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Addressing Health Inequalities

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Challenge: advance whole-person care by tackling health inequalities

Improving the health of the populations you serve without understanding the conditions in which they live is a difficult undertaking. Non-clinical factors can impact as much as 80% of a person's overall health1 and understanding the social risk factors your population is experiencing can be challenging. Lack of standardised data collection, incomplete data, and limited resources and tools can create barriers to intervening on the social needs of populations.

The concept of addressing the wider determinants of health isn’t new. Integrated care systems increasingly seek information and technology capabilities to address the wider determinants of their population through data-driven analytics and point-of-care tools across health and care.

COVID-19 disproportionately impacted those living with these conditions, as well as those in the most deprived areas.2 Given regulatory and local pressures, understanding and responding to health inequalities in the population is vital.

The NHS has established the Core20PLUS5 approach to help identify and reduce health inequalities, and set priorities at both national and system level. Core20PLUS5 sets out five impactable clinical areas of focus:2

  • Early cancer diagnosis (screening and early referral)
  • Hypertension case finding
  • Chronic respiratory disease (driving COVID and flu vaccination uptake)
  • Annual health checks for people with serious mental illness 
  • Continuity of maternity care plans 

1 Core20PLUS5 – An approach to reducing health inequalities
2 Canadian Medical Association. Canada’s health system is on life support: Health workers call for urgent mobilization to address shortages, burnout and backlog issues

Oracle Cerner solutions impacting social determinants of health

Oracle Cerner enables integrated care systems to tackle health inequalities. Whether you’re conducting outreach and clinical interventions for vulnerable patients, digitalising clinical pathways to reduce variation in care that may exacerbate inequalities, facilitating data exchange across health and social care organisations, or implementing interventions across the system, our capabilities are available to help you.




Near real-time, longitudinal, agnostic, person-centric data, enabling person-to-system and system-to-person intelligence, intervention and impact redesign.

The infrastructure of a 21st century integrated care system.




Tools for insight

Gain a better understanding of the risk factors impacting your patient population using advanced analytics, powered by clinical and determinants of health data, to inform your population health and care management strategies.

HealtheEDW℠ Advanced



Tools for transformation

Intervene at the point of care using evidence-based screening tools and suggested goals/activities in your patient’s care plan to reduce gaps in care and provide more patient-centred, equitable care.

Patient Portal UK



Tools for measurement and consulting

Consider the wider determinants of health to commission for outcomes, drive quality across person-centric pathways and create co-produced services impacting upstream demand.


The Oracle Cerner difference
Oracle Cerner is at the forefront of healthcare innovation, promoting whole-person care and advancing health equity by combining more than four decades of EHR experience, determinants of health data and identifying variation in communities with social risks, such as food and housing insecurity, equity in waits and data science-led prioritisation.
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We can help you equip your organization with the right tools and technology to transform into a Real-Time Health System.
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