case study asset management

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Case studies

Working with clients to solve short-term fixed income needs

FEATURED CASE STUDIES

Meituan-Dianping: A unicorn’s path to achieve world-class treasury

All case studies, vertex pharmaceuticals.

Vertex Pharmaceuticals transforms its investment processes with Morgan Money.

Kulicke & Soffa

Kulicke & Soffa meets strong risk management standard with MORGAN MONEY’s cash optimizer.

Nigeria LNG

Harnessing the Power of Technology. Nigeria LNG transforms Money Market Fund investments with MORGAN MONEY.

Micro Focus

Short-term AAA-rated money market funds provide short-term investment opportunities for divestment proceeds.

Liquidity and security over yield deliver investment benefits to NIO

Active Super (previously known as Local Government Super)

Prioritizing cash management at scale, Active Super (previously known as Local Government Super), an Australian superannuation fund, found “operational alpha”.

Meituan-Dianping

Meituan-Dianping, a growing unicorn, had a major challenge to accurately forecast its cash flow beyond three months.

NTUC Income

Singapore-based insurance provider NTUC Income had always handled its investments entirely through its internal portfolio management team.

Recruit Holdings

As the business has grown globally, liquidity and cash positions outside of Japan have expanded, creating foreign exchange (FX) exposure.

The challenge: to assess the optimal level of liquidity required to ensure John Lewis Partnership has continued financial sustainability.

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Cash investment policy statement

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Leveraging the power of cash segmentation

The most effective strategy incorporates a clear investment policy, well-defined goals and parameters for liquidity, quality and return.

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Modernizing enterprise asset management

• Call for Change
• When Tech Meets Human Ingenuity
• A Valuable Difference
• Meet the Team
• Related Capabilities

Call for change

To manage Accenture’s enterprise assets, teams across Accenture were using a variety of solutions and processes. Much of the data capturing was manual and inconsistent across systems, driving the need for a modern, integrated system.

Our global IT and Corporate Services & Sustainability  organizations collaborated to develop a solution. As we continually look to obtain new value from our ServiceNow platform , we recognized that the ServiceNow IT Asset Management solution held the potential to address enterprise asset management (EAM) needs across Accenture.

As a result, we partnered with ServiceNow to influence the solution road map. This joined effort between global IT and Corporate Services & Sustainability teams such as Local Technology Services, Procurement, and Workplace, also collaborated with Controllership within Accenture Finance , to ultimately enable a cross-function, integrated approach.

Our objective was to launch a program to create a single system to manage software, hardware and workplace assets, establishing standard processes and facilitating consistent accounting and end-to-end life cycle management. Software covers license management and modernization of our current software catalog. Hardware assets include such items as workstations, mobile devices, servers, and video conferencing devices. And, workplace assets include such items as office furniture, fixtures, kitchen equipment and TVs.

A single solution would allow us to decommission the disparate range of tools that teams were using across the organization, reducing manual efforts and improving data quality and centralized management with better visibility on asset location and movement.

Accenture Enterprise Asset Management solution overview

Asset management process reengineering and software implementation: software, hardware and workplace

Estimated number of assets for migration

Software spend tracked

Estimated asset value

Software products tracked

When tech meets human ingenuity

Our cross-functional, enterprise asset management (EAM) program team needed to address an environment of disparate solutions and processes in order to migrate asset information to the ServiceNow Asset Management product. The goal was to have consistent global processes across Accenture and a capability to track assets from end to end with a single enterprise system.

Getting to this end state would require three phases of effort over a three-year period: establishing a foundational capability, deploying targeted geographies, and evolving the enterprise asset management (EAM) solution.

Establishing the foundation centered around rationalizing processes, data and establishing core integrations. Our project team migrated an initial 800,000 assets from disparate tools to the ServiceNow platform. This number is projected to reach 4 million. We rationalized data and implemented system controls to drive standardization and data integrity across asset information. Data governance controls and legal compliance guidelines were automated. Global ownership of data governance was established as well.

In addition, our team built integrations with ServiceNow and core platforms to drive automation with SAP Ariba for asset procurement and a single global SAP system instance for financial data. These connections help facilitate an integrated, end-to-end asset management life cycle by tracking assets from procurement until disposal, along with real-time audit and reconciliation capabilities.

During this time and in the subsequent phases, our team focused development on four key elements:

Global processes

Our team inventoried existing asset management processes across Accenture’s geographies and selected the best of them. We used these to reengineer new, end-to-end asset life cycle processes to get to a standard, global solution.

This solution can be customized at local levels to address specific regulatory compliance requirements. Designing this global process flow formed the "core" for deploying the asset management application in stages to Accenture’s 50 countries.

Custom portal

To provide an enhanced user experience, the team developed a custom, mobile-friendly service portal with an intuitive and interactive user interface. Key features include auto-generation of standardized asset tags and QR codes when assets are received. The asset manager capability lets asset teams view and edit assets, check the activity log as well as reprint asset tags. Asset teams can upload assets in bulk using an intuitive and easy-to-use template.

The portal is also accessible on mobile devices via a browser, making it easy for asset managers to tag assets and generate bar codes directly from their devices. For software managers, the portal enables end-user license management giving software owners the capability to allocate and manage the licenses they are responsible for. In addition, all Accenture people are able to view assets assigned to them and confirm receipt of assets shipped to them. This ability was especially important when thousands of laptops needed to be shipped to our people who needed to work remotely due to the COVID-19 pandemic.

The team created several role-based dashboards that provide real-time reporting to govern data. The dashboard for asset managers provides the ability to precisely track all their assets, confirm data governance and accurately forecast stock refresh.

Those in asset operations can monitor and directly engage in asset life cycle activities (movement, maintenance and disposal) and related compliance tasks. The dashboards for Accenture Controllership give users end-to-end visibility on fixed-asset creation, accruals and overall reconciliation of physical assets in the EAM system and fixed assets in SAP. The dashboard for software asset administrators displays actionable information, trends and a cost-savings view.

The integration of the dashboards with Accenture’s SAP ERP system facilitates financial reconciliation of assets and eliminates the need for users to toggle between ServiceNow and SAP to download and compare records. Manual effort is greatly reduced, and users now have one unified view of asset records and consolidated reports.

Working jointly with ServiceNow, the team developed a powerful mobile app to register, manage and periodically audit assets from anywhere. The app has several distinct features, one of which is a multi-scan capability that enables asset teams to scan QR or bar codes on multiple assets in one pass. The mobile app is integrated with the overall solution and automates and accelerates the amount of time it takes to register assets, resulting in increased operational efficiencies and major time savings.

Collaboration counts

The EAM program teams consist of many members with specialized skills from different locations, working on different areas but toward one common goal. In our day-to-day efforts, our teams engaged more than 200 global stakeholders representing 50 countries. Team members and stakeholders participated in design thinking workshops to complete a gap assessment of the current processes and then developed "to-be" processes to finalize designs. Business analysts converted those processes into user stories that were then passed to the development team to write the code.

Other teams at Accenture’s Innovation Centers collaborated on the mobile app development together with ServiceNow. The collaboration of all our teams made tremendous progress in deploying the asset management solution to nearly all of Accenture’s geographic units globally. We continue to evolve and improve the solution.

A valuable difference

Accenture is transforming the way the company tracks and manages software, hardware and workplace assets globally. This single, integrated solution significantly streamlines the process and helps to manage the life cycle of assets from beginning to end.

In just one Accenture location alone, the introduction of the mobile application to manage assets through their life cycles reduced time spent resolving location discrepancies by 40 percent, reduced the time to perform asset audits by 50 percent and improved asset issue resolution time by 25 percent.

When the COVID-19 pandemic set in and Accenture needed to move desktops and other hardware assets to employee homes quickly, our EAM program team was able to take advantage of the work accomplished to date. We quickly spun up an ad hoc asset tracking solution onto the ServiceNow platform, made some enhancements to the mobile app to enable check-in and check-out of the assets, as well as developed a way to automate the return-to-office process . These capabilities helped other Accenture teams quickly and effectively perform large numbers of equipment moves.

In terms of software, the management of software publishers that have previously audited Accenture has currently surpassed 67% and will continue to climb. The EAM system will provide time-saving reconciliation reports to possibly eliminate or avoid future software audits.

Data from the EAM system is also providing functionality previously unavailable for tracking workplace assets related to furniture moves within an office or between different office locations and managing the refurbishment and recycling of furniture. The data is helping to deliver cost benefits, enable depreciation and support our our sustainability efforts .

Benefits of Accenture’s enterprise asset management system on ServiceNow:

"This intelligent, automated asset management system is enabling a whole new level of agility, tracking and forecasting in our workplace. It is accessible and meets Web Content Accessibility Guidelines." — Margaret Smith , Senior Managing Director and Executive Director – Corporate Services & Sustainability and Business Operations, Accenture

Centralizes software, hardware and workplace assets, providing enterprise visibility

Standardizes the asset management process

Performs auto-discovery of software and hardware assets

Enables end-user license management and software requests

Enables anytime, anywhere access with a mobile app

Meets Web Content Accessibility Guidelines (WCAG)

Automates data controls, governance, and risk and compliance activities

Established governance and compliance policies

Meet the team

Tami McNairy

David Schneiderman

Renee Cordova Lottes

Indranil Datta

Related capabilities, how accenture does it, corporate services & sustainability.

These teams are enabling innovation, growth and business continuity for Accenture.

Accenture + ServiceNow

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Asset Management Operations Case Studies

• Case Studies

Case Study Basics

What is a case study *.

A case study is a snapshot of an organization or an industry wrestling with a dilemma, written to serve a set of pedagogical objectives. Whether raw or cooked , what distinguishes a pedagogical case study from other writing is that it centers on one or more dilemmas. Rather than take in information passively, a case study invites readers to engage the material in the case to solve the problems presented. Whatever the case structure, the best classroom cases all have these attributes: (1)The case discusses issues that allow for a number of different courses of action – the issues discussed are not “no-brainers,” (2) the case makes the management issues as compelling as possible by providing rich background and detail, and (3) the case invites the creative use of analytical management tools.

Case studies are immensely useful as teaching tools and sources of research ideas. They build a reservoir of subject knowledge and help students develop analytical skills. For the faculty, cases provide unparalleled insights into the continually evolving world of management and may inspire further theoretical inquiry.

