The case for tackling health inequalities is clear and overwhelming, and yet attempts to do so in recent decades have had mixed success. Crucially, none of these efforts have translated into the enduring focus on addressing health inequalities that is needed.
While inequalities in health have always been a problem, the Covid-19 pandemic has shone a spotlight on inequalities, and created an opportunity for change. In this long read we make the case for developing a long-term approach to tackling health inequalities that will endure and consider past attempts, highlighting learnings for the renewed effort. Concurrent action is needed at multiple levels: an enduring national mission to tackle inequality; a new local and national partnership to create the conditions for system success; and local leadership to nurture the disruption needed to sustain success.
The worst health outcomes
Health inequalities are avoidable, unfair and systematic differences in health between different groups of people. They are rooted deep within our society, and they are widening, leading to disparate outcomes, varied access to services, and poor experiences of care. This results in earlier deaths, lost years of healthy life, intergenerational effects from traumatic experiences, and has significant economic costs for society. Yet, health inequalities are often preventable.
Life expectancy is one way to measure the health of a population or particular group. Since 2010, improvements in life expectancy have stalled for the population as a whole, and for the poorest 10 per cent of women they have declined. Before the pandemic, the gap in life expectancy between the most and least deprived areas in England had grown to 10.3 years for men and 8.3 years for women. Narrowing this gap demands a more preventive approach to health and a focus on the broader determinants of health.
Why is now a moment for change?
The pandemic has turned a spotlight on the impact of health inequalities. Alongside the continued moral and economic case for acting, the pandemic has brought new factors into play that can be harnessed to drive improvements.
Intolerance of injustice: the experience of Covid-19 has hit some populations, including people with disabilities and people from ethnic minority backgrounds, particularly hard. This has coincided with the growth of movements like Black Lives Matter in response to the death of George Floyd and reactions to the treatment of the Windrush generation suggesting growing resistance to societal racism.
A determination to address geographical disparity: the government has published a White Paper setting out its approach to ‘levelling up’ across the UK. This approach involves a mission to improve healthy life expectancy and narrow the gap between areas where it is greatest.
A cross-government mandate to tackle health inequalities: the establishment of the Office for Health Improvement and Disparities and the NHS Race and Health Observatory marks a change in national public health structures. The Office for Health Improvement and Disparities has a clear mandate to support policy development across Whitehall. The establishment of the NHS Race and Health Observatory in 2021 is a complimentary step designed to keep a focus on ethnic health inequalities.
A framework for action across the NHS: Core20plus5 is NHS England’s new approach to tackling health inequalities. It focuses on improvements for the most deprived 20 per cent of the population (core20), reducing inequalities for particular population groups identified locally (plus) and accelerating improvements in five clinical areas (5).
New public service roles: NHS and other organisations are increasingly acting as anchor institutions, using their assets to promote the health and wellbeing of their local communities. Networks of anchors are creating a collaborative movement, harnessing the spending power of local institutions to tackle health inequalities, innovate and invest for wealth and health.
Heightened appreciation of the role and potential of local action: the response to the Covid-19 pandemic – including the vaccine programme – offers valuable lessons on reaching into communities that have traditionally been excluded by public services and has underlined the power of community action.
Unfortunately, such changed context is not enough to inspire a different outcome in addressing inequalities. Opportunity needs to be matched by action.
The problem: how to deliver enduring change
The urgent call to address health inequalities has been made before. Reports led by Douglas Black in 1980 and Donald Acheson in 1998 made the case for sustained intervention to address health inequalities and address the wider determinants of health. In 2002, a review chaired by Derek Wanless looked at the level of long-term health funding that would be required under a ‘fully engaged’ scenario, where a well-informed public takes control of their own health. Michael Marmot’s review team assessed progress in 2010 and outlined a renewed plan of action, which was updated in 2020.
The similarity of these reports’ recommendations and the limited progress made illustrate the challenge still faced: how to implement change across a complex system so that it endures over time.
In 2020, a Health Devolution commission sought to address this challenge. In reshaping how the NHS partners, is organised, and targets its effort, it argued:
At the core of the commission’s thinking was a clear view about the central importance of the wider determinants of health. This is not new news to many of us – but the reality is that the knowledge of this has not translated into thinking about how government approaches public service delivery and economic growth… health in all policies is easy to say but takes real political commitment (at all levels) to see it through in a meaningful way.
A new approach is needed. This should recognise three fundamental realities that have to be hard-wired into the implementation of any approach to addressing health inequalities.
Endurance: inequality reduction needs a long-term programme that takes it beyond planning cycles, political attention spans and leadership tenure. Its scale requires a balancing of short-, medium- and long-term actions, and a belief that brave changes are being built to last.
Partnership: tackling inequalities is a multi-agency effort. It cannot be achieved by one part of the system acting alone. Central government, the NHS and local government need to work in close partnership, harnessing the contribution of the voluntary, statutory and private sectors.
