Health Inequalties Framework

Working Together for Health Equity in Eastern Devon

Everyone, no matter their background or postcode, can live a longer, healthier, more fulfilling life.

• Integrated Neighbourhood Teams (INTs)
• Community insight and data
• VCSE partnerships
• Shared accountability and learning

Reduce health inequalities in Eastern Devon by aligning action, empowering communities, and tackling root causes.

• Test and learn new models
• Prioritise underserved groups
• Align local resources and plans
• Prioritise Core20PLUS5 populations and neighbourhoods facing greatest disadvantage

• Promote wellbeing and act early
• Reduce – Target support where it’s needed most
• Empower – Strengthen community voice and leadership
• Transform – Create joined-up, proactive local systems

• Reduced health gaps
• Stronger community partnerships
• Better access and experience for underserved groups
• More integrated and equitable service delivery

One Eastern Devon LCP is a collaborative partnership of organisations committed to addressing the unfair and preventable inequalities that impact people’s ability to live healthy, fulfilling lives. It is one of 5 Local Care Partnerships in Devon.

By tackling issues such as inadequate housing, limited job opportunities, and social isolation, we aim to prevent the negative health outcomes that often arise from these social, economic, and environmental challenges.

Our joint efforts focus on maximising impact and minimising waste to effectively reduce inequalities and enhance the health and wellbeing of the communities in Eastern Devon. This covers a large area from Axminster to Okehampton and include Exeter, with a total population of around 400,000 people.

We will work collaboratively to improve health and wellbeing and tackle inequalities to enhance the quality of life for the people of Eastern Devon. This approach involves connecting with communities, actively listening to their needs, and taking meaningful action based on our insights. As a result, we aspire to build a solid foundation of strong relationships, empower individuals, foster resilient communities, and create lasting positive change.

Our objectives include:

• Breaking the cycle of deprivation by addressing root causes, enabling us to prevent poor health, promote wellbeing, and enhance the quality of life for all.
• Reducing harm and inequity within our communities.
• Minimising duplication of efforts and maximising the collective resources at our disposal.

One Eastern Devon covers a large area of Devon from Axminister in the East to Okehampton in the West and includes the city of Exeter. The locality includes a mix of rural, urban, and coastal towns and their hinterlands and includes a number of areas of deprivation.

• Rural and coastal poverty is often hidden by average affluence.
• Healthy life expectancy varies by up to 9 years between richest and poorest areas.
• Poor transport and digital access isolate many rural communities.
• Fuel poverty is widespread due to old housing and off-grid energy use.
• Low pay and insecure jobs are common in tourism, care, and agriculture.
• Child poverty exceeds 25% in parts of Exmouth and Honiton.
• Older people living alone face isolation and digital exclusion.

A detailed analysis of the Joint Strategic Needs Assessment and other related data, as well as community insights across the locality have informed our understanding of health inequalities in Eastern Devon. Health inequalities are shaped by a combination of geographic, socioeconomic and demographic factors and are often experienced intersectionally:

• Life expectancy gaps of 7–20 years across communities
• High prevalence of long-term conditions in rural/coastal area
• Poor access to services in Cranbrook, Mid Devon and East Devon
• Significant number of unpaid carers, especially older spousal carer
• High number of children and young people with behavioural/emotional needs in Honiton, Exmouth, and Tiverton
• Limited access and long waits for mental health services
• Social determinants, such as poverty, housing instability and isolation, exacerbate health issues

Residents across Eastern and Mid Devon value strong social networks and the rural environment for wellbeing. Key barriers include poor transport, digital exclusion, inaccessible facilities, and fragmented healthcare.

There’s a clear call for better local services, more inclusive activities, improved communication, and joined-up working across sectors — especially to support carers, older adults, and people with long-term conditions.