There are many case formats. A traditional case study presents a management issue or issues calling for resolution and action. It generally breaks off at a decision point with the manager weighing a number of different options. It puts the student in the decision-maker’s shoes and allows the student to understand the stakes involved. In other instances, a case study is more of a forensic exercise. The operations and history of a company or an industry will be presented without reference to a specific dilemma. The instructor will then ask students to comment on how the organization operates, to look for the key success factors, critical relationships, and underlying sources of value. A written case will pre-package appropriate material for students, while an online case may provide a wider variety of topics in a less linear manner.

Choosing Participants for a Case Study

Many organizations cooperate in case studies out of a desire to contribute to management education. They understand the need for management school professors and students to keep current with practice.

Organizations also cooperate in order to gain exposure in management school classrooms. The increased visibility and knowledge about an organization’s operations and culture can lead to subsidiary benefits such as improved recruiting.

Finally, organizations participate because reading a case about their operations and decision making written by a neutral observer can generate useful insights. A case study preserves a moment in time and chronicles an otherwise hidden history. Managers who visit the classroom to view the case discussion generally find the experience invigorating.

The Final Product

Cases are usually written as narratives that take the reader through the events leading to the decision point, including relevant information on the historical, competitive, legal, technical, and political environment facing the organization. A written case study generally runs from 5,000 to 10,000 words of text supplemented with numerous pages of data exhibits. An online raw case may have less original text, but will require students to extract information from multiple original documents, videos of company leaders discussing the challenges, photographs, and links to articles and websites.

The first time a case is taught represents something of a test run. As students react to the material, plan to revise the case to include additional information or to delete data that does not appear useful. If the organization’s managers attend the class, their responses to student comments and questions may suggest some case revisions as well.

The sponsoring professor will generally write a “teaching note” to give other instructors advice on how to structure classroom discussion and useful bits of analysis that can be included to explicate the issues highlighted in the case study.

Finally, one case may inspire another. Either during the case writing process or after a case is done, a second “B” case might be useful to write that outlines what the organization did or that outlines new challenges faced by the organization after the timeframe of the initial case study.

* Portions of this note are adapted from E. Raymond Corey, “Writing Cases and Teaching Notes,” Harvard Business School case 399-077, with updates to reflect Yale School of Management practices for traditional and raw cases.

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The Case for Asset Management

What is asset management.

It's a balancing act between cost, risk and performance. We invite you to watch this 5 minute video for a great overview:

Why Asset Management?

Case studies that highlight the benefits of asset management.

PEMAC is producing a series of Canadian case studies in video format that highlight the real-world benefits of applying Asset Management principles. These will be organized according to the four fundamentals, "Assurance", "Alignment", "Value", and "Leadership".

The initial funding for this project has come from a grant that we received through FCM’s Municipal Asset Management Program (MAMP) (see bottom of the page for more information).  Asset Management benefits are not only being realized by municipalities.  We will start with municipal stories and move on from there.

Questions leaders can ask to drive the conversation

This initiative is delivered through the Municipal Asset Management Program, which is delivered by the Federation of Canadian Municipalities and funded by the Government of Canada.

Funding for this initiative is provided through FCM’s Municipal Asset Management Program (MAMP), an eight-year, $110-million program, delivered through the Federation of Canadian Municipalities and funded by the Government of Canada.

Check out our new Consent management feature here

• Case Studies
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5 Case Studies of Successful Digital Asset Management Implementation

Discover five real-life case studies of successful digital asset management implementation.

Digital asset management (DAM) has become an essential tool for businesses in the modern era. The ability to store, organize, and distribute digital assets efficiently is crucial for companies of all sizes and industries. In this article, we will explore five case studies of successful DAM implementation, highlighting the challenges faced, strategies employed, and the remarkable results achieved by these companies. Through these real-life examples, we hope to provide valuable insights and inspiration for those considering implementing DAM in their own organizations.

Introduction to Digital Asset Management (DAM)

Before delving into the case studies, let's first establish a clear understanding of what digital asset management entails. At its core, DAM is a system or platform that allows businesses to store, organize, search, and distribute their digital assets, such as images, videos, documents, and audio files. It provides a centralized repository for these assets, making them easily accessible to authorized stakeholders while ensuring proper permissions and version control.

What is Digital Asset Management?

Digital asset management refers to the process of managing and optimizing digital assets throughout their lifecycle. It involves tasks such as ingestion, metadata tagging, storage, retrieval, and distribution of assets, all within a secure and user-friendly environment. By implementing DAM, businesses can save valuable time and resources, streamline workflows, and enhance collaboration among teams.

Importance of DAM in the modern business landscape

In today's digital age, businesses generate an enormous amount of digital assets daily. Managing these assets efficiently is paramount to maintaining brand consistency, improving productivity, and maximizing return on investment. A solid DAM strategy ensures that assets are organized, searchable, and accessible to stakeholders across various departments and locations. It also serves as a valuable resource for marketing, sales, and creative teams, enabling them to deliver consistent and compelling content to their target audience.

Case Study 1: Company A's Digital Asset Management Implementation

Company A is a leading e-commerce retailer in the fashion industry, with a vast catalog of products and numerous marketing campaigns running simultaneously. Before implementing DAM, their digital assets were scattered across multiple servers, making it challenging to locate and use them effectively. They faced difficulties in maintaining brand consistency across various marketing channels and struggled to keep track of the latest versions of creatives. Recognizing these pain points, Company A decided to invest in a robust DAM solution.

Overview of Company A's business and industry

Company A operates in a highly competitive industry, where delivering visually appealing and up-to-date content is crucial in attracting and retaining customers. With a wide range of products, they needed a comprehensive DAM system that could accommodate their vast collection of images and videos while ensuring easy access for their marketing, sales, and design teams.

Challenges faced by Company A before implementing DAM

Prior to implementing DAM, Company A faced several challenges in managing their digital assets effectively. The absence of a centralized system made it difficult to locate specific assets quickly, resulting in wasted time and duplicated efforts. Collaborating with multiple internal and external stakeholders became cumbersome, often leading to miscommunications and inconsistencies in branding. Furthermore, their existing file storage system lacked proper metadata tagging, making it hard to retrieve relevant assets when needed most.

Strategies and steps taken to implement DAM successfully

To overcome these challenges, Company A embarked on a comprehensive DAM implementation plan. They conducted extensive research to identify a suitable DAM solution that met their specific requirements. After careful evaluation, they chose the HIVO DAM platform, known for its robust features, user-friendly interface, and scalability.

The implementation process began with a thorough assessment of Company A's existing digital asset management practices and workflows. This analysis helped identify areas that needed improvement and set clear objectives for the DAM implementation. The next step involved migrating existing assets to the HIVO platform, ensuring that metadata was accurately tagged to facilitate easy search and retrieval. A dedicated team was responsible for defining and implementing a standardized metadata taxonomy, ensuring consistency throughout the system.

In parallel, Company A conducted training sessions to familiarize their employees with the HIVO platform. They emphasized the importance of DAM best practices and encouraged active participation from all teams, promoting a culture of collaboration and knowledge sharing.

Results and benefits achieved after implementing DAM

The successful implementation of the HIVO DAM platform brought significant improvements to Company A's operations. With assets centralized in a single location, employees could easily locate and reuse assets, reducing the time spent searching for files. The automated metadata tagging and advanced search capabilities provided by HIVO further enhanced efficiency, enabling users to quickly find the most relevant assets for their campaigns.

Company A witnessed a remarkable increase in productivity and collaboration among teams. Sales and marketing departments benefited from the ability to share assets seamlessly, resulting in more targeted and consistent brand messaging across various channels. The DAM system also played a vital role in maintaining brand integrity by ensuring that the latest approved versions of assets were used consistently across all touchpoints.

Furthermore, with the HIVO DAM platform, Company A gained valuable insights into asset usage and performance metrics. This data-driven approach allowed them to optimize their marketing strategies and make data-backed decisions, contributing to improved ROI and overall business growth.

Case Study 2: Company B's Digital Asset Management Implementation

Company B, a multinational technology corporation, embarked on a journey to streamline their global operations and improve collaboration among their geographically dispersed teams. With an extensive portfolio of digital assets and the need for efficient asset distribution, they realized the importance of implementing a robust DAM system to facilitate their operations.

Overview of Company B's business and industry

As a technology leader, Company B operates in a fast-paced industry with ever-evolving customer demands. They constantly generate a vast array of digital assets, including product images, marketing collateral, and technical documentation. Ensuring seamless access to these assets across global teams and departments is crucial for delivering top-quality products and services.

Challenges faced by Company B before implementing DAM

Prior to implementing DAM, Company B faced challenges in maintaining version control and consistency across their global operations. The absence of a centralized system made it difficult for geographically dispersed teams to collaborate effectively and access the latest assets. As a result, there were instances of miscommunication, duplicated efforts, and delays in project delivery. Recognizing the need for better asset management, Company B set out to implement a DAM solution that could address these challenges.

Company B's DAM implementation journey started with a thorough analysis of their existing asset management workflows. They identified areas that needed improvement, such as version control, permission management, and secure distribution across teams.

After extensive evaluation, Company B selected the HIVO DAM platform as their preferred solution due to its robust security features, multi-lingual support, and scalability. The implementation process began with migrating existing assets to HIVO, ensuring that metadata tagging and permissions were properly configured. Integration with other internal systems, such as project management and collaboration tools, further streamlined workflows and enhanced cross-team collaboration.

Throughout the implementation process, Company B paid particular attention to change management and employee training. They conducted comprehensive training sessions and provided ongoing support to ensure that employees embraced and mastered the DAM platform effectively.

Implementing the HIVO DAM platform brought significant improvements to Company B's operations. The centralized repository of assets made it easy for teams to access the latest versions and collaborate seamlessly, regardless of their location. The ability to set granular permissions ensured that only authorized personnel could access and modify assets, ensuring data security.

With HIVO's powerful search capabilities, Company B experienced a considerable reduction in time spent searching for assets. This not only increased productivity but also improved project delivery timelines, leading to greater customer satisfaction. Automatic version control within the DAM platform ensured that everyone was working on the latest approved asset, eliminating any confusion or inconsistencies.

Furthermore, Company B benefited from the seamless integration between HIVO and their existing project management systems. This integration eliminated duplicate data entry and enabled real-time updates, optimizing their overall workflows.

