These case studies showcase how our partners across north west London are improving access to services, support, and care, and the meaningful impact these efforts are having on the lives of our communities.
Early years and children's health
StartWell Ealing brings early-years support into GP practices, helping families with young children (0–3) build strong bonds and access vital developmental and wellbeing services. By embedding Family Link Workers and using data-led case finding, the project connects families to holistic, local support.
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The Willesden Early Years Asthma Clinic brings together GPs, paediatricians, and care coordinators to provide personalised asthma support for under-5s in one of Brent’s most deprived areas. The pilot offers longer appointments, Asthma Action Plans, and help with wider needs like housing and smoking cessation to improve outcomes and reduce inequalities.
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Working as part of the Early Years GP Health Hubs Pilots for North West London Integrated Care Board, Optivita Harrow launched a specialist clinic in the summer of 2023, focused on Postnatal Group Consultations in collaboration with local primary care network and voluntary sector partners.
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Mental health and wellbeing
Football for Wellbeing is a pioneering community initiative designed to address mental health challenges, social isolation, and health inequalities through the power of football and human connection. The project combines therapeutic sessions and competitive play to support recovery, inclusion, and personal growth, while delivering measurable benefits to participants and potential cost-savings for the NHS.
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Finding Rhythms partnered with local services in Harrow to co-deliver a therapeutic music project supporting young Black men’s mental health, using creativity to rebuild trust and strengthen community connection.
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Wider determinants of health
WorkWell offers free, holistic support to people facing health-related employment challenges. Since launching in 2024, it has supported over 1,200 residents to overcome complex barriers and improve both work and wellbeing outcomes.
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Working with under-resources and vulnerable communities
This model enhances health access for people experiencing homelessness by embedding a flexible, trauma-informed nursing team across hostels and street-based settings. By increasing nurse capacity and running dedicated women’s services, the initiative has improved engagement, reduced emergency service use, and addressed wider determinants of health, such as food and digital access.
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Hounslow’s Health Outreach Team uses data-driven, community-based approaches to deliver targeted health checks, build trust, and improve uptake of preventative services in underserved communities. With mobile and static teams, the model has driven increases in vaccination rates, early detection of chronic conditions, and generated thousands of resident engagements each year.
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This north west London scheme supports individuals who frequently use emergency services due to complex needs. Using data dashboards and borough-based care coordination, the project has improved identification, care planning, and system-wide training. It’s reducing pressures on urgent care by shifting toward long-term, holistic support rooted in equity and integration.
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Applying population health management methods
In north west London, population health management is evolving into a person-centred, equity-focused approach. The team supports system-wide adoption by providing the practical tools to turn strategy into action.
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Waiting Well was launched to improve the experiences of patients – particularly from Black, Asian, and socioeconomically deprived backgrounds – who are waiting for orthopaedic treatment. Through co-production and patient storytelling, the initiative developed practical tools like peer-led physiotherapy letters, coping toolkits, check-in messages, and staff training to enhance wellbeing and reduce inequalities during long waiting periods.
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This programme worked with communities to tackle barriers to using NHS digital tools. Through co-production and training, it supported over 440 residents to build confidence, access care online, and reduce digital health inequalities.