• Life expectancy is high overall, but varies sharply. Exeter aligns with national averages, while East Devon performs better.
• Suicide and self-harm rates exceed national levels, especially among young people and in more deprived areas.
• Rural and coastal communities face poor access to services due to transport and digital barriers; seasonal work and housing issues affect wellbeing.
• Poor housing conditions — including damp and inadequate heating — contribute to respiratory and heart problems.
• Income inequality limits access to healthy food, green space, and recreation; children in low-income families face higher mental health risks.
• Educational attainment gaps and insecure employment fuel long-term health disadvantage.
• Social isolation, particularly among older people in rural areas, remains a major concern.

Groups most at risk of poor health:

• People in areas of cumulative disadvantage (urban, rural, and coastal)
• Minority ethnic communities
• Inclusion health groups (e.g. people experiencing homelessness, refugees, Gypsy/Roma/Traveller communities)
• Children, young people and adults with SEND
• People with severe mental illness, learning disability, or maternity vulnerability

Neighbourhoods facing intersecting disadvantages, particularly:

• Isolated rural communities with access challenges
• Urban populations facing economic deprivation, poor housing and limited services
• Coastal and market towns with ageing populations and service gaps

This Framework invites partners to work collectively to:

• Tackle inequalities in health outcomes and access.
• Address the wider determinants of health.
• Share power and resources with communities.
• Build a joined-up local system rooted in neighbourhood-level delivery.

Key partners:

• NHS Providers and Commissioners (e.g. RDUH, PCNs; DPT; Integrated Care Board)
• Local Authorities (e.g. Devon County Council, district/borough councils)
• Voluntary, Community and Social Enterprise organisations (the VCSE sector)
• Primary Care Networks and GP practices
• Community Health and Adult Social Care teams
• Public Health Teams
• Housing associations and landlords
• Police/Probation/ Criminal Justice System
• Education providers (schools, colleges, HEIs)
• DWP
• Faith groups
• Employers and the private sector
• Transport and infrastructure bodies

“C.D., aged 38, is a carer for her grandparents and her children, three of whom are autistic. She wanted digital support to better manage online meetings and forms related to her children’s needs and her caring responsibilities.

At Okehampton Library, she received a one-to-one session with Wellmoor’s Digital Support Provider. They downloaded and practised using Microsoft Teams, explored the chat function, reviewed NHS MyCare use, introduced Microsoft Authenticator and discussed completing online forms.

C.D. said the session made online courses and meetings much easier to join and described the support as “helpful.” She was offered further sessions if needed.”

Katie Taylor, Wellmoor

“Parental Minds CIC chairs the Young People’s Mental Health strand of work in the ELCP. This group delivered an Attendance & Wellbeing pilot project across coastal, rural and more deprived communities in Eastern Devon. It focused on families at higher risk of poor health and educational outcomes — including neurodivergent children and young people, and families who are often wary of statutory services. This aligns directly with Core20PLUS5 priorities.

Initially focused on two schools, the project expanded recruitment routes to improve equity of access.

The Family Minds Partnership brings together 13 VCSE partners with schools, Early Help, MHST, the ICB and Devon County Council in monthly multi-agency huddles. This creates rapid learning loops, clear referral routes and warm transfers.

By June 2025, the partnership had supported 397 families with school attendance challenges. Shared VCSE infrastructure kept delivery costs to around £200 per family, offering strong value.

Outcomes show measurable improvements: increased optimism, improved school connection, strengthened problem-solving, better attendance trajectories, and improved parent confidence. CYP highlight trusted relationships and regulation skills built in safe, relational spaces.

A representative journey: a co-produced learner profile (“What I wish people knew about me”) prevented exclusion for one young person.

System learning includes stronger cross-organisational awareness, better information sharing, clearer referrals and increased trust.”

Vanessa Rossiter

Director of Business & Strategy, Parental Minds CIC

We invite current and new partners to support our work. We can only make a difference by collective actions. By endorsing this Framework, partners commit to:

• Acting on the shared vision and strategic pillars
• Embedding this Framework in organisational plans and priorities
• Working collaboratively across sectors to reduce health inequalities and making best use of limited resources through shared upstream investment
• Sharing data, insights, and resources to support neighbourhood delivery
• Upholding the principles of shared power, co-design, and community leadership
• Participating in ongoing learning and review, and being accountable to each other and the communities we serve
• Focusing particular attention to the specific populations who experience health inequity (the intersection between deprivation and inclusion groups)

This is not just a strategy — it is a partnership compact. Together, we are choosing to lead, align, and act for a fairer Eastern Devon.