Case Study 3: Company C's Digital Asset Management Implementation

Company C, a global hospitality chain, recognized the need for a robust DAM system to manage their vast library of digital assets, including hotel images, videos, and branding materials. With a rapidly expanding portfolio and the goal of delivering personalized experiences to their guests, they set out on a mission to transform their asset management practices.

Overview of Company C's business and industry

As a major player in the hospitality industry, Company C operates numerous hotels and resorts worldwide. A vital aspect of their brand identity is providing visually stunning experiences to their guests. Managing the vast library of digital assets, including high-resolution images and videos, is crucial for delivering on this promise.

Challenges faced by Company C before implementing DAM

Prior to implementing DAM, Company C faced several challenges in managing their digital assets effectively. Their existing system relied heavily on manual processes, resulting in inefficiencies and delays in accessing assets. Collaboration among the marketing and operations teams was hindered by the absence of a centralized platform, leading to fragmented and inconsistent branding efforts. Recognizing the need for a scalable solution, Company C decided to invest in a DAM platform that could address their pain points.

Company C's DAM implementation journey started with a thorough evaluation of their existing asset management practices and identifying areas that needed improvement. They outlined clear objectives and established a cross-functional team to oversee the implementation process.

After exploring various options, Company C selected the HIVO DAM platform for its robust features, scalability, and support for large file sizes. The migration process involved transforming assets from various formats and ensuring accurate metadata tagging for easy searching and retrieval. The implementation team worked closely with each department, defining workflows and permissions to suit their specific needs.

Employee training and change management were crucial components of Company C's DAM implementation. They conducted comprehensive training sessions, focusing not only on the technical aspects but also on the benefits and best practices of using DAM. Periodic reviews and feedback sessions helped them fine-tune the system and address any concerns.

Implementing the HIVO DAM platform revolutionized Company C's asset management practices. The centralized repository made it easy for employees across departments and locations to access the assets they needed, resulting in faster content creation and delivery.

The advanced search capabilities offered by HIVO significantly reduced the time spent searching for assets and eliminated duplicated efforts. With the ability to preview assets before downloading, teams could quickly identify the most suitable assets for their projects, improving overall efficiency.

Brand consistency across hotels and resorts was enhanced through the DAM platform, ensuring that the latest branding materials were readily available to all stakeholders. The automated version control within HIVO prevented inconsistencies and helped maintain a unified brand image.

Additionally, Company C's marketing campaigns witnessed a boost in performance, thanks to the insights provided by HIVO's analytics and reporting capabilities. Data-driven decisions enabled more targeted and impactful campaigns, resulting in increased customer engagement and loyalty.

These case studies highlight the remarkable results achieved by companies that successfully implemented digital asset management solutions. The adoption of robust DAM platforms, such as HIVO, enabled businesses to overcome challenges, improve productivity, and deliver consistent branding across various channels.

Whether you operate in e-commerce, technology, or the hospitality industry, implementing a DAM solution tailored to your specific needs can bring significant benefits. The case studies presented in this article demonstrate the transformative power of DAM, resulting in streamlined workflows, enhanced collaboration, and improved return on investment.

So, if you find your digital asset management practices in need of an upgrade, take inspiration from these success stories and embark on your own DAM implementation journey. Your organization can reap the rewards of a centralized, organized, and efficient digital asset management system.

How Camuzzi Gas Distributor Saved Over 1,000 Hours a Year in Asset Management with InvGate Insight

Camuzzi is the largest natural gas distributor in Argentina in terms of volume, infrastructure magnitude, and geographical coverage. The company serves over 2,000,000 households across 45% of the national territory.

With over 30 years as the leading distributor in the industry, Camuzzi faced significant challenges in managing its IT infrastructure during the company's transition to a hybrid work model.

In this context, InvGate Insight provided a series of advanced functionalities that were key to addressing the issues faced in IT Asset Management .

Let's take a look at this process with some precise numbers.

Challenges Faced by Camuzzi

Before migrating to InvGate Insight, Camuzzi used an internally developed tool that had significant limitations in facilitating the growth and sophistication of IT support provided to its teams.

This complexity was represented by over 3,000 technological assets and 1,700 employees spread across 16 business units.

Some of the inefficiencies of the previous tool included manually tracking and administering their IT assets and limited capabilities to generate accurate reports on their status and location.

Additionally, in a company with a vast geographical dispersion, each local team was responsible for manually updating the status of their assets, resulting in fragmented information and a lack of a single reliable source of information.

This prevented the company, among other issues, from planning and executing technological updates effectively to meet business demands.

Migration to InvGate Insight

In this context, at the beginning of 2023, Camuzzi began working with ThinkHub to implement InvGate Insight as their Asset Management tool .

The migration process was completed in two months, including configuration and review, and involved managing 3000 IT assets, such as workstations, laptops, and mobile phones.

Some of the key advanced functionalities that InvGate Insight provided to solve Camuzzi's problems were:

• Continuous reporting agent : Offering real-time data on the status of software, hardware, users, and the overall health of equipment, eliminating the need for constant manual supervision.
• Real-time discovery : Providing an updated and comprehensive view of all devices on the network, improving Resource and Security Management.

Keys to Camuzzi's Success with InvGate Insight

With the implementation of InvGate Insight and this combination of advanced Asset Management capabilities, Camuzzi streamlined processes and scaled the implementation of best practices across the company.

The keys to success were access to an accurate and updated view of the entire IT infrastructure (eliminating previous information fragmentation), the implementation of automations that reduced time and human errors, and the introduction of reliable metrics for informed decision-making.

An example of this is that InvGate Insight allowed Camuzzi to quickly identify devices with outdated operating systems. This visibility was essential to developing and implementing an update plan, ensuring compliance with security and compliance standards.

It is also important to highlight the outstanding support provided by ThinkHub, which maintained constant follow-up after the implementation, offering technical support and advice to optimize the use of the tool and solve any problems that might arise.

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Small Business Management Software: Case Studies of Successful Implementations

Small business management software has helped companies across different industries successfully transition from a bootstrapped startup or a “mom and pop” operation to an efficiently run small or medium sized enterprise. Today, no longer is business management software only for the large corporation, but increasingly, vendors are focused on developing powerful small business management software solutions specifically tailored to meet the expanding needs of smaller-sized organizations.

Small business management software includes software for Accounting, Enterprise Resource Planning (ERP), Customer Relationship Management (CRM) , and Email Marketing. This article will examine some real life examples of organizations that have taken their business operations to the next level after having successfully implemented some unique small business management software solutions.

A. Accounting Software Case Study: Bascome Trim and Upholstery and Intuit QuickBooks Enterprise

Bryce Forney is the founder of Forney Accountancy Corporation in Pleasant Hill, CA. In 2000, Bryce Forney, CPA, left a big accounting firm to realize his vision of providing value-added accounting for small business owners. He currently consults with over 50 companies in the San Francisco Bay Area and recommends QuickBooks software for most of his small business clients. For example, he has recommended as a small business management software solution to his clients QuickBooks Enterprise Solutions, which supports higher transaction volumes, faster performance, expanded inventory control, and job-costing to help his clients see the exact price of doing business. The story of one of Forney’s clients who has benefited from QuickBooks Enterprise Solutions is listed as follows:

In 2002, Bascom Trim and Upholstery, a busy car repair shop with 30 employees in Santa Clara, CA implemented QuickBooks Enterprise Solutions under Forney’s advisement. The company’s data file had outgrown QuickBooks Pro, so that only six months’ worth of transactions could be online at a time. This slowed down dealing with repeat customers, who had to be re-entered in the system from scratch. The new system accelerated many parts of an operation already know for its efficiency. General Manager John Wardell says the company was particularly interested in linking its repair orders directly with the accounting system. Before Enterprise, these orders were all recorded in FileMaker Pro, then transferred manually everyday into QuickBooks Pro. Now everything is handled with Enterprise Solutions, which saves hours in reconciling and helps the company clear up any payment issues faster and more professionally.

Bascom also has a more streamlined inventory process thanks to QuickBooks Enterprise. Before, it used to count up items and then match them to the yearend sales figures, a process Bryce says was “painful and inaccurate.” Now whenever any item is purchased, that transaction is entered automatically into the system, so that inventory records are always accurate and up-to-date.

And John can now track inventory from four companies under the same roof—for upholstery, stereos, glass, and detailing — and consolidate them all in the same report, or break out each one separately. “It’s fabulous to get 10 different reports, because I can see 10 different sides of the business,” says John. “We’re really pleased with all the reports we can pull off this system.” John can also do a time-cost analysis for each of his employees. This has led the company to start tying part of an employee’s pay check to their productivity.

Overall, Bascom Trim and Upholstery has been happy with QuickBooks Enterprise. “Everything is all right there in front of you. You can put it all together with QuickBooks payroll, inventory, and time-tracking,” says John. “You don’t need more employees to run the system, and you don’t need to outsource your bookkeeping because you can do it right here.” As a small business management software solution for accounting, QuickBooks delivers a lot of value to small companies who are trying to streamline their operations.

B. ERP Software Case Study: SixApart and the NetSuite Solution

As the developers of TypePad and Movable Type, the world’s leading solutions for bloggers and Web publishers, Six Apart has a complex, growing business that spans the globe. As a fast-growing international company, one of its many challenges was that it needed financial visibility across geographies and currencies for its ongoing operations. Another issue was that its customer subscription model was causing headaches in revenue recognition and compliance. With nothing but QuickBooks and spreadsheets to work with, Six Apart’s revenue recognition was a tedious, error-prone process. Lastly, as the company continued to grow in size and scale, it became clear that high-level managers would need a quick way to quickly capture and synthesize the performance of multiple departments, with complete support for multi-language data.

Six Apart addressed these needs with the implementation of the NetSuite OneWorld platform, a small business management software solution that enabled the company to operate one consolidated Software-as-a-Service ERP system, including financials and revenue recognition, in a unified and fully compliant manner without having to use a large accounting staff or deploying an expensive on-premise software. Moreover, with the OneWorld solution, Six Apart was able to quickly combine its three separate instances of NetSuite into a single, unified operational and reporting platform. This small business management software solution has helped Six Apart avoid spending upwards of $100K per year in IT administration costs and has also shaved days off its monthly closing cycle – making the company much more efficient and GAAP compliant, as well as giving executives insight into any detail they need, by channel customer, product or region.

