Health inequalities: impatient for change from a government committed to tackling them

‘Let’s stop admiring the problem and start admiring the solutions’, said Bola Owolabi, Director of Health Inequalities at NHS England, at The King’s Fund’s health inequalities conference in early May, as she shared a truly impressive and practical body of work from the past few years associated with the Core20PLUS5 approach to health inequalities. Bola is right, and what followed throughout the day was a truly impressive and inspiring group of people sharing how they have brought about change on health inequalities, in all its forms.

We were also fortunate to hear from Ashley Dalton MP about her commitment to health inequalities as Parliamentary Under-Secretary of State for Public Health and Prevention, including a focus on working with other government departments. What I took from all this is that we are fortunate in England (and the wider UK) to have so many of the raw materials to close the gap in health inequalities: amazing data, hugely impressive analysis, strong communities and leaders who ‘get it’, willing networks for change, and underpinning all this a deep well of academic knowledge and practical experience. We are on a continual journey of learning and improvement nationally, regionally and locally.

But I’ll be honest, there was also much uncertainty and worry – about the disruption of organisational change in the NHS and in local government, about huge and growing issues such as poverty, racism, cuts to community services and the other drivers of health inequalities, and about the challenges of poor care and lack of control for individuals, as well as systematic inequities between different groups in terms of access, experience and outcomes, of many in the room and those they support and work with.  

Work and progress on health inequalities are always constantly at risk and unstable; they are too fragile, too dependent on goodwill and fighting the cause, too reliant on exceptionalism, and frankly, too prone to being crowded out by more discrete and bounded problems such as waiting lists. This matters, since while the vast majority of what actually happens to tackle health inequalities will always be sub-national – at regional, local and neighbourhood level – the government sets the framework for that by its actions or inactions.

To its immense credit, the last Labour government was the first government to tackle health inequalities head on, and the first that did not implicitly assume that a taxpayer-funded and free at the point of use NHS would be enough on its own. It learnt that otherwise good-looking policies usually widen health inequalities, unless explicitly designed not to do so, that unless accountability for health inequalities is hardwired through targets or other means they also widen, that systems need support as well as performance management for health inequalities, that resource allocation needs to follow where the need for health inequalities is, and finally, that the whole of government is needed to tackle health inequalities, not just the NHS. Over time it developed a coherent but adaptable strategy for health inequalities that worked.

Since then, we have gone backwards, since there has been no overall coherent approach. We have seen some progress, particularly in acknowledging and tackling racial health inequalities, through Core20PLUS5 and the role of anchor institutions, and we are in a happier position in that far more key leaders beyond those in public health now understand what drives health inequalities – indeed integrated care systems were partly set up to tackle them and many of their leaders took the jobs to do so.

But all of that expertise and raw materials for change have not had enough support or leadership from the centre. Over time, we have slipped back in terms of the overall coherent policy response; the last cross-government strategy from any government on health inequalities was in 2008 (itself an update of a consistent but adaptable and coherent programme of work over time, more on the components and evaluation here), such a long time ago. Since then, we have seen isolated initiatives and impressive work from many people, but nothing truly coherent and lasting that brings together all of the many levers for change through the NHS and beyond it, aligns them and sets out a strong vision that holds systems, places and leaders to account, while giving them the consistent resources, right tools and support to really make a lasting difference. The Conservative government may have come close but we will never know, as it pulled its health ‘disparities’ strategy, allegedly with days to go just before its launch.

The current government has said very little about its future plans for health inequalities. This is surprising, considering it came into power with a truly extraordinary goal of ‘halving the gap in healthy life expectancy between the richest and poorest regions in England’. It was truly welcome to hear Ashley Dalton recommit to this in her speech. But the government now needs to say, swiftly and credibly, how it means to achieve that, and whether it is an overarching goal or a precise target. It has the architecture of missions, the 10-year plan, the future of integrated care systems and English devolution to use, the accumulated evidence and experience of many years, and leaders and communities desperate to see change and impatient to support and deliver it. Whether it’s called a strategy, a framework, a plan or something else doesn’t matter, but we urgently need to hear from a government committed to tackling health inequalities how it is going to do so, so that those in the room at our conference and beyond can help direct all the raw materials we have towards achieving that goal.