28 June 2021

Bedfordshire Wellbeing Service’s Triple Aim QI Project: The Three-Part Data Review

By Lawrence Chung, Business Manager and Kayleigh Sanders, Trainee Psychological Wellbeing Practitioner

8 minute read

This story explains how Bedfordshire Wellbeing Service, known as BWS, have made recent progress in their project on reducing inequalities. They share how they have used data to learn more about their chosen population segment; Asian or Asian British men over the age of 40 who are living in Bedford.

As part of the Triple Aim approach, it is important to understand the needs and assets that service users already have within the system. Solely focusing on needs however, can lead to a narrow view where the team focuses too much on the deficiencies of a population. Instead, adopting an assets-based approach will allow the project team to understand the strengths and capacities that could be harnessed for the individuals or populations to thrive.

One way to explore the assets and needs within a population is through conducting a  Three part data review. This includes:

  1. The available data to identify patterns of service usage, wider demographics and inequalities that impact the population.
  2. Understanding perspectives of care teams and professionals supporting the populations.
  3. Service user and citizen interviews/engagement to understand their experience and perspectives.


Figure 1 below outlines how Bedfordshire Wellbeing Service went about collecting this data:

Figure 1: Three-Part Data Review Summary


Quantitative data on service usage wider demographics and inequalities

We collated data on our client base from IAPTUS, an electronic patient record system and from census data for our communities. For instance, only 5% of referrals to Bedfordshire Wellbeing Service were from the Asian, or Asian British community. Moreover, the Indices of Deprivation 2019 Report highlighted that Bedford Borough, Flitwick and Houghton Regis are the most deprived areas of Bedfordshire.

Partner Interviews (care teams and professionals providing care or support to the population)

The team conducted interviews with several healthcare professionals and figure heads from the community. To do so, all the communities that would be helpful to speak to were listed on a Jamboard page and were split amongst the team to contact (Figure 1). Following this, the team created a questionnaire in order to collect the views of the partner agencies who provide care and support to this community. It took approximately 2 months to finish collecting this data.

Services that were contacted include: Sports Development at Bedford Borough Council, Carers in Bedfordshire, Bedfordshire Community Physiotherapy Service, Bedfordshire Recovery College, Bedfordshire Heart Failure Service, Biggleswade Job centre Plus, Social Prescribing Teams, and Fairlight Zen Buddhist Temple in Luton.

Summary of key learning from the partner interviews

Following thematic analysis, findings highlighted the following areas to prioritise; reducing stigma, use of language relating to mental health and collaborative working.


Reducing Stigma
Individuals noted that there are cultural beliefs and stigma surrounding mental health and the use of services within Asian and Asian British communities. It was also suggested that there is little publicity and community education related to mental health and services particularly targeted to a specific audience.

There was discussion relating to the misinterpretation of experiencing mental health conditions as a sign of weakness.



Use of language relating to mental health
Language was discussed from several angles. It was identified that descriptions of mental health conditions may need to be altered. For example, altering depression to low in energy. Furthermore, a suggestion that less use of medical terms may be more beneficial.

It was also highlighted that accessibility to multilingual information is a necessity in reducing inequalities.

Collaborative working
Assets identified the need to utilise the community and the people and places it has to offer. They also noted that it is important for services to be seen working with one another to support individuals rather than looking like a separate entity.

From identifying these themes, we created a series of questions with the plan to interview previous and current service users as well as identifying individuals who may also have direct contact or work with individuals from our target population.

Service user interviews

Bedfordshire Wellbeing Service is currently in the process of recruiting individuals for interviews. The project team created a poster for social media in order to encourage people to get involved.

Utilising the learning from the partner interviews, the team focused on reviewing the choice of language, and have translated the poster in Hindi, Gujurati, Urdu, Punjabi and Tamil.

Referral data was reviewed again to highlight potential services users who could be interviewed. Invitations have been sent out and the team hope to interview approximately 6 service users by August 2021.




























Figure 2: Posters in English and in Gujarati


Next Steps

By collating all this data, the project team will be in a better position to identify and address the gap in services, in order to reduce health inequalities for this community.

Ultimately, this will help achieve the following outcomes:

  • Outcomes for people who receive support

The people who receive support will benefit from the key elements of their needs being communicated and highlighted effectively between appropriate services.

  • Outcomes for the workforce

The service will build on its cultural competency, enabling it to thrive in a diverse population. Staff will also gain a greater understanding of the needs of the identified population and are mindful of the steps they take to reach out for help.

  • Outcome for the identified population

The wellbeing, life and health of the identified population is improved by ensuring they are aware of the help available to them.

  • Outcomes for the organisation

Improvements in value, efficiency and safety across services whilst enabling shared learning from actively contributing to the wider system and strengthening working relationships.




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