“The ELCP funded a Social Prescribing pilot in RD&E Emergency Department from February 2024 to February 2025. The pilot aimed to reduce avoidable re-attendance, improve wellbeing and demonstrate cost savings.

266 referrals were supported: 56.7% female; highest participation aged 78–88; 56.49% lived alone; 12.21% were homeless. Presenting needs included mental health (40.97%), physical health (32.7%) and loneliness (27.06%). 46.6% engaged in three or more sessions; 41.4% achieved a positive outcome.

The pilot engaged a diverse population and showed early signs of improved wellbeing. Non-engagement remains a challenge, highlighting the need for more flexible follow-up.

There is strong interest in renewing and expanding the model.”

Westbank Community Health & Care

1. ‘Prevent’ ill health and inequality by acting early, promoting wellbeing, and addressing risk factors before they escalate.

2.  ‘Reduce’ disparities by targeting support and resources to those at greatest risk, ensuring our services are equitable and inclusive.

3.  ‘Empower’ communities, investing in local capacity and leadership so that solutions are designing together and community-led.

4.  ‘Transform’ the way we work together across the system – shifting from reactive service provision to proactive, integrated partnership.

These four pillars are underpinned by a commitment to groups most at risk of poor health, the principle of whole-area approach, and an adaptive learning mindset. Our framework is not about new bureaucracy, but about aligning what we already do in smarter, more connected ways. It provides a lens through which we can review existing activity, guide new investment, and hold ourselves accountable to the outcomes that matter most to our communities.

1. Targeted Action

Using data and real-life experience to identify and prioritise interventions in the neighbourhoods and communities most affected by inequality. Focus on proactive outreach and locally tailored solutions.

2. Invest in Prevention

Shifting the focus and funding upstream to reduce the risk of ill health. This includes supporting early years, mental health, healthy ageing, and preventing long-term conditions.

3. Empower Communities

Building local capacity through investment in the voluntary and community organisations sector, support community leadership, and embed designing together in service planning.

4. System Alignment

Strengthening working together across sectors, reduce duplication, and ensure all parts of the system work towards the same goals.

Our priorities in 2025-2027

• Prioritise initiatives that directly address or prevent health inequalities, with a clear focus on the most disadvantaged or underserved groups.
• Support proposals that demonstrate strong potential to reduce system pressures — including emergency admissions, readmissions, delayed discharges, and the impact of chronic conditions.
• Favour projects that align with data-informed priorities, build on existing work, and strengthen or extend partnership working together.
• Give priority to initiatives that offer added value in tackling health inequalities, rather than duplicating existing services or filling basic operational gaps.

At the heart of this Framework is a shared commitment to not only what we do but how we do it. Our approach to partnership must reflect our values of:

• Codeveloped, equity, respect, trust and shared power with voluntary and community organisations and communities.
• We will share power and decision-making, particularly with voluntary and community organisations partners and communities who have too often been on the receiving end of decisions made elsewhere.
• We will create space for difficult conversations, respect diverse forms of knowledge, and prioritise relationships over processes.
• By agreeing a common set of principles, we enable consistency across our diverse places while respecting local nuance. This is about system culture change – creating a new default for how partners interact, share risk, and build shared ownership of outcomes.

Whole-area approach

Improving outcomes and reducing inequalities means working across organisational boundaries, not just within them. A whole-place/health equity in all approach brings partners together around shared priorities, aligning resources to meet the real needs of communities.

For One Eastern Devon, this means joining up services, investing in prevention, and tackling wider health determinants like housing, income, and social connection. It’s about listening to communities, building on local strengths, and supporting people with lived experience to shape solutions. By focusing on place, not silos, we can achieve better outcomes, smarter investment, and more resilient communities — working differently, together, to make life better for everyone.