Disruption: to make intervening in care upstream a mainstream model is not an add-on project but a re-invention of the status quo, with all the innovation that this demands. It disrupts patterns of public service delivery that fail to tackle inequalities and which, in some cases, reinforces them.
What can we learn from past attempts?
1997-2010: a concerted and systematic attempt at health inequality reduction?
It took time for the Labour government to take concerted action on health inequalities. However, the government’s strategy emerged more strongly in the early 2000s, building on health action zones (area-based initiatives focused on community approaches to tackling health inequalities), and set out in a cross-government strategy. This had a dual focus on meeting short-term national targets while pursuing longer-term challenges relating to the underlying causes of health inequalities.
The strategy was operationalised through a public service agreement between the Department of Health and HM Treasury, which included 82 cross-government commitments.
Two time-limited targets were the missions of the day, to be achieved by 2010.
Starting with local authorities, to reduce by at least 10 per cent the gap in life expectancy between the fifth of areas with the worst health and deprivation indicators (known as the spearhead group) and the population as a whole.
Starting with children aged under one year, to reduce by at least 10 per cent the gap in mortality between those in households where the main wage-earner is in routine and manual occupations and the population as a whole.
The Health Inequalities National Support Team was set up to support local areas in meeting these targets. This support included deep dives into progress in specific local authority spearhead areas and evidence-based guides and tools. Local areas received additional direct funding in some years, and NHS resource allocation was amended to increase the share of funding given to deprived areas.
A central Department of Health team was held to account through the public service agreement and the Prime Minister’s Delivery Unit, and there was an independent advisory group that published annual status reports on progress.
Did this approach work?
In 2010, the National Audit Office reviewed progress on the life expectancy element. It suggested that, despite great efforts, critical work had started late and the targets were unlikely to be met. Subsequent independent studies have used a wider range of more up-to-date data to show that these efforts had a positive effect on reducing health inequalities against a number of measures:
the relationship between income inequalities and health inequalities got weaker over the period and there was a reduction in amenable mortality in deprived areas consistent with how funding had been allocated
inequalities in life expectancy between deprived and non-deprived local authorities narrowed
there were reductions in inequalities in infant mortality.
2010-20: a more locally driven approach?
Against the context of public spending cuts and reductions in local government revenues, NHS funding was protected during the years of austerity from 2010. The coalition government’s (and subsequent government’s) approach to health inequalities mirrored its wider philosophy: less reliance on targets and structured approaches from the centre, more on incentives, information and local freedom.
The Health and Social Care Act 2012 introduced duties on a range of NHS bodies to have ‘due regard’ to reducing health inequalities in exercising their functions. The newly established Public Health England led work on a place-based approaches to health inequalities tool, an evolution of the analytical work and performance support approach that underpinned the previous public service agreement. While tackling health inequalities featured in early NHS England Mandates, in practice the targets, support and tools to do this were removed and it became a lower priority. The coalition government’s flagship health premium aimed to incentivise local authorities to reduce health inequalities, but in practice it was undermined by a lack of funding and disappeared from view.
Government did sustain work to tackle major public health harms, implementing the comprehensive approach to tackling smoking rates that had been legislated for before 2010, including a ban on smoking in enclosed spaces, changes to packaging and pricing, and increased funding for local stop-smoking support. It also legislated for a ‘sugar tax’ that came into effect in 2018.
There were notable examples of local work that showed promise in bucking national trends. For example, Wigan tackled unhealthy life expectancy and created a novel set of partnerships with the community. The ‘Wigan Deal’ focused on developing capability for self-help, community action and resident-led solutions. In Fleetwood, a broad partnership of voluntary sector and statutory bodies worked to harness community power to build resilience and address physical and mental health needs. This work changed the workforce model in some health services, notably primary care, and sought to increase use of social prescribing.
Did it work?
The 2012 Act committed the Department of Health to giving an annual assessment of progress on inequalities in health. These were usually found in their annual reports but did not make happy reading. The assessment against the public health and NHS outcomes frameworks for 2016/17 showed that inequalities on all 15 indicators had widened.
While some of the principles and learning from earlier years continued to inform Public Health England’s efforts and work in the NHS (notably informing policy on cardiovascular disease and work in local areas, such as Hope Citadel’s efforts to reduce inequalities through primary care in Greater Manchester), there is less evidence of an attempt by government to hard-wire health inequalities into local systems.
By 2020, Michael Marmot led a review of progress in tackling health inequalities as the issues identified in his 2010 report had highlighted a widening of the health gap. The deterioration during a period of austerity is clear, yet relative prosperity in the previous decade did not see a narrowing of outcomes on the scale now needed to address the gap in healthy life expectancy by 2030.
What does history tell us about the best route forward?
The zigzag of approaches over the past 20 years testifies to varied ideas about how to achieve change. There is a tension, but not a competition, between local and national action. However, the right tier must be found for specific types of intervention, and we should recognise that that the layering may differ between, for example, the most excluded areas and those ’in the middle’. There must also be a balance between binding national ambitions and the innovation of local action.
