- A collaborative approach to digital health prevention was associated with 61% of people reporting progress toward reaching their personal health goals over a 6 month period
- The flexible software platform provides configurable data dashboards to support public health teams in accessing and visualising service level ‘live’ information, including insights relating to residents in deprived areas, and those experiencing homelessness or drug misuse
A pioneering mobile health initiative in County Durham is successfully transforming how healthcare is being delivered to the region’s most vulnerable and underserved residents. The Health Squad, delivered in partnership by County Durham and Darlington NHS Foundation Trust (CDDFT) and the Pioneering Care Partnership (PCP), is taking interventions directly into the heart of communities to support those who face the greatest barriers to traditional GP-based care.
The initiative focuses on engaging individuals who may be at greatest risk of poor health outcomes who face significant adversity, including those experiencing homelessness, substance misuse, contact with the criminal justice system, and members of the travelling community, as well as veterans, migrants, and residents of deprived areas. By deploying three dedicated mobile outreach teams, the Health Squad provides vital physical and mental health checks where they are needed most, to reach people who might otherwise remain undetected by the healthcare system.
INSIGHTS FROM OUTREACH IN UNDER-SERVED COMMUNITIES
The initiative uses a specially tailored version of Health Options® CS – the software platform provided by Health Diagnostics – which supports public health practitioners in recording information, generating personalised health reports, and facilitating administrative processes such as referrals for mental health support or drug and alcohol recovery. Almost two thirds of the population were identified to have severe anxiety, scoring 15-21 on the GAD-7 scale – significantly higher than the UK average of 5.15. Fiona Mawson, Public Health Practitioner at Durham County Council, explains, “The system has been able to provide not only individual personal health plans but also include vulnerable cohorts ‘who will not attend a GP practice’. It also tracks the client’s journey from initial assessment to the achievement of individual goals.”
The engagement of 500 clients over 6 months (April to Sept 2025) provided insights into service delivery, highlighting significant unmet needs within the target population:
- 91% of engaged clients received a full health check assessment.
- 61% of the 97 clients who received a follow-up consultation within 6 months reported they had achieved their personal health goals (e.g. stopping smoking)
DATA INSIGHTS TO SUPPORT SERVICE PLANNING
To support responsiveness to local needs, the partnership between Health Diagnostics and Durham Public Health uses real-time data, accessed via a tailored, Power BI dashboard. This enables the team to review aggregated service data, and track health outcomes which are filterable by age, ethnicity and deprivation deciles. Crucially, this ensures that resources are consistently and efficiently directed toward reducing health inequalities.
The success of this model was recently recognised at the Health Tech News (HTN) Now Awards 2025/26 where the partnership was Highly Commended in the ‘Healthcare Improvement and Operations Transformation’ category. Julie Evason, Founder and Managing Director of Health Diagnostics, notes, “The fact that 61% of goals aimed at addressing serious health and wellbeing concerns have been achieved within six months is a testament to the Health Squad’s model. Our mission is to make individually focused, proactive care accessible to everyone, regardless of their circumstances, because prevention is always better than cure.”
A PROVEN MODEL FOR EFFECTIVE PREVENTION
The success of this Durham initiative mirrors the broader impact of Health Diagnostics’ work across the UK. The company was recently a finalist for ‘Most Impactful Partnership in Population Health’ at the HSJ Partnership Awards 2026. The nomination recognised its long-standing collaboration with Medway Council, which, since 2017, has helped reshape how NHS Health Checks and community-based prevention are delivered at scale. This has supported the completion of over 1,500 blood pressure checks in a single month, and has enabled broader engagement with underserved communities, with the region’s most deprived communities reached, helping to support earlier access to appropriate care.
Both the Durham and Medway examples above show the power of close collaboration between outreach teams and smart software providers, such as Health Diagnostics, to turn data into meaningful action.
