Taking Healthcare to the Heart of Underserved Communities:
The Health Squad, in collaboration with Health Diagnostics, demonstrates an effective partnership.
We’re incredibly proud to share a case study involving our ongoing partnership with the Health Squad, commissioned by Durham County Council and delivered in partnership by County Durham and Darlington NHS Foundation Trust (CDDFT) and the Pioneering Care Partnership (PCP). Below, we convey the remarkable difference the initiative is making to some of County Durham’s most vulnerable and underserved residents.
Reaching the people who need it most
NHS Health Checks have long struggled to reach individuals who face the greatest barriers to accessing care. Individuals experiencing homelessness, substance misuse, contact with the criminal justice system and members of the travelling community are among those least likely to engage with traditional GP-based services. The same challenges apply to veterans, migrants, and people living in areas of high deprivation. These groups are often at the greatest risk of undetected and untreated health conditions, making it important to target those most in need
The Health Squad has introduced a targeted ‘Enhanced Health Check’ initiative to directly address these challenges. Three mobile outreach teams deliver health checks and wellbeing support within community settings and proactively take services to people, rather than relying on them to seek help. The initiative aims to boost GP registrations, reduce health inequalities and deliver measurable outcomes.
A tailored digital solution to meet a unique challenge
Building on our previous experience working with Durham County Council, where our patient-focused solution supported GP providers, pharmacy and outreach teams, the Health Squad approached us, recognising both the value of our solution and its ability to be tailored to meet the Health Squad’s specific needs. As such, we worked closely with the team to configure our Health Options® CS platform around their specific workflows and objectives. A major focus was placed on incorporating ongoing feedback and enabling continuous enhancements as the initiative grew. Health Squad Programme Lead, Alan Hodgson, states:
“Introducing the Health Options platform has been key in enabling our team to support our clients to the fullest. The system has allowed us to work efficiently with other health service providers by enabling quick onward referrals when appropriate. That, alongside effective follow up processes, has ensured the best possible outcomes for our clients.”
The Health Squad now access a fully integrated system that supports the entire client journey, from initial health assessment and personalised health reports, through to one-click referrals and a structured follow-up process. Referral pathways are key to the solution flow, ensuring clients are made aware of the range of support that is available and introducing them to the services with GPs, respiratory clinicians, drug and alcohol recovery services, diabetes specialists, weight management support and mental health services.
With access to the real-time Power BI data dashboard, the commissioners have clear, filterable insights into outcomes across the programme. Data can be viewed by gender, age, ethnicity, deprivation deciles, and Core20PLUS5 health inclusion cohorts, ensuring meaningful visibility of reach and impact and enabling a proactive approach to managing the service.
Fiona Mawson, Public Health Practitioner at Durham Public Health, explains more:
“Health Diagnostics’ secure, fully auditable solution ensures seamless integration with GP clinical systems, enabling safe data transmission and compliance with reporting. The system’s ability to create customisable assessments, workflows, and personalised health reports enhances our efficiency and client engagement.”
The flexibility of this system is already demonstrating value beyond County Durham. A closely aligned programme is now being implemented in Darlington, built on the same framework but tailored to reflect local referral pathways and assessment requirements. The fact that a second authority has adopted the model speaks volumes about the success of our collaboration with the Health Squad.
Continuity of care: Going beyond the first contact
A defining feature of the Health Squad approach is its commitment to ongoing support of those engaging. The Health Squad team collaborate with individuals to set personal health goals, then schedules structured follow-up appointments to monitor, record progress and provide ongoing support. This level of continuity isn’t always standard within prevention services, but it is proving to be key in evidencing the meaningful, real-world impact the programme is achieving.
Our cloud-based platform enables this continuity of care to be possible ‘at scale’, tracking each client’s journey from their initial assessment and risk profile through to goal achievement, enabling a detailed analysis of their outcomes and the programme’s impact over time. Fiona adds:
From a commissioning perspective, the ongoing tracking of the client journey from initial health check to follow-up at the GP, and the other specialist involvement has provided us with data that enables us to better understand the wider impact of the initial health check assessment delivery contract. These include the short-term KPIs, including the risk status of those engaging in the programme, through to what happened following any GP referrals. This helps public health to better understand the elusive “so what” was the impact of the initial engagement, health check and support provided
The results: Remarkable outcomes, achieved against the odds
Between April and September 2025, the Health Squad engaged with over 500 vulnerable people across County Durham. Of those, 91% received a full health check, and 68% were referred to GPs for identified risk factors, including high blood pressure, elevated cholesterol, and cardiovascular risk.
The mental health needs identified were equally significant: with almost two-thirds scoring 15-21 on the GAD-7 scale, indicating ‘severe anxiety’. This is significantly higher than the UK average of 5.15 and highlights the scale of unmet need, which is being tackled through the Health Squad’s outreach.
Perhaps most powerfully, of the 97 clients who received a follow-up consultation within six months, 61% had fully achieved their personal health goal, and a further 12% were actively working towards their goals. Given the adversity many of these individuals face day-to-day, these outcomes are remarkable. As Julie Evason, Founder and Managing Director at Health Diagnostics, reflects:
The fact that 61% of participants’ goals, aimed at addressing serious health and wellbeing concerns, have been achieved within 6 months is a testament to the Health Squad’s drive and commitment to improving the health and wellbeing of their community.
Highly Commended at the Health Tech News Now Awards 2025/26!
We were delighted to see our partnership gain recognition beyond County Durham. The programme was Highly Commended in the Healthcare Improvement and Operations Transformation category at the Health Tech News Now Awards 2025/26. This acknowledgement reflects the real impact that targeted outreach can achieve – when powered by the right digital tools and driven by a genuine commitment to support underserved communities as part of public health work.
Award Win: HSJ Partnership Awards 2026
We’re also thrilled to share that the Health Squad has just been announced as the HSJ Partnership Awards 2026 winner for Most Impactful Project Addressing Health Inequalities. This national recognition reflects the extraordinary commitment of the Health Squad teams and their partners in tackling long‑standing health inequalities and delivering meaningful change for underserved communities.
For us, it’s a proud reflection of our wider mission: To make individually focused, proactive, preventative care accessible to everyone, regardless of their circumstances. Because prevention is ALWAYS better than cure.
To find out more about the real-world impact of using Health Options®CS in preventative health projects, go to our Proven Results page by clicking here