The most deprived 20% of the national population as identified by the national Index of Multiple Deprivation (IMD).


PLUS population groups should be identified at a local level. This might be identified as the following: people from ethnic minority communities; people with a learning disability and autistic people; people with multiple long-term health conditions; other groups that share protected characteristics as defined by the Equality Act 2010; groups experiencing social exclusion, known as inclusion health groups coastal communities (where there may be small areas of high deprivation hidden amongst relative affluence).

There are five clinical areas of focus which require faster improvement.

1. Maternity

  • Ensuring continuity of care for women from Black, Asian and minority ethnic communities and from the most deprived groups. This model of care requires appropriate staffing levels to be implemented safely.

2. Severe mental illness (SMI)

  • Ensuring annual health checks for 60% of those living with SMI (bringing SMI in line with the success seen in learning disabilities).

3. Chronic respiratory disease

  • A clear focus on Chronic Obstructive Pulmonary Disease (COPD) driving up uptake of COVID, flu and pneumonia vaccines to reduce infective exacerbations and emergency hospital admissions due to those exacerbations.

4. Early cancer diagnosis

  • 75% of cases diagnosed at stage 1 or 2 by 2028.

5. Hypertension case-finding and optimal management and lipid optimal management

  • To allow for interventions to optimise blood pressure and minimise the risk of myocardial infarction and stroke.


Reducing healthcare inequalities for children and young people. The Core20PLUS5 approach is designed to support integrated care system to drive action in health inequalities improvement.

Target population


The most deprived 20% of the national population as identified by the national Index of Multiple Deprivation (IMD)


Integrated care system-chosen population groups experiencing poorer-than-average health access, experience and/or outcomes, who may not be captured within the Core20 alone and would benefit from a tailored healthcare approach e.g. inclusion health groups.

Key clinical areas of health inequalities

Asthma: Address over reliance on reliever medications and decrease the number of asthma attacks.

Diabetes: Increase access to real-time continuous glucose monitors and insulin pumps in the most deprived quintiles and from ethnic minority backgrounds and increase proportion of children and young people with Type 2 diabetes receiving annual health checks.

Epilepsy: Increase access to epilepsy specialist nurses and ensure access in the first year of care for those with a learning disability or autism.

Oral health: Address the backlog for tooth extractions in hospital for the under 10s.

Mental health: Improve access rates to children and young people’s mental health services for 0-17 year olds, for certain ethnic groups, age, gender and deprivation.