C. CRM Software Case Study: The Honey Baked Ham Company and the Salesforce Solution

Following the addition of 120 people to its sales force, The HoneyBaked Ham Company of Georgia, a purveyor of high-quality ham, needed a robust yet simple CRM solution to effectively manage its business gifting and catering sales channels. Neither the company’s ACT! database nor the Microsoft Excel database was equipped to scale to support its rapid growth. The company had no visibility into sales activities or a gauge on the effectiveness of its myriad marketing efforts. Because HoneyBaked’s IT team was busy with other development projects, the small business management software solution they needed had to be one that required minimal infrastructure and maintenance. The company also wanted a system that would not intimidate its non-technical users.

After considering developing a small business management software system in-house, HoneyBaked selected Salesforce CRM because it was easy to implement, easy to use, and provided best-in-class functionality out of the box. The company initially tested Salesforce CRM Professional Edition, then quickly rolled out the solution to 130 users company-wide; a dedicated Salesforce.com customer service manager, along with a trained in-house administrator, helps maintain the system.

Salesforce’s small business management software provided the HoneyBaked Ham Company with personalized dashboards, which allowed reps to track sales activities, which were then rolled up to the district manager level, enabling them to see a company-wide view, as well as pipeline and forecast activities. Next, web-to-lead functionality fed incoming inquiries into assignments, providing a way to track lead sources. HoneyBaked also downloaded features such as Opportunity Pop-Up Calculator, Adoption Dashboards, and Account Weather Information applications from AppExchange, which extended the value of Salesforce CRM with solutions that continue to enhance the original investment. Lastly, integration with an order POS and management system on the front end enabled users to update opportunities and accounts within Salesforce CRM.

Overall, the implementation of this small business management software resulted in a dramatic increase in pipeline visibility, giving management the ability to monitor performance, to accurately forecast, and to plan for success. The company now has visibility into its 100 different lead sources, allowing managers to shift marketing and lead generation efforts in the most profitable direction. Instant user adoption improved productivity quickly. Additionally, because users no longer had to fish for information, conversations with customers became more meaningful and productive. Overall, Salesforce’s small business management software for customer relationship management was an effective tool in improving the HoneyBaked Ham Company’s sales and marketing activities.

D. Email Marketing Software Case Study: Finale Desserterie & Bakery and Constant Contact

Established in July 1998, by Paul Conforti and Kim Moore, Finale set out to make super-premium desserts available to everyone. By Valentine’s Day of the following year, Finale had attracted a lot of buzz from local and national media as well as a curious customer base. Having celebrated 10 years in business in 2008, Finale added three more locations and, consequently, more sensational dessert experiences for thousands.

Since Finale is focused exclusively on desserts, the restaurant didn’t suffer from a great deal of competition, but they did face the perception that decadent dessert is an extravagant indulgence that may be out of the price range of many diners. In addition, while weekends, holidays, and special occasions generated consistent business, attracting customers to the restaurant mid-week was a challenge.

As the media continued to highlight Finale’s ultra-premium desserts, it became more imperative to communicate the message that Finale’s desserts were not limited to special occasions, but ideal for everyone, anytime. In addition, Finale had cultivated a loyal, growing customer base to which it needed to communicate. Finale began using small business management software that included an email marketing solution from Constant Contact to communicate events, new desserts, special offers, or other news to its customers. Finale quickly realized that it was experiencing a significant boost in reservations and inquiries following each email campaign it sent. “We always sell out events when we use Constant Contact to tell our customers about them,” said Conforti. “For example, we recently used it to tell our guests about a tasting at our Coolidge Corner location. We sold out 40 seats from an email we sent the week before. At $30 per seating for 40 seats, that’s $1200 in revenue with one e-mail message.”

The restaurant has also used Constant Contact to request feedback from its customer base. For example, in July, Finale sent out an email asking customers what they’d like to see on the holiday menu. Finale received more than 100 responses to its mailing in 24 hours and more than 300 in 72 hours. “People are writing back just saying thanks for asking,” says Kim Moore, Finale’s co-founder. “It’s a very real way to be connected to our customer base.”

Finale now has more than 14,000 customers who receive its emails. The results have been absolutely sensational since implementing a small business management software system. From sold out events to customer feedback, Finale recognizes the tremendous value Constant Contact has provided to the business.

In addition, based on the success of the holiday menu email they sent that requested feedback, Finale will also soon roll-out Constant Contact’s ListenUp! online survey tool in order to obtain even more valuable feedback from customers. “No matter how successful a restaurant is, having the time and budget for a successful marketing campaign is difficult. Advertising costs too much money and it doesn’t guarantee that guests will come to your wine dinner. And your publicist can’t guarantee that the local paper will write about your event either,” said Moore. “For us, we have been successful at filling the room on a Monday night with clear and simple email marketing through Constant Contact. And it only costs us a small monthly fee.”

Overall, Constant Contact’s small business management software has been instrumental in helping Finale execute successful marketing campaigns, while nurturing a loyal and engaged customer base.

This article has highlighted many examples of how small business management software in a variety of industries has helped companies around the world compete more effectively in the marketplace. As small businesses grow into larger companies, and their needs require greater levels of support, many small business management software vendors have begun to provide solutions to address those specific needs and have greatly added value to enhance small-business operations across the globe.

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• Open access
• Published: 10 August 2024

How can health systems approach reducing health inequalities? An in-depth qualitative case study in the UK

• Charlotte Parbery-Clark 1 ,
• Lorraine McSweeney 2 ,
• Joanne Lally 3 &
• Sarah Sowden 4  

BMC Public Health volume  24 , Article number:  2168 ( 2024 ) Cite this article

250 Accesses

Metrics details

Addressing socioeconomic inequalities in health and healthcare, and reducing avoidable hospital admissions requires integrated strategy and complex intervention across health systems. However, the understanding of how to create effective systems to reduce socio-economic inequalities in health and healthcare is limited. The aim was to explore and develop a system’s level understanding of how local areas address health inequalities with a focus on avoidable emergency admissions.

In-depth case study using qualitative investigation (documentary analysis and key informant interviews) in an urban UK local authority. Interviewees were identified using snowball sampling. Documents were retrieved via key informants and web searches of relevant organisations. Interviews and documents were analysed independently based on a thematic analysis approach.

Interviews ( n  = 14) with wide representation from local authority ( n  = 8), NHS ( n  = 5) and voluntary, community and social enterprise (VCSE) sector ( n  = 1) with 75 documents (including from NHS, local authority, VCSE) were included. Cross-referenced themes were understanding the local context, facilitators of how to tackle health inequalities: the assets, and emerging risks and concerns. Addressing health inequalities in avoidable admissions per se was not often explicitly linked by either the interviews or documents and is not yet embedded into practice. However, a strong coherent strategic integrated population health management plan with a system’s approach to reducing health inequalities was evident as was collective action and involving people, with links to a “strong third sector”. Challenges reported include structural barriers and threats, the analysis and accessibility of data as well as ongoing pressures on the health and care system.

We provide an in-depth exploration of how a local area is working to address health and care inequalities. Key elements of this system’s working include fostering strategic coherence, cross-agency working, and community-asset based approaches. Areas requiring action included data sharing challenges across organisations and analytical capacity to assist endeavours to reduce health and care inequalities. Other areas were around the resilience of the system including the recruitment and retention of the workforce. More action is required to embed reducing health inequalities in avoidable admissions explicitly in local areas with inaction risking widening the health gap.

Highlights:

• Reducing health inequalities in avoidable hospital admissions is yet to be explicitly linked in practice and is an important area to address.

• Understanding the local context helps to identify existing assets and threats including the leverage points for action.

• Requiring action includes building the resilience of our complex systems by addressing structural barriers and threats as well as supporting the workforce (training and wellbeing with improved retention and recruitment) in addition to the analysis and accessibility of data across the system.

Peer Review reports

Introduction

The health of our population is determined by the complex interaction of several factors which are either non-modifiable (such as age, genetics) or modifiable (such as the environment, social, economic conditions in which we live, our behaviours as well as our access to healthcare and its quality) [ 1 ]. Health inequalities are the avoidable and unfair systematic differences in health and healthcare across different population groups explained by the differences in distribution of power, wealth and resources which drive the conditions of daily life [ 2 , 3 ]. Essentially, health inequalities arise due to the systematic differences of the factors that influence our health. To effectively deal with most public health challenges, including reducing health inequalities and improving population health, broader integrated approaches [ 4 ] and an emphasis on systems is required [ 5 , 6 ] . A system is defined as ‘the set of actors, activities, and settings that are directly or indirectly perceived to have influence in or be affected by a given problem situation’ (p.198) [ 7 ]. In this case, the ‘given problem situation' is reducing health inequalities with a focus on avoidable admissions. Therefore, we must consider health systems, which are the organisations, resources and people aiming to improve or maintain health [ 8 , 9 ] of which health services provision is an aspect. In this study, the system considers NHS bodies, Integrated Care Systems, Local Authority departments, and the voluntary and community sector in a UK region.

A plethora of theories [ 10 ], recommended policies [ 3 , 11 , 12 , 13 ], frameworks [ 1 , 14 , 15 ], and tools [ 16 ] exist to help understand the existence of health inequalities as well as provide suggestions for improvement. However, it is reported that healthcare leaders feel under-skilled to reduce health inequalities [ 17 ]. A lack of clarity exists on how to achieve a system’s multi-agency coherence to reduce health inequalities systematically [ 17 , 18 ]. This is despite some countries having legal obligations to have a regard to the need to attend to health and healthcare inequalities. For example, the Health and Social Care Act 2012 [ 19 ], in England, mandated Clinical Commissioning Groups (CCGs), now transferred to Integrated Care Boards (ICBs) [ 20 ], to ‘have a regard to the need to reduce inequalities between patients with respect to their ability to access health services, and reduce inequalities between patients with respect to the outcomes achieved for them by the provision of health services’. The wider determinants of health must also be considered. For example, local areas have a mandatory requirement to have a joint strategic needs assessment (JSNA) and joint health and wellbeing strategy (JHWS) whose purpose is to ‘improve the health and wellbeing of the local community and reduce inequalities for all ages' [ 21 ] This includes addressing the wider determinants of health [ 21 ]. Furthermore, the hospital care costs to the NHS associated with socioeconomic inequalities has been previously reported at £4.8 billion a year due to excess hospitalisations [ 22 ]. Avoidable emergency admissions are admissions into hospital that are considered to be preventable with high-quality ambulatory care [ 23 ]. Both ambulatory care sensitive conditions (where effective personalised care based in the community can aid the prevention of needing an admission) and urgent care sensitive conditions (where a system on the whole should be able to treat and manage without an admission) are considered within this definition [ 24 ] (encompassing more than 100 International Classification of Diseases (ICD) codes). The disease burden sits disproportionately with our most disadvantaged communities, therefore highlighting the importance of addressing inequalities in hospital pressures in a concerted manner [ 25 , 26 ].

