improving coding and identifying disparities in outcomes and access
• Deprivation – understanding layered disadvantage beyond postcode alone
• Language and communication needs – highlighting barriers to engagement
• Digital exclusion – identifying populations less able to access digital services

This insight supports practical action, such as targeted outreach, early intervention, and service design that reflects how people access care. The aim is to improve services, not to label communities.

CIPHA supports responsible interpretation of data alongside clinical insight, local knowledge, and lived experience, helping systems make informed, inclusive decisions.

 

From Insight to Action: Partnering with Communities

Reducing health inequalities requires collaboration across health, care, and community organisations.

CIPHA supports partnership working by providing shared intelligence across the NHS, local authorities, and voluntary, community and social enterprise (VCSE) organisations.

A shared view of population need helps partners:

• Align around the same priorities
• Target outreach programmes
• Co-design services with communities
• Monitor impact over time

In Cheshire and Merseyside, population health insight supports place-based decision-making. This allows local teams to respond to need in ways that reflect their communities rather than relying on top-down reporting.

 

Governance, Trust, and Public Confidence 

Working with sensitive data requires trust, particularly when it relates to marginalised or underrepresented groups.

Strong information governance is essential to ensuring data is used safely, lawfully, and transparently.

CIPHA operates within clear governance frameworks and publicly available privacy notices, supporting accountability and confidence in how data is used.

Good governance acts as an enabler of equity. It allows systems to use data responsibly to improve outcomes, rather than creating barriers to action.

 

Enabling Fairer Outcomes Through Inclusive Analytics

Health inequalities require system-wide, data-informed action. Insight alone is not enough, but without good data, systems cannot target resources effectively or understand where support is most needed.

CIPHA supports ICSs to:

• Understand inequality in context
• Target resources where they will have the greatest impact
• Work with communities to close gaps in access and outcomes

By embedding inclusion into how data is linked, analysed, and applied, CIPHA helps systems move from identifying inequality to actively reducing it, supporting fairer, more inclusive health outcomes at scale.

If you’re exploring how to turn insight into action, Graphnet can share what’s worked for other ICSs and help shape an approach that fits your local context. Contact us to find out more.