The lightbulb moment of the Covid-19 experience to date – that inequalities in health and their causes run deep through our society and through how people access, experience and receive care from the NHS – must not be lost. That is why it is crucial that NHS England and NHS Improvement’s new ‘Core20plus5’ approach to health inequalities works and is given the tools to make it work. And it’s why there needs to be a mix of patience and impatience in seeing it through – recognising some things will take time to work, but understanding that many have waited a long time for the NHS to join local government in being overwhelmingly interested in equity.
This approach focuses on three core components:
The ‘Core20’ – a focus on the 20 per cent of the population in the lowest deprivation quintile, which is meant to pick up and take on the overarching impact of deprivation on access, experience and outcomes.
The ‘plus’ –an additional focus on local inequalities, determined by integrated care systems (ICSs), perhaps in an additional or intersecting population group (eg particular ethnic minority communities or inclusion health groups)
The 5 – the five key clinical areas prioritised in the NHS long term plan, ie continuity of maternity care for women in the most deprived areas and those from Black, Asian and minority ethnic groups, annual health checks for those with serious mental illness, chronic obstructive pulmonary disease management (with a focus on Covid-19, flu and pneumonia vaccination uptake), early cancer diagnosis and hypertension case-finding.
A new health inequalities improvement dashboard will help track progress (although this should be opened up to local citizens and non-governmental organisations to build public understanding of inequalities), and NHS England’s survey on what practical further support the NHS needs to help deliver has recently closed and should help answer practical questions like what sort of support from the centre is required. So what to make of this?
'NHS England has clearly understood that inequalities is not one thing and has sought to develop a genuinely nuanced approach.'
NHS England has clearly understood that inequalities is not one thing and has sought to develop a genuinely nuanced approach. Core20plus5, covers key aspects and different lenses on health inequalities, giving a steer and direction from the top while also recognising local systems will understand their populations far better than the centre. The approach and dashboard provide a way in for leaders and non-experts in public health to have oversight of what communities have a right to expect as the NHS seeks to move forward on health inequalities. But if it is going to have a chance of making a difference it needs more than practical support, welcome though this is. There are some key risks and some further changes to help that happen.
First, the approach must be ‘and 5’, not ‘5 first’. If push comes to shove the temptation and incentives will be for areas to focus most efforts on ‘the 5’, since these are clinical, known to the system, have specific targets and have existing accountability arrangements. This risks reverting to highly medicalised and siloed single-disease and condition-focused models of inequalities only, failing to recognise the many millions for whom inequalities in health do not come through these five routes alone but from multiple long-term conditions and the complexities that underly them.
Second, the lack of clarity on accountability for the elements beyond ‘the 5’ and lack of specificity on the focus within them risks efforts being confused. Integrated care partnerships, as the alliance of local leaders within the ICS, need to embrace the Core20plus5 model as their lever to set strategy for the integrated care board to enact, as the Health and Care Bill currently at second reading in the Lords intends them to do.
'Core20plus5 must not be the sole source or focus for action on health inequalities.'
Finally, Core20plus5 must not be the sole source or focus for action on health inequalities. The NHS is not an island, either nationally or locally, though sometimes it can feel like it is and is often perceived as one. The NHS cannot tackle health inequalities alone, but the NHS can make a greater impact itself by being a stronger partner for health inequality reduction in place, contributing to tackling wider issues such as poverty, through acting as an anchor and understanding the social value it can help create. This is where the ambition and commitment behind Core20plus5 needs to go next, and where some, such as the West Yorkshire Partnership are already going, including through the development of a health inequalities academy. This is one reason why we have argued for parliament to amend the Health and Care Bill to incorporate reducing health inequalities within the new duty on NHS organisations to have regard to the ‘triple aim’ of ensuring better health and wellbeing, improving the quality of services and making efficient use of resources. So Core20plus5 is a good start and needs to be supported and applauded, but it is the first few rungs on the NHS’s new journey on health inequality reduction, not the whole ladder.
There have been many attempts to tackle health inequalities over the past three decades, but none has resulted in the lasting change that is needed. This long read draws out what can be learnt from the past and makes the case for developing a long-term approach to tackling health inequalities that endures.