Research examining one component of an intervention, or even one part of the system, [ 27 ] or which uses specific research techniques to control for the system’s context [ 28 ] are considered as having limited use for identifying the key ingredients to achieve better population health and wellbeing [ 5 , 28 ]. Instead, systems thinking considers how the system’s components and sub-components interconnect and interrelate within and between each other (and indeed other systems) to gain an understanding of the mechanisms by which things work [ 29 , 30 ]. Complex interventions or work programmes may perform differently in varying contexts and through different mechanisms, and therefore cannot simply be replicated from one context to another to automatically achieve the same outcomes. Ensuring that research into systems and systems thinking considers real-world context, such as where individuals live, where policies are created and interventions are delivered, is vital [ 5 ]. How the context and implementation of complex or even simple interventions interact is viewed as becoming increasingly important [ 31 , 32 ]. Case study research methodology is founded on the ‘in-depth exploration of complex phenomena in their natural, or ‘real-life’, settings’ (p.2) [ 33 ]. Case study approaches can deepen the understanding of complexity addressing the ‘how’, ‘what’ and ‘why’ questions in a real-life context [ 34 ]. Researchers have highlighted the importance of engaging more deeply with case-based study methodology [ 31 , 33 ]. Previous case study research has shown promise [ 35 ] which we build on by exploring a systems lens to consider the local area’s context [ 16 ] within which the work is implemented. By using case-study methodology, our study aimed to explore and develop an in-depth understanding of how a local area addresses health inequalities, with a focus on avoidable hospital admissions. As part of this, systems processes were included.

Study design

This in-depth case study is part of an ongoing larger multiple (collective [ 36 ]) case study approach. An instrumental approach [ 34 ] was taken allowing an in-depth investigation of an issue, event or phenomenon, in its natural real-life context; referred to as a ‘naturalistic’ design [ 34 ]. Ethics approval was obtained by Newcastle University’s Ethics Committee (ref 13633/2020).

Study selection

This case study, alongside the other three cases, was purposively [ 36 ] chosen considering overall deprivation level of the area (Indices of Multiple Deprivation (IMD) [ 37 ]), their urban/rural location, differing geographical spread across the UK (highlighted in patient and public feedback and important for considering the North/South health divide [ 38 ]), and a pragmatic judgement of likely ability to achieve the depth of insight required [ 39 ]. In this paper, we report the findings from one of the case studies, an urban local authority in the Northern region of the UK with high levels of socioeconomic disadvantage. This area was chosen for this in-depth case analysis due to high-level of need, and prior to the COVID-19 pandemic (2009-2018) had experienced a trend towards reducing socioeconomic inequalities in avoidable hospital admission rates between neighbourhoods within the local area [ 40 ]. Thereby this case study represents an ‘unusual’ case [ 41 ] to facilitate learning regarding what is reported and considered to be the key elements required to reduce health inequalities, including inequalities in avoidable admissions, in a local area.

Semi-structured interviews

The key informants were identified iteratively through the documentary analysis and in consultation with the research advisory group. Initially board level committee members (including lay, managerial, and clinical members) within relevant local organisations were purposively identified. These individuals were systems leaders charged with the remit of tackling health inequalities and therefore well placed to identify both key personnel and documents. Snowball sampling [ 42 ] was undertaken thereafter whereby interviewees helped to identify additional key informants within the local system who were working on health inequalities, including avoidable emergency admissions, at a systems level. Interview questions were based on an iteratively developed topic guide (supplementary data 1), informed from previous work’s findings [ 43 ] and the research advisory network’s input. A study information sheet was emailed to perspective interviewees, and participants were asked to complete an e-consent form using Microsoft Forms [ 42 ]. Each interviewee was interviewed by either L.M. or C.P.-C. using the online platforms Zoom or Teams, and lasted up to one hour. Participants were informed of interviewers’ role, workplace as well as purpose of the study. Interviewees were asked a range of questions including any work relating to reducing health inequalities, particularly avoidable emergency admissions, within the last 5 years. Brief notes were taken, and the interviews were recorded, transcribed verbatim and anonymised.

Documentary analysis

The documentary analysis followed the READ approach [ 44 ]. Any documents from the relevant local/regional area with sections addressing health inequalities and/or avoidable emergency admissions, either explicitly stated or implicitly inferred, were included. A list of core documents was chosen, including the local Health and Wellbeing Strategy (Table 1 ). Subsequently, other documents were identified by snowballing from these core documents and identification by the interviewees. All document types were within scope if produced/covered a period within 5 years (2017-2022), including documents in the public domain or not as well as documents pertaining to either a regional, local and neighbourhood level. This 5-year period was a pragmatic decision in line with the interviews and considered to be a balance of legacy and relevance. Attempts were made to include the final version of each document, where possible/applicable, otherwise the most up-to-date version or version available was used.

An Excel spreadsheet data extraction tool was adapted with a priori criteria [ 44 ] to extract the data. This tool included contextual information (such as authors, target area and document’s purpose). Also, information based on previous research on addressing socioeconomic inequalities in avoidable emergency admissions, such as who stands to benefit, was extracted [ 43 ]. Additionally, all documents were summarised according to a template designed according to the research’s aims. Data extraction and summaries were undertaken by L.M. and C.P.-C. A selection was doubled coded to enhance validity and any discrepancies were resolved by discussion.

Interviews and documents were coded and analysed independently based on a thematic analysis approach [ 45 ], managed by NVivo software. A combination of ‘interpretive’ and ‘positivist’ stance [ 34 , 46 ] was taken which involved understanding meanings/contexts and processes as perceived from different perspectives (interviewees and documents). This allowed for an understanding of individual and shared social meanings/reasonings [ 34 , 36 ]. For the documentary analysis, a combination of both content and thematic analysis as described by Bowen [ 47 ] informed by Braun and Clarke’s approach to thematic analysis [ 45 ] was used. This type of content analysis does not include the typical quantification but rather a review of the document for pertinent and meaningful passages of text/other data [ 47 ]. Both an inductive and deductive approach for the documentary analysis’ coding [ 46 , 47 ] was chosen. The inductive approach was developed a posteriori; the deductive codes being informed by the interviews and previous findings from research addressing socioeconomic inequalities in avoidable emergency admissions [ 43 ]. In line with qualitative epistemological approach to enquiry, the interview and documentary findings were viewed as ‘truths’ in themselves with the acceptance that multiple realities can co-exist [ 48 ]. The analysis of each set of themes (with subthemes) from the documentary analysis and interviews were cross-referenced and integrated with each other to provide a cohesive in-depth analysis [ 49 ] by generating thematic maps to explore the relationships between the themes. The codes, themes and thematic maps were peer-reviewed continually with regular meetings between L.M., C.P.-C., J.L. and S.S. Direct quotes are provided from the interviews and documentary analysis. Some quotes from the documents are paraphrased to protect anonymity of the case study after following a set process considering a range of options. This involved searching each quote from the documentary analysis in Google and if the quote was found in the first page of the result, we shortened extracts and repeated the process. Where the shortened extracts were still identifiable, we were required to paraphrase that quote. Each paraphrased quote and original was shared and agreed with all the authors reducing the likelihood of inadvertently misinterpreting or misquoting. Where multiple components over large bodies of text were present in the documents, models were used to evidence the broadness, for example, using Dahlgren’s and Whitehead’s model of health determinants [ 1 ]. Due to the nature of the study, transcripts and findings were not shared with participants for checking but will be shared in a dissemination workshop in 2024.

Patient and public involvement and engagement

Four public contributors from the National Institute for Health and Care Research (NIHR) Research Design Service (RDS) North East and North Cumbria (NENC) Public and Patient Involvement (PPI) panel have been actively engaged in this research from its inception. They have been part of the research advisory group along with professional stakeholders and were involved in the identification of the sampling frame’s key criteria. Furthermore, a diverse group of public contributors has been actively involved in other parts of the project including developing the moral argument around action by producing a public facing resource exploring what health inequalities mean to people and public views of possible solutions [ 50 ].

Semi-structured interviews: description

Sixteen participants working in health or social care, identified through the documentary analysis or snowballing, were contacted for interview; fourteen consented to participate. No further interviews were sought as data sufficiency was reached whereby no new information or themes were being identified. Participant roles were broken down by NHS ( n  = 5), local authority/council ( n  = 8), and voluntary, community and social enterprise (VSCE) ( n  = 1). To protect the participants’ anonymity, their employment titles/status are not disclosed. However, a broad spectrum of interviewees with varying roles from senior health system leadership (including strategic and commissioner roles) to roles within provider organisations and the VSCE sector were included.

Documentary analysis: description

75 documents were reviewed with documents considering regional ( n  = 20), local ( n  = 64) or neighbourhood ( n  = 2) area with some documents covering two or more areas. Table 2 summarises the respective number of each document type which included statutory documents to websites from across the system (NHS, local government and VSCE). 45 documents were named by interviewees and 42 documents were identified as either a core document or through snowballing from other documents. Of these, 12 documents were identified from both. The timescales of the documents varied and where possible to identify, was from 2014 to 2031.

Integrative analysis of the documentary analysis and interviews

The overarching themes encompass:

Understanding the local context

Facilitators to tacking health inequalities: the assets

Emerging risks and concerns

Figure 1 demonstrates the relationships between the main themes identified from the analysis for tackling health inequalities and improving health in this case study.

Diagram of the relationship between the key themes identified regarding tackling health inequalities and improving health in a local area informed by 2 previous work [ 14 , 51 ]. NCDs = non-communicable diseases; HI = health inequalities

Understanding the local context was discussed extensively in both the documents and the interviews. This was informed by local intelligence and data that was routinely collected, monitored, and analysed to help understand the local context and where inequalities lie. More bespoke, in-depth collection and analysis were also described to get a better understanding of the situation. This not only took the form of quantitative but also considered qualitative data with lived experience:

‛So, our data comes from going out to talk to people. I mean, yes, especially the voice of inequalities, those traditional mechanisms, like surveys, don't really work. And it's about going out to communities, linking in with third sector organisations, going out to communities, and just going out to listen…I think the more we can bring out those real stories. I mean, we find quotes really, really powerful in terms of helping people understand what it is that matters.’ (LP16).