“There has always been a strong ethos that the ELCP is not statutory-owned, led or driven; it is a collaborative. While the breadth and diversity of the VCSE sector across Eastern Devon presents challenges for connectivity, the Partnership recognises the importance of the sector’s perspectives, experience and contribution. The VCSE Partnership provides a dedicated space for the sector, although colleagues from a wide range of VCSE organisations also participate in work across the ELCP. We recognise this value by being the only Local Care Partnership to offer backfill for VCSE attendance at meetings.

When work on the Health Inequalities Strategy began, the VCSE Partnership was a key route for inviting people into the working group. We also drew on the Partnership to develop the ‘community voices’ element of the strategy, recognising how vital local experiences are to shaping our approach.

As facilitator of this meeting — and in my wider role as an advocate and resource for the VCSE sector — I act as a conduit for information sharing, feedback and influence, carrying insights into wider ELCP discussions while recognising the time and resource pressures the VCSE sector often faces.

As we continue to adapt to evolving priorities, we are now aiming to give this partnership even more of a community feel by involving the Community Health and Wellbeing Alliance Chairs. We want to ensure that place-based conversations are at the forefront and that we continue to create space to highlight the fantastic work VCSE groups and organisations are doing in and with their communities.

This will become even more crucial as the NHS 10-Year Plan shapes our direction, particularly around the shift from ‘hospital to community’ and ‘sickness to prevention’. We have a strong foundation to build from.”

Ellie Barnes

To deliver this Framework, we need to address the foundations that enable sustainable system change. Key to this is:

• Investing in ongoing data and insight – combining numerical analysis with real-life experience and feedback loops to ensure our decisions are grounded in reality.
• Evolving the relationship with the voluntary and community organisations sector as equal partners in decision-making structure and delivery, but as equal system partners, embedded in decision-making structure, designing together, and delivery.
• Governance arrangements must enable local autonomy within a shared framework, with clear lines of shared accountability and support.
• The development of integrated neighbourhood teams – multidisciplinary, cross-sector groups rooted in local places, able to respond flexibly to population needs.
• Working to align funding streams, reduce duplication and build cross-sector capability.
• These enabling structures are not ends in themselves – they are the scaffolding on which better outcomes are built. If we want real change, we must invest in the infrastructure that supports local leadership, innovation, and sustained action at neighbourhood level.
• Ensuring trauma-informed practice.

Integrated Neighbourhood Teams

Integrated Neighbourhood Teams (INTs) are a key part of national plans to deliver more joined-up, localised care. They will bring together professionals from general practice, community health, adult social care, mental health, the voluntary sector, and community groups to work as one team around defined neighbourhoods. The aim is to provide more coordinated, person-centred support — particularly for people with complex needs or at risk of poor outcomes.

By reducing duplication, enabling earlier intervention, and drawing on local insight and assets, INTs are intended to improve outcomes and make care feel more connected. In Eastern Devon, early work is underway to explore how INTs can be developed in partnership with communities. This shift has the potential to place prevention, continuity, and local relationships at the heart of care delivery.

“The Eastern Devon Healthy Ageing Partnership identified dementia as a priority but lacked a clear picture of local provision. A mapping exercise was undertaken to understand and coordinate support.

Age UK Exeter compiled an initial map of dementia-related services, which was reviewed by 25 attendees from health, social care and VCSE organisations. Services were updated collectively and edited by Innovations in Dementia to ensure “dementia accessibility.”

The map is now publicly available and will be kept updated by the new Eastern Devon Dementia Worker. The exercise improved visibility, strengthened organisational connections and supports a more coordinated dementia pathway.”

Link: https://www.ageuk.org.uk/exeter/about-us/news/articles/dementia-map/east-devon-dementia-map/

Reducing health inequalities cannot be achieved by health services alone. The root causes of poor health – poor housing, low income, education, environment and access – sit largely outside the NHS.

This strategy is a call to action for all sectors to align their work around the goal of health equity. It highlights the opportunity for OED to act as a convening platform, bringing together councils, voluntary and community organisations, faith groups, police, schools, the private sector, local residents and many others to tackle the social determinants of health at neighbourhood level.

