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.
Most recent case studies: NEW 2026
Vena Sinclair is a clinical nurse specialist in Northwick Park Hospital's Renal
Outpatient Department. In her role she supports people starting dialysis, a life-sustaining medical
treatment that filters waste products, toxins and excess fluid from the blood when
kidneys fail.
Vena noticed patients, especially from Brent's Black community were crash landing
into treatment, not always knowing how diabetes and hypertension played a role in
leading them there.
The Black community faces a disproportionately higher levels of kidney disease,
linked to a greater prevalence of risk factors, but Vena said it wasn't just a lack of
knowledge in how to manage those risks, but also an issue of trust.
Together with her consultant colleague Dr Neil Duncan from Imperial College Healthcare Trust, Vena decided to create something different from a traditional health intervention, but rather a local community event celebrating local Caribbean culture to help support patients in their care.
In NHS North West London, improving health inequalities is more than just a strategy. Itʼs
about equipping the local workforce with the skills and confidence to turn insight into
action.
Two years ago, the NWL Population Health Management & Health Equity Academy was
launched to do exactly that. Free for all staff across the Integrated Care System, the
Academy builds practical skills in data, community partnership, leadership and using
evidence to make better heath and care commissioning decisions.
And it's working. Since April 2025, the Academy has offered almost 800 training
opportunities — from hands-on analytics sessions, to cultural competence workshops, to
masterclasses in evaluation and health economics.
NHS North West London is bringing together two powerful data tools to create a single
joined-up picture of need, service use and spend that puts people, not services, at the
centre of commissioning decisions.
The Population Health Management (PHM) team use data from their Integrated Needs
Assessment (INA) and Aligning Resource to Need (ARtN) projects to map and analyse
activity and costs across the system.
They take into account demographics, geography and care setting data to support
decision making on system spend against need.
By combining robust analysis with conversations with frontline teams and communities,
the work is turning insight into action—shaping fairer commissioning and more equitable
care.
For adults with Special Educational Needs and Disabilities (SEND), access to
employment is more than a job opportunity, it's a way of improving health,
wellbeing and feelings of inclusion in society.
The West London Alliance Open Minds programme set out to show that
employment is a powerful public health intervention.
By providing bespoke support to help disabled adults gain employment in the NHS,
it directly addressed the issue of economic exclusion as one of the most persistent
drivers of health inequality.
The programme demonstrated that with the right support, disabled adults can be
confident, economically active community members while also helping NHS recruit
to its workforce from the communities it serves.
Health inequalities affecting Black and African Caribbean communities in
North West London are stark. Data shows Black adults are three times more
likely to have diabetes and twice as likely to have hypertension than the
ethnic groups with the lowest rates. These disparities are driven by structural
racism, socio economic barriers and past experiences that have led to a deep
mistrust of public services.
In response, the North West London Integrated Care System, through its
strategic Race Steering Group forum, spent two years developing and testing
a model that deliberately shifts healthcare out of clinics into trusted
community spaces.
Each hub offers a fully integrated health and care offer for Black and African
Caribbean residents in spaces that are informative, uplifting and shows their
communities that they are valued, heard and being responded to in a way that
makes them feel part of the answer.
The result is the In-Reach programme: a network of co-designed,
community-based health and wellbeing hubs across five North West
London boroughs: Brent, the bi-borough Westminster with Kensington and
Chelsea, Hammersmith and Fulham, Ealing and Harrow.
The North West London talent and recruitment hub provides a single, accessible entry point to jobs, volunteering and development opportunities across the local health and care system.
As part of the NW London health and social care skills academy, it was created to tackle the inconsistent recruitment practices, high turnover and exclusionary job criteria linked to health inequalities.
Its simple mission is to support building a local workforce that truly reflects North West London.
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
The Hillingdon Back to Health programme is a community-led initiative developed by NHS North West London ICB to support residents in recovering from the physical, mental, and social impacts of the COVID-19 pandemic. By focusing on early intervention, integrated care, and collaboration with local voluntary sector partners, the programme aims to improve access to preventative services, address wider determinants of health, and reduce pressure on primary and acute care systems.
WorkWell supports patients by tackling the link between unemployment and poor health, offering integrated health and employment services that restore wellbeing, confidence, and independence.
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.