The NHS has a critical role in reducing health inequalities. When we look at what determines our health, we know that treatment comes in third place: after the wider determinants of health, and our health behaviours.
But even third place means that around 10–20 per cent (or more, by some estimates) of our health outcomes are directly determined by the NHS. Crucially, NHS leaders have huge control over that chunk and they can influence beyond that into the wider determinants and our behaviours. We should therefore be expecting a lot from the long-term plan on health inequalities.
There are some clues about what we might see. Some of those are specific to health inequalities, see particularly NHS England’s board papers from earlier this year. Some are more general. For example, in return for what it considers to be a very generous funding settlement, the Treasury is likely to want specific and clear deliverables set out in the NHS plan that can be project-managed with precision. This points to a focus on reducing inequalities through a ‘costed interventions’ approach, for example in the incidence, prevalence and access to care for specific areas such as cardiovascular disease and mental health conditions.
There is nothing wrong with this in itself but, in my view, tackling inequalities in these areas should already be core business for the NHS. The NHS plan should be about it playing a fuller part in tackling inequalities in health, as much about changing the way it does things as specific interventions. On my list would be the following.
Get out of your disease and condition silos. We know that multimorbidity strikes 10–15 years earlier in disadvantaged populations. This should shock and shame us. Tackling this inequality needs to be a priority across the plan.
Refocus integrated care. The 2012 Act says that its purpose is quality improvement and inequality reduction. The plan needs to take this legal duty seriously, and to hold integrated care systems to account for reducing inequalities. The recent learning on health inequalities from the vanguards will be helpful in this.
Work with and, if necessary, fund your partners. The plan will not be successful if it is a plan about just the NHS. For example, local authorities are innovating in tackling the four big risk factors that have the most impact on people’s health – smoking, excessive alcohol consumption, poor diet and lack of exercise – by developing new services that focus on addressing these risk factors together, rather than in isolation. These services are well set up to tackle health inequalities, and the NHS plan should be supporting them first, not inventing new programmes.
Rediscover, implement and scale up what has worked in the recent past. We have lots of learning on what works on tackling inequalities through practical actions delivered through services and communities that can make a difference to key issues such as high blood pressure, diabetes and smoking rates. We know that we can do this quickly by working with local systems. But the system’s institutional memory has been lost and fragmented. We need to bring back the support (including the Health Inequalities National Support Team) that we now know made a difference up to 2010.
Harness the power of the NHS as a wider determinant of health. The NHS is an economic and social giant in every community and is especially important in poorer places. How it employs, commissions and procures has an impact on inequalities in health beyond the treatments it funds. The Social Value Act is a lever for doing this, requiring public-sector commissioners to consider economic, social and environmental wellbeing when they procure services. Its aim is to encourage wider public benefits for the community beyond the provision and delivery of the service being commissioned. For example, an NHS trust could contract with a social enterprise that employs and trains unemployed young people. There is guidance on how this can be used for tackling inequalities in the NHS; although this approach is a legal duty, it is not being used.
Change payment systems to strengthen support for inequality reduction. Capitated budgets and other payment reforms should be used to incentivise tackling health inequalities. Face the fact that tackling inequalities may require more costly and complex interventions for some groups – and pay for them.
Use the power of data and analysis to tackle inequalities in health in populations. Segment and stratify with the goal of inequality reduction. Most population health management, at its heart, is about cost control; this needs to be turned on its head.
Set goals, ambitions and targets with consequences. The issue of reducing inequalities is so critical and cross-cutting that – without strong incentives, leadership and signals – it simply will not be a priority in practice, as opposed to in rhetoric. There are many specific candidates for this but any targets around the NHS plan must have an inequalities aspect, and the NHS must be held transparently to account for the actions above.
The prize if we do this is great. Public Health England’s Health profile for England for 2018 confirms that inequalities in life expectancy are widening: males and females from the most disadvantaged 10 per cent of areas on average now die 9.3 and 7.3 years earlier than those in the 10 per cent least-disadvantaged areas. Not only that, but both men and women from those areas spend almost 20 years more in poor health than those from the least-disadvantaged areas.
The NHS plan is the opportunity for it to wake up to the fact that more of the solution to these inequalities in health lies in its own hands than it realises. This does require costed, line-by-line proposals and intervention. But it’s not all about the money. In fact, the bigger change needs to be in how the NHS does things, underpinned by recognition that it has more tools and power to reduce inequalities in health than it thinks it does.