We seek to develop joint plans with clear roles for all partners, co-invest in local initiatives, and align funding and planning and funding to shared outcomes. Examples include improving housing conditions through place-based inspections, enhancing rural transport through joint planning, and integrating welfare and employment support into primary care hubs.

The key is to use the strength of the partnership – trust, relationships and shared insight – to unlock collective impact.

We will also make better use of anchor institutions’ levers – such as local recruitment, procurement and land use – to shape healthier environments. This is how we move from programmes to population-level impact

“The Social Health project emerged from the Loneliness and Social Isolation Partnership Group. It aimed to explore what enables social health to thrive in communities through a cross-sector, bottom-up approach.

Between July 2024 and March 2025, the team held 17 learning conversations with over 200 participants across diverse settings. Groups explored who facilitates connection, the functions of these roles, their vulnerabilities, and what resources strengthen them.

Six foundational conditions emerged: coordination, investment, voice, resources, space and insight. When present, these conditions supported a stronger culture of connection.

A workshop in March 2025 refined the emerging model. The learning informed a framework now being piloted in Moreton Hampstead, supported by a new Community Builder role.”

Matt Smith

Director, The Wafflehouse CIC

We are committed to a robust and transparent approach to assessment and improvement. We will:

• Develop an outcomes framework that includes numerical and descriptive measures – from traditional health measurements (like emergency admissions and life expectancy) to community voice, wellbeing and levels of trust in services.
• Report on progress regularly to the OED Forum and local communities. Our monitoring approach will include both headline indicators and localised measurements tailored to neighbourhood priorities.
• Operate as a learning system, reviewing data and insights in real time and using them to adjust approaches as needed. Feedback loops with voluntary and community organisations, primary care networks, and community groups will ensure ongoing relevance.
• Track both ‘what we do’ and ‘how we do it’ – examining partnership behaviours, inclusivity, and trust. Our ambition is not just to demonstrate impact but to build a culture where reflection, adaptation, and shared ownership are the norm.
• Work with existing frameworks and, where appropriate, commission independent assessment, and use stories of change, alongside data, to capture and share learning across the system.

We see the period to March 2027 as a further ‘test’ period. Over the last few years the partnership has funded a number of innovative projects aimed at tackling some of the key health inequality issues in the area, and has done so again in 2024-25. These projects have allowed us to start to test new models of working, to strengthen and expand the partnership, to develop insights into population health challenges, and potential avenues for future investment. Evaluation and learning from this investment is currently being considered so that, during 2026, we will be in a better place to refine and agree our strategic priorities and action.

We need to keep abreast of changes locally, regionally and nationally, in particular local government reorganisation, closer ties with Cornwall, the development of NHS Neighbourhood Teams and the NHS Ten Year Strategy. How these changes will impact the partnership and our local populations remains unknown but it is likely they will have a significant impact on our actions.

Our strategic framework is about intention – based on core principles – and we need to be flexible. This means we can outline what we are aiming to achieve long-term and how we hope to work, without committing to over-ambitious, detailed plans. In the short-term, our more iterative approach means we can continue to take onboard opportunities and ‘test the water’, while we take stock of the wider context. This approach means, within six months, we will be able to create a more detailed, informed and achievable Strategy and Action Plan.

onedevon.org.uk/about-us/areas-covered-lcps/eastern-devon/

• Case Studies of funded work 2023-24
• Draft outcomes dashboard
• Summary of engagement feedback
• Governance and partner roles
• Risks
• ICS alignment

Plain Language Glossary

Health inequalities:

Unfair and avoidable differences in people’s health.

Total Place

Looking at all services and resources in one area together.

Neighbourhood teams:

Groups of professionals working in local communities.

Proportionate universalism:

Helping everyone, but giving more support to those who need it most.

Co-design:

Planning services together with the people who use them.

VCSE:

Voluntary, community, and social enterprise organisations.

Anchor institutions:

Large local employers like hospitals and councils that can support community wellbeing.

Adaptive learning:

Trying new ideas, learning from results, and improving as we go.