All the evidence shows that the NHS is one of the fairest health systems in the world, but it is not perfect. The much-maligned Health and Social Care Act 2012 introduced a new duty on the Secretary of State, NHS England and clinical commissioning groups to ‘have regard to the need to reduce inequalities’ in access to care and outcomes of care. However, given the wider furore over the Act and what followed, you would be forgiven for not having noticed that.
That’s why it is important to highlight the work of Richard Cookson and colleagues from the University of York, who released the first set of NHS equity indicators in January. These indicators help to assess whether the NHS is acting consistently with this duty and its founding principle of equity. They measure inequality gaps, adjusted for need, for a wide range of indicators including:
GPs per head
primary care quality
emergency hospitalisation for ambulatory care-sensitive conditions
dying in hospital
mortality amenable to health care.
For the first time, they also provide methods for comparing the performance of local NHS areas in tackling inequalities in health care. This means we can find out which clinical commissioning groups are doing better or worse than the national average on equity, and which are improving or deteriorating.
Alongside similar indicators for the wider determinants of health, such as the Marmot indicators, these will be important in assessing how well the NHS is tackling inequalities across a broad range of issues. Indeed, they have already been used to explore the under-acknowledged link between preventable A&E admissions and social deprivation.
This work highlights the fact that the NHS’s interface with inequalities is much broader than simply free access at the point of use, no matter how precious that principle remains. Our own work on inequalities here at the Fund has looked at the impact of the NHS on areas like the wider determinants of health, support to change health behaviours and issues with services.
In Tackling poverty, we argued that the NHS’s role as a massive economic and social entity needs to be recognised and the NHS challenged to make the most of its economic and employing power in local communities.
In Clustering of unhealthy behaviours over time we contended that the Department of Health’s policies should take into account the complex patterns of unhealthy behaviours, in particular the way in which they are concentrated among the poorest in society.
However, there is little public debate about the NHS and health inequalities. If you dig through the provisions of the Health and Social Care Act 2012 you will find that tackling inequalities in health is meant to be one of the overarching purposes of integration. Yet inequalities are hardly mentioned in the examples, policy pronouncements and, most importantly, evaluations of integration. One test of this is to search for ‘integration of health and social care’ and ‘inequalities in health’ in Google Scholar; among the millions of records you will find just 94 where both phrases are mentioned, and only 30 of these are from works published since 2012.
Nevertheless there are some welcome signs that this may be changing. For example, the Institute of Health Equity is supporting the vanguards’ work on inequalities in health. For our part, we are increasingly seeking to place integration within the wider context of population health systems, where inequalities in health are obviously a key concern.
To help move things along, we are holding a conference in May to explore some of these issues and to showcase examples where the NHS is making a difference. We will hear from system leaders, NHS England, Public Health England, the developers of the new equity indicators and the vanguards about a wide spectrum of ways in which the NHS needs to, and is, addressing inequality.