However, there were limitations to the available data including the quality as well as having enough time to do the analysis justice. This resulted in difficulties in being able to fully understand the context to help identify and act on the required improvements.

‘A lack of available data means we cannot quantify the total number of vulnerable migrants in [region]’ (Document V).

‛So there’s lots of data. The issue is joining that data up and analysing it, and making sense of it. That’s where we don’t have the capacity.’ (LP15).

Despite the caveats, understanding the context and its data limitations were important to inform local priorities and approaches on tackling health inequalities. This understanding was underpinned by three subthemes which were understanding:

the population’s needs including identification of people at higher risk of worse health and health inequalities

the driving forces of those needs with acknowledgement of the impact of the wider determinants of health

the threats and barriers to physical and mental health, as well as wellbeing

Firstly, the population’s needs, including identification of people at higher risk of worse health and health inequalities, was important. This included considering risk factors, such as smoking, specific groups of people and who was presenting with which conditions. Between the interviews and documents, variation was seen between groups deemed at-risk or high-risk with the documents identifying a wider range. The groups identified across both included marginalised communities, such as ethnic minority groups, gypsy and travellers, refugees and asylum seekers as well as people/children living in disadvantaged area.

‘There are significant health inequalities in children with asthma between deprived and more affluent areas, and this is reflected in A&E admissions.' (Document J).

Secondly, the driving forces of those needs with acknowledgement of the impact of the wider determinants of health were described. These forces mapped onto Dahlgren’s and Whitehead’s model of health determinants [ 1 ] consisting of individual lifestyle factors, social and community networks, living and working conditions (which include access to health care services) as well as general socio-economic, cultural and environmental conditions across the life course.

…. at the centre of our approach considering the requirements to improve the health and wellbeing of our area are the wider determinants of health and wellbeing, acknowledging how factors, such as housing, education, the environment and economy, impact on health outcomes and wellbeing over people’s lifetime and are therefore pivotal to our ambition to ameliorate the health of the poorest the quickest. (Paraphrased Document P).

Thirdly, the threats and barriers to health included environmental risks, communicable diseases and associated challenges, non-communicable conditions and diseases, mental health as well as structural barriers. In terms of communicable diseases, COVID-19 predominated. The environmental risks included climate change and air pollution. Non-communicable diseases were considered as a substantial and increasing threat and encompassed a wide range of chronic conditions such as diabetes, and obesity.

‛Long term conditions are the leading causes of death and disability in [case study] and account for most of our health and care spending. Cases of cancer, diabetes, respiratory disease, dementia and cardiovascular disease will increase as the population of [case study] grows and ages.’ (Document A).

Structural barriers to accessing and using support and/or services for health and wellbeing were identified. These barriers included how the services are set up, such as some GP practices asking for proof of a fixed address or form of identification to register. For example:

Complicated systems (such as having to make multiple calls, the need to speak to many people/gatekeepers or to call at specific time) can be a massive barrier to accessing healthcare and appointments. This is the case particularly for people who have complex mental health needs or chaotic/destabilized circumstances. People who do not have stable housing face difficulties in registering for GP and other services that require an address or rely on post to communicate appointments. (Paraphrased Document R).

A structural threat regarding support and/or services for health and wellbeing was the sustainability of current funding with future uncertainty posing potential threats to the delivery of current services. This also affected the ability to adapt and develop the services, or indeed build new ones.

‛I would say the other thing is I have a beef [sic] [disagreement] with pilot studies or new innovations. Often soft funded, temporary funded, charity funded, partnership work run by enthusiasts. Me, I've done them, or supported people doing many of these. And they're great. They can make a huge impact on the individuals involved on that local area. You can see fantastic work. You get inspired and you want to stand up in a crowd and go, “Wahey, isn't this fantastic?” But actually the sad part of it is on these things, I've seen so many where we then see some good, positive work being done, but we can't make it permanent or we can't spread it because there's no funding behind it.’ (LP8).

Facilitators to tackling health inequalities: the assets

The facilitators for improving health and wellbeing and tackling health inequalities are considered as assets which were underpinned by values and principles.

Values driven supported by four key principles

Being values driven was an important concept and considered as the underpinning attitudes or beliefs that guide decision making [ 52 ]. Particularly, the system’s approach was underpinned by a culture and a system's commitment to tackle health inequalities across the documents and interviews. This was also demonstrated by how passionately and emotively some interviewees spoke about their work.

‛There's a really strong desire and ethos around understanding that we will only ever solve these problems as a system, not by individual organisations or even just part of the system working together. And that feels great.’ (LP3).

Other values driving the approach included accountability, justice, and equity. Reducing health inequalities and improving health were considered to be the right things to do. For example:

We feel strongly about social justice and being inclusive, wishing to reflect the diversity of [case study]. We campaign on subjects that are important to people who are older with respect and kindness. (Paraphrased Document O).

Four key principles were identified that crosscut the assets which were:

Shared vision

Strong partnership

Asset-based approaches

Willingness and ability to act on learning

The mandated strategy, identifying priorities for health and wellbeing for the local population with the required actions, provided the shared vision across each part of the system, and provided the foundations for the work. This shared vision was repeated consistently in the documents and interviews from across the system.

[Case study] will be a place where individuals who have the lowest socioeconomic status will ameliorate their health the quickest. [Case study] will be a place for good health and compassion for all people, regardless of their age. (Paraphrased Document A).

‛One thing that is obviously becoming stronger and stronger is the focus on health inequalities within all of that, and making sure that we are helping people and provide support to people with the poorest health as fast as possible, so that agenda hasn’t shifted.’ (LP7).

This drive to embed the reduction of health inequalities was supported by clear new national guidance encapsulated by the NHS Core20PLUS5 priorities. Core20PLUS5 is the UK's approach to support a system to improve their healthcare inequalities [ 53 ]. Additionally, the system's restructuring from Clinical Commissioning Groups (CCGs) to Integrated Care Boards (ICBs) and formalisation of the now statutory Integrated Care Systems (ICS) in England was also reported to facilitate the driving of further improvement in health inequalities. These changes at a regional and local level helped bring key partners across the system (NHS and local government among others) to build upon their collective responsibility for improving health and reducing health inequalities for their area [ 54 ].

‛I don’t remember the last time we’ve had that so clear, or the last time that health inequalities has had such a prominent place, both in the NHS planning guidance or in the NHS contract. ’ (LP15). ‛The Health and Care Act has now got a, kind of, pillar around health inequalities, the new establishment of ICPs and ICBs, and also the planning guidance this year had a very clear element on health inequalities.’ (LP12)

A strong partnership and collaborative team approach across the system underpinned the work from the documents and included the reoccurrence of the concept that this case study acted as one team: ‘Team [case study]'.

Supporting one another to ensure [case study] is the best it can be: Team [case study]. It involves learning, sharing ideas as well as organisations sharing assets and resources, authentic partnerships, and striving for collective impact (environmental and social) to work towards shared goals . (Paraphrased Document B).

This was corroborated in the interviews as working in partnership to tackle health inequalities was considered by the interviewees as moving in the right direction. There were reports that the relationship between local government, health care and the third sector had improved in recent years which was still an ongoing priority:

‘I think the only improvement I would cite, which is not an improvement in terms of health outcomes, but in terms of how we work across [case study] together has moved on quite a lot, in terms of teams leads and talking across us, and how we join up on things, rather than see ourselves all as separate bodies' (LP15).

‘I think the relationship between local authorities and health and the third sector, actually, has much more parity and esteem than it had before.' (LP11)

The approaches described above were supported by all health and care partners signing up to principles around partnership; it is likely this has helped foster the case study's approach. This also builds on the asset-based approaches that were another key principle building on co-production and co-creation which is described below.

We begin with people : instead of doing things to people or for them, we work with them, augmenting the skills, assets and strength of [case study]’s people, workforce and carers. We achieve : actions are focused on over words and by using intelligence, every action hones in on the actual difference that we will make to ameliorate outcomes, quality and spend [case study]’s money wisely; We are Team [case study ]: having kindness, working as one organisation, taking responsibility collectively and delivering on what we agreed. Problems are discussed with a high challenge and high support attitude. (Paraphrased Document D).

At times, the degree to which the asset-based approaches were embedded differed from the documents compared to the interviews, even when from the same part of the system. For example, the documents often referred to the asset-based approach as having occurred whilst interviewees viewed it more as a work in progress.

‘We have re-designed many of our services to focus on needs-led, asset-based early intervention and prevention, and have given citizens more control over decisions that directly affect them .’ (Document M).

‘But we’re trying to take an asset-based approach, which is looking at the good stuff in communities as well. So the buildings, the green space, the services, but then also the social capital stuff that happens under the radar.’ (LP11).

A willingness to learn and put in action plans to address the learning were present. This enables future proofing by building on what is already in place to build the capacity, capability and flexibility of the system. This was particularly important for developing the workforce as described below.

‘So we’ve got a task and finish group set up, […] So this group shows good practice and is a space for people to discuss some of the challenges or to share what interventions they are doing around the table, and also look at what other opportunities that they have within a region or that we could build upon and share and scale.’ (LP12).

These assets that are considered as facilitators are divided into four key levels which are the system, services and support, communities and individuals, and workforce which are discussed in turn below.

Firstly, the system within this case study was made up of many organisations and partnerships within the NHS, local government, VSCE sector and communities. The interviewees reported the presence of a strong VCSE sector which had been facilitated by the local council's commitment to funding this sector:

‘Within [case study], we have a brilliant third sector, the council has been longstanding funders of infrastructure in [case study], third sector infrastructure, to enable those links [of community engagement] to be made' (LP16).

In both the documents and interviews, a strong coherent strategic integrated population health management plan with a system’s approach to embed the reduction of health inequalities was evident. For example, on a system level regionally:

‘To contribute towards a reduction in health inequalities we will: take a system wide approach for improving outcomes for specific groups known to be affected by health inequalities, starting with those living in our most deprived communities….’ (Document H).

This case study’s approach within the system included using creative solutions and harnessing technology. This included making bold and inventive changes to improve how the city and the system linked up and worked together to improve health. For example, regeneration work within the city to ameliorate and transform healthcare facilities as well as certain neighbourhoods by having new green spaces, better transport links in order to improve city-wide innovation and collaboration (paraphrased Document F) were described. The changes were not only related to physical aspects of the city but also aimed at how the city digitally linked up. Being a leader in digital innovation to optimise the health benefits from technology and information was identified in several documents.

‘ Having the best connected city using digital technology to improve health and wellbeing in innovative ways.’ (Document G).

The digital approaches included ongoing development of a digitalised personalised care record facilitating access to the most up-to-date information to developing as well as having the ‘ latest, cutting edge technologies’ ( Document F) in hospital care. However, the importance of not leaving people behind by embedding digital alternatives was recognised in both the documents and interviews.

‘ We are trying to just embed the culture of doing an equity health impact assessment whenever you are bringing in a digital solution or a digital pathway, and that there is always an alternative there for people who don’t have the capability or capacity to use it. ’ (LP1).

The successful one hundred percent [redacted] programme is targeting some of our most digitally excluded citizens in [case study]. For our city to continue to thrive, we all need the appropriate skills, technology and support to get the most out of being online. (Paraphrased Document Q)

This all links in with the system that functions in a ‘place' which includes the importance of where people are born, grow, work and live. Working towards this place being welcoming and appealing was described both regionally and locally. This included aiming to make the case study the place of choice for people.

‘Making [case study] a centre for good growth becoming the place of choice in the UK to live, to study, for businesses to invest in, for people to come and work.’ (Document G).

Services and support

Secondly, a variety of available services and support were described from the local authority, NHS, and voluntary community sectors. Specific areas of work, such as local initiatives (including targeted work or campaigns for specific groups or specific health conditions) as well as parts of the system working together with communities collaboratively, were identified. This included a wide range of work being done such as avoiding delayed discharges or re-admissions, providing high quality affordable housing as well as services offering peer support.

‘We have a community health development programme called [redacted], that works with particular groups in deprived communities and ethnically diverse communities to work in a very trusted and culturally appropriate way on the things that they want to get involved with to support their health.’ (LP3 ).

It is worth noting that reducing health inequalities in avoidable admissions was not often explicitly specified in the documents or interviews. However, either specified or otherwise inferred, preventing ill health and improving access, experience, and outcomes were vital components to addressing inequalities. This was approached by working with communities to deliver services in communities that worked for all people. Having co-designed, accessible, equitable integrated services and support appeared to be key.

‘Reducing inequalities in unplanned admissions for conditions that could be cared for in the community and access to planned hospital care is key.’ (Document H)

Creating plans with people: understanding the needs of local population and designing joined-up services around these needs. (Paraphrased Document A).

‘ So I think a core element is engagement with your population, so that ownership and that co-production, if you're going to make an intervention, don't do it without because you might miss the mark. ’ (LP8).

Clear, consistent and appropriate communication that was trusted was considered important to improve health and wellbeing as well as to tackle health inequalities. For example, trusted community members being engaged to speak on the behalf of the service providers:

‘The messenger is more important than the message, sometimes.’ (LP11).

This included making sure the processes are in place so that the information is accessible for all, including people who have additional communication needs. This was considered as a work in progress in this case study.

‘I think for me, things do come down to those core things, of health, literacy, that digital exclusion and understanding the wider complexities of people.’ (LP12)

‘ But even more confusing if you've got an additional communication need. And we've done quite a lot of work around the accessible information standard which sounds quite dry, and doesn't sound very- but actually, it's fundamental in accessing health and care. And that is, that all health and care organisations should record your communication preferences. So, if I've got a learning disability, people should know. If I've got a hearing impairment, people should know. But the systems don’t record it, so blind people are getting sent letters for appointments, or if I've got hearing loss, the right provisions are not made for appointments. So, actually, we're putting up barriers before people even come in, or can even get access to services.’ (LP16).

Flexible, empowering, holistic care and support that was person-centric was more apparent in the documents than the interviews.

At the centre of our vision is having more people benefiting from the life chances currently enjoyed by the few to make [case study] a more equal place. Therefore, we accentuate the importance of good health, the requirement to boost resilience, and focus on prevention as a way of enabling higher quality service provision that is person-centred. [Paraphrased Document N).

Through this [work], we will give all children and young people in [case study], particularly if they are vulnerable and/or disadvantaged, a start in life that is empowering and enable them to flourish in a compassionate and lively city. [Paraphrased Document M].

Communities and individuals

Thirdly, having communities and individuals at the heart of the work appeared essential and viewed as crucial to nurture in this case study. The interconnectedness of the place, communities and individuals were considered a key part of the foundations for good health and wellbeing.

In [case study], our belief is that our people are our greatest strength and our most important asset. Wellbeing starts with people: our connections with our friends, family, and colleagues, our behaviour, understanding, and support for one another, as well as the environment we build to live in together . (Paraphrased Document A).

A recognition of the power of communities and individuals with the requirement to support that key principle of a strength-based approach was found. This involved close working with communities to help identify what was important, what was needed and what interventions would work. This could then lead to improved resilience and cohesion.

‛You can't make effective health and care decisions without having the voice of people at the centre of that. It just won't work. You won't make the right decisions.’ (LP16).

‘Build on the strengths in ourselves, our families, carers and our community; working with people, actively listening to what matters most to people, with a focus on what’s strong rather than what’s wrong’ (Document G).

Meaningful engagement with communities as well as strengths and asset-based approaches to ensure self-sufficiency and sustainability of communities can help communities flourish. This includes promoting friendships, building community resilience and capacity, and inspiring residents to find solutions to change the things they feel needs altering in their community . (Paraphrased Document B).

This close community engagement had been reported to foster trust and to lead to improvements in health.

‘But where a system or an area has done a lot of community engagement, worked really closely with the community, gained their trust and built a programme around them rather than just said, “Here it is. You need to come and use it now,” you can tell that has had the impact. ' (LP1).

Finally, workforce was another key asset; the documents raised the concept of one workforce across health and care. The key principles of having a shared vision, asset-based approaches and strong partnership were also present in this example:

By working together, the Health and Care sector makes [case study] the best area to not only work but also train for people of all ages. Opportunities for skills and jobs are provided with recruitment and engagement from our most disadvantaged communities, galvanizing the future’s health and care workforce. By doing this, we have a very skilled and diverse workforce we need to work with our people now as well as in the future. (Paraphrased Document E).

An action identified for the health and care system to address health inequalities in case study 1 was ‘ the importance of having an inclusive workforce trained in person-centred working practices ’ (Document R). Several ways were found to improve and support workforce skills development and embed awareness of health inequalities in practice and training. Various initiatives were available such as an interactive health inequalities toolkit, theme-related fellowships, platforms and networks to share learning and develop skills.

‛We've recently launched a [redacted] Fellowship across [case study’s region], and we've got a number of clinicians and managers on that………. We've got training modules that we've put on across [case study’s region], as well for health inequalities…we've got learning and web resources where we share good practice from across the system, so that is our [redacted] Academy.’ (LP2).

This case study also recognised the importance of considering the welfare of the workforce; being skilled was not enough. This had been recognised pre-pandemic but was seen as even more important post COVID-19 due to the impact that COVID-19 had on staff, particularly in health and social care.

‛The impacts of the pandemic cannot be underestimated; our colleagues and services are fatigued and still dealing with the pressures. This context makes it even more essential that we share the responsibility, learn from each other at least and collaborate with each other at best, and hold each other up to be the best we can.’ (Document U).

Concerns were raised such as the widening of health inequalities since the pandemic and cost of living crisis. Post-pandemic and Brexit, recruiting health, social care and third sector staff was compounding the capacity throughout this already heavily pressurised system.

In [case study], we have seen the stalling of life expectancy and worsening of the health inequality gap, which is expected to be compounded by the effects of the pandemic. (Paraphrased Document T)

‘I think key barriers, just the immense pressure on the system still really […] under a significant workload, catching up on activity, catching up on NHS Health Checks, catching up on long-term condition reviews. There is a significant strain on the system still in terms of catching up. It has been really difficult because of the impact of COVID.’ (LP7).

‘Workforce is a challenge, because the pipelines that we’ve got, we’ve got fewer people coming through many of them. And that’s not just particular to, I don't know, nursing, which is often talking talked [sic] about as a challenged area, isn't it? And of course, it is. But we’ve got similar challenges in social care, in third sector.’ (LP5).

The pandemic was reported to have increased pressures on the NHS and services not only in relation to staff capacity but also regarding increases in referrals to services, such as mental health. Access to healthcare changed during the pandemic increasing barriers for some:

‘I think people are just confused about where they're supposed to go, in terms of accessing health and care at the moment. It's really complex to understand where you're supposed to go, especially, at the moment, coming out of COVID, and the fact that GPs are not the accessible front door. You can't just walk into your GP anymore.’ (LP16).

‘Meeting this increased demand [for work related to reducing ethnic inequalities in mental health] is starting to prove a challenge and necessitates some discussion about future resourcing.’ (Document S)

Several ways were identified to aid effective adaptation and/or mitigation. This included building resilience such as developing the existing capacity, capability and flexibility of the system by learning from previous work, adapting structures and strengthening workforce development. Considerations, such as a commitment to Marmot Principles and how funding could/would contribute, were also discussed.

The funding’s [linked to Core20PLUS5] purpose is to help systems to ensure that health inequalities are not made worse when cost-savings or efficiencies are sought…The available data and insight are clear and [health inequalities are] likely to worsen in the short term, the delays generated by pandemic, the disproportionate effect of that on the most deprived and the worsening food and fuel poverty in all our places. (Paraphrased Document L).

Learning from the pandemic was thought to be useful as some working practices had altered during COVID-19 for the better, such as needing to continue to embed how the system had collaborated and resist old patterns of working:

‘So I think that emphasis between collaboration – extreme collaboration – which is what we did during COVID is great. I suppose the problem is, as we go back into trying to save money, we go back into our old ways of working, about working in silos. And I think we’ve got to be very mindful of that, and continue to work in a different way.’ (LP11).

Another area identified as requiring action, was the collection, analysis, sharing and use of data accessible by the whole system.

‘So I think there is a lot of data out there. It’s just how do we present that in such a way that it’s accessible to everyone as well, because I think sometimes, what happens is that we have one group looking at data in one format, but then how do we cascade that out?’ (LP12)

We aimed to explore a system’s level understanding of how a local area addresses health inequalities with a focus on avoidable emergency admissions using a case study approach. Therefore, the focus of our research was strategic and systematic approaches to inequalities reduction. Gaining an overview of what was occurring within a system is pertinent because local areas are required to have a regard to address health inequalities in their local areas [ 20 , 21 ]. Through this exploration, we also developed an understanding of the system's processes reported to be required. For example, an area requiring action was viewed as the accessibility and analysis of data. The case study described having health inequalities ‘at the heart of its health and wellbeing strategy ’ which was echoed across the documents from multiple sectors across the system. Evidence of a values driven partnership with whole systems working was centred on the importance of place and involving people, with links to a ‘strong third sector ’ . Working together to support and strengthen local assets (the system, services/support, communities/individuals, and the workforce) were vital components. This suggested a system’s committed and integrated approach to improve population health and reduce health inequalities as well as concerted effort to increase system resilience. However, there was juxtaposition at times with what the documents contained versus what interviewees spoke about, for example, the degree to which asset-based approaches were embedded.

Furthermore, despite having a priori codes for the documentary analysis and including specific questions around work being undertaken to reduce health inequalities in avoidable admissions in the interviews with key systems leaders, this explicit link was still very much under-developed for this case study. For example, how to reduce health inequalities in avoidable emergency admissions was not often specified in the documents but could be inferred from existing work. This included work around improving COVID-19 vaccine uptake in groups who were identified as being at high-risk (such as older people and socially excluded populations) by using local intelligence to inform where to offer local outreach targeted pop-up clinics. This limited explicit action linking reduction of health inequalities in avoidable emergency admissions was echoed in the interviews and it became clear as we progressed through the research that a focus on reduction of health inequalities in avoidable hospital admissions at a systems level was not a dominant aspect of people’s work. Health inequalities were viewed as a key part of the work but not necessarily examined together with avoidable admissions. A strengthened will to take action is reported, particularly around reducing health inequalities, but there were limited examples of action to explicitly reduce health inequalities in avoidable admissions. This gap in the systems thinking is important to highlight. When it was explicitly linked, upstream strategies and thinking were acknowledged as requirements to reduce health inequalities in avoidable emergency admissions.

Similar to our findings, other research have also found networks to be considered as the system’s backbone [ 30 ] as well as the recognition that communities need to be central to public health approaches [ 51 , 55 , 56 ]. Furthermore, this study highlighted the importance of understanding the local context by using local routine and bespoke intelligence. It demonstrated that population-based approaches to reduce health inequalities are complex, multi-dimensional and interconnected. It is not about one part of the system but how the whole system interlinks. The interconnectedness and interdependence of the system (and the relevant players/stakeholders) have been reported by other research [ 30 , 57 ], for example without effective exchange of knowledge and information, social networks and systems do not function optimally [ 30 ]. Previous research found that for systems to work effectively, management and transfer of knowledge needs to be collaborative [ 30 ], which was recognised in this case study as requiring action. By understanding the context, including the strengths and challenges, the support or action needed to overcome the barriers can be identified.

There are very limited number of case studies that explore health inequalities with a focus on hospital admissions. Of the existing research, only one part of the health system was considered with interviews looking at data trends [ 35 ]. To our knowledge, this research is the first to build on this evidence by encompassing the wider health system using wider-ranging interviews and documentary analysis. Ford et al. [ 35 ] found that geographical areas typically had plans to reduce total avoidable emergency admissions but not comprehensive plans to reduce health inequalities in avoidable emergency admissions. This approach may indeed widen health inequalities. Health inequalities have considerable health and costs impacts. Pertinently, the hospital care costs associated with socioeconomic inequalities being reported as £4.8 billion a year, mainly due to excess hospitalisations such as avoidable admissions [ 58 ] and the burden of disease lies disproportionately with our most disadvantaged communities, addressing inequalities in hospital pressures is required [ 25 , 26 ].

Implications for research and policy

Improvements to life expectancy have stalled in the UK with a widening of health inequalities [ 12 ]. Health inequalities are not inevitable; it is imperative that the health gap between the deprived and affluent areas is narrowed [ 12 ]. This research demonstrates the complexity and intertwining factors that are perceived to address health inequalities in an area. Despite the evidence of the cost (societal and individual) of avoidable admissions, explicit tackling of inequality in avoidable emergency admissions is not yet embedded into the system, therefore highlights an area for policy and action. This in-depth account and exploration of the characteristics of ‘whole systems’ working to address health inequalities, including where challenges remain, generated in this research will be instrumental for decision makers tasked with addressing health and care inequalities.

This research informs the next step of exploring each identified theme in more detail and moving beyond description to develop tools, using a suite of multidimensional and multidisciplinary methods, to investigate the effects of interventions on systems as previously highlighted by Rutter et al. [ 5 ].

Strengths and limitations

Documentary analysis is often used in health policy research but poorly described [ 44 ]. Furthermore, Yin reports that case study research is often criticised for not adhering to ‘systematic procedures’ p. 18 [ 41 ]. A clear strength of this study was the clearly defined boundary (in time and space) case as well as following a defined systematic approach, with critical thought and rationale provided at each stage [ 34 , 41 ]. A wide range and large number of documents were included as well as interviewees from across the system thereby resulting in a comprehensive case study. Integrating the analysis from two separate methodologies (interviews and documentary analysis), analysed separately before being combined, is also a strength to provide a coherent rich account [ 49 ]. We did not limit the reasons for hospital admission to enable a broad as possible perspective; this is likely to be a strength in this case study as this connection between health inequalities and avoidable hospital admissions was still infrequently made. However, for example, if a specific care pathway for a health condition had been highlighted by key informants this would have been explored.

Due to concerns about identifiability, we took several steps. These included providing a summary of the sectors that the interviewees and document were from but we were not able to specify which sectors each quote pertained. Additionally, some of the document quotes required paraphrasing. However, we followed a set process to ensure this was as rigorous as possible as described in the methods section. For example, where we were required to paraphrase, each paraphrased quote and original was shared and agreed with all the authors to reduce the likelihood to inadvertently misinterpreting or misquoting.

The themes are unlikely to represent an exhaustive list of the key elements requiring attention, but they represent the key themes that were identified using a robust methodological process. The results are from a single urban local authority with high levels of socioeconomic disadvantage in the North of England which may limit generalisability to different contexts. However, the findings are still generalisable to theoretical considerations [ 41 ]. Attempts to integrate a case study with a known framework can result in ‘force-fit’ [ 34 ] which we avoided by developing our own framework (Fig. 1 ) considering other existing models [ 14 , 59 ]. The results are unable to establish causation, strength of association, or direction of influence [ 60 ] and disentangling conclusively what works versus what is thought to work is difficult. The documents’ contents may not represent exactly what occurs in reality, the degree to which plans are implemented or why variation may occur or how variation may affect what is found [ 43 , 61 ]. Further research, such as participatory or non-participatory observation, could address this gap.

Conclusions

This case study provides an in-depth exploration of how local areas are working to address health and care inequalities, with a focus on avoidable hospital admissions. Key elements of this system’s reported approach included fostering strategic coherence, cross-agency working, and community-asset based working. An area requiring action was viewed as the accessibility and analysis of data. Therefore, local areas could consider the challenges of data sharing across organisations as well as the organisational capacity and capability required to generate useful analysis in order to create meaningful insights to assist work to reduce health and care inequalities. This would lead to improved understanding of the context including where the key barriers lie for a local area. Addressing structural barriers and threats as well as supporting the training and wellbeing of the workforce are viewed as key to building resilience within a system to reduce health inequalities. Furthermore, more action is required to embed reducing health inequalities in avoidable admissions explicitly in local areas with inaction risking widening the health gap.

Availability of data and materials

Individual participants’ data that underlie the results reported in this article and a data dictionary defining each field in the set are available to investigators whose proposed use of the data has been approved by an independent review committee for work. Proposals should be directed to [email protected] to gain access, data requestors will need to sign a data access agreement. Such requests are decided on a case by case basis.

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Acknowledgements

Thanks to our Understanding Factors that explain Avoidable hospital admission Inequalities - Research study (UNFAIR) PPI contributors, for their involvement in the project particularly in the identification of the key criteria for the sampling frame. Thanks to the research advisory team as well.

Informed consent statement

Informed consent was obtained from all subjects involved in the study.

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The manuscript is not currently under consideration or published in another journal. All authors have read and approved the final manuscript.

This research was funded by the National Institute for Health and Care Research (NIHR), grant number (ref CA-CL-2018-04-ST2-010). The funding body was not involved in the study design, collection of data, inter-pretation, write-up, or submission for publication. The views expressed are those of the authors and not necessarily those of the NIHR, the Department of Health and Social Care or Newcastle University.

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Charlotte Parbery-Clark

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Lorraine McSweeney

Senior Research Methodologist & Public Involvement Lead, Faculty of Medical Sciences, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK

Joanne Lally

Senior Clinical Lecturer &, Faculty of Medical Sciences, Honorary Consultant in Public Health, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK

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Conceptualization - J.L. and S.S.; methodology - C.P.-C., J.L. & S.S.; formal analysis - C. P.-C. & L.M.; investigation- C. P.-C. & L.M., resources, writing of draft manuscript - C.P.-C.; review and editing manuscript L.M., J.L., & S.S.; visualization including figures and tables - C.P.-C.; supervision - J.L. & S.S.; project administration - L.M. & S.S.; funding acquisition - S.S. All authors have read and agreed to the published version of the manuscript.

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Correspondence to Charlotte Parbery-Clark or Sarah Sowden .

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The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board (or Ethics Committee) of Newcastle University (protocol code 13633/2020 on the 12 th of July 2021).

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The authors declare no competing interests.

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Parbery-Clark, C., McSweeney, L., Lally, J. et al. How can health systems approach reducing health inequalities? An in-depth qualitative case study in the UK. BMC Public Health 24 , 2168 (2024). https://doi.org/10.1186/s12889-024-19531-5

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Received : 20 October 2023

Accepted : 18 July 2024

Published : 10 August 2024

DOI : https://doi.org/10.1186/s12889-024-19531-5

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