Doing better this time requires concurrent action at multiple levels. The recent White Paper on health and social care integration commits to a new approach to how local and national actors co-design solutions, and it acknowledges the importance of relational levers and the difficulties of maintaining these relationships over time. The White Paper invites a focus on how leaders are valued and how financial flows operate to reflect shared priorities rather than institutional silos. To tackle inequalities, collaboration between local government and health services must reach further than solely social care, but many of the same principles could apply.
We discuss below the balance of three related tiers of action:
an enduring national mission to tackle inequality
a local and national partnership to create the conditions for system success
local leadership to nurture the disruption needed to sustain success.
Across these tiers, we suggest seven steps that need to be incorporated into a renewed approach to implementing programmes to address inequality.
An enduring national mission to tackle inequality
|Practical steps to make this happen
|A stronger focus on prevention and people with multiple unhealthy behaviours
|The government's health disparities White Paper must comprehensively address the role of prevention in tackling clustered unhealthy behaviours
|National targets, delivered locally
|There is a need to identify a clear set of national outcome and process measures to reduce inequalities that can form the basis for shared accountability locally
A local and national partnership effort to create the conditions for system success
|Practical steps to make this happen
|Opening up the data
|A shared local view of what the latest data shows about inequalities is essential, and must be available to the public
|Distilling what works and sharing it
|A multi-sectoral support approach to sharing and implementing best practice is necessary
|Making tackling health inequalities business as usual for the NHS
|Making tackling health inequalities central to the work of the NHS requires a real shift in what is prioritised, valued and regulated
A local leadership role to nurture the disruptive capability to sustain success
|Practical steps to make this happen
|Moving money and changing outcomes
|All NHS organisations, including hospitals, need to challenge themselves to both push care upstream and tackle the underlying causes of inequality
|Prioritise building community capability
|Asset-based approaches to care should be at the heart of ICSs' plans
An enduring national mission to tackle inequality
A stronger focus on prevention and people with multiple unhealthy behaviours
The government’s health disparities White Paper must comprehensively address the role of prevention and target support at people with multiple unhealthy behaviours.
Tackling the root of health inequalities requires a shift to more effective disease prevention. The government has established a health promotion taskforce, at Cabinet level, to move forward prevention policy and a health disparities White Paper is due later this year. There is much to be learnt from empirical analysis of recent efforts to tackle smoking, obesity and alcohol misuse, all of which are more prevalent in disadvantaged communities. Even where smoking has reduced over time, it is in these communities where national strategies have been least effective.
Addressing these issues requires a comprehensive policy that uses all the levers of central government – not only providing advice but changing point-of-sale displays, gearing price and establishing supply models for healthier alternatives. Many of the steps required – for example, exploring how to provide excluded communities with access to nicotine replacement therapy or vaping – go beyond information about behaviour and seek to address people’s agency. Learning from the approach to sugar, there is a need for boldness in the face of the challenge – using tax and regulation to shape product formulation and support healthy behaviours.
This national, comprehensive approach has to be matched by local action. From using what GPs know about their practice populations through to Making Every Contact Count interventions in all health settings, the health service has to use all opportunities to renew its work to become systematically preventive. Local authorities and their public health teams must be at the forefront of this effort: thoughtful use of social marketing, digital technology and working with trusted messengers within communities should all be part of a new campaign to address major health harms at a local level.
Unhealthy behaviours cluster in specific populations and so reinforcing actions across different health harms are needed. These actions must recognise those within a neighbourhood’s population who may have multiple needs and find solutions that consider root causes, including underlying poverty.
National targets in a locally led system
A clear set of national measures is needed to track progress in reducing inequalities and form the basis for shared accountability locally.
The commitment in the levelling up White Paper to improve healthy life expectancy and narrow the gap between local areas where it is widest provides a clear starting point. However, improving health life expectancy is a massive challenge and is only a part of what is required.
What success looks like in addressing health inequalities has to be explicit and measured. The experience of the past two decades suggests that thoughtful targets are helpful. The integration White Paper’s proposal for a shared outcomes framework across health and care in 2023 offers a tangible route to putting this into place, which recognises unavoidably distributed accountability at a local level.
While the NHS is used to working towards top-down standards, local authorities have autonomy to define local measures so there is a need to strike the right balance between national consistency and local discretion. The new Core20plus5 health inequalities policy helpfully expects local leaders to make choices about which areas to focus on in reducing inequality, within an overall framework set by NHS England. This has some similarities with local government approaches taken under the Local Area Agreements regime in selecting from national indicators a decade ago.
Having multiple national policies and initiatives – levelling up, a health disparities White Paper, NHS England’s framework, and others – risks divergent local action. Synthesis is needed and co-ordination across government is essential, either via the prevention taskforce or with advice from the proposed levelling-up commission.
A local and national partnership to create the conditions for system success
Opening up the data
A shared local view of the latest data is essential and must be available to the public.
Collecting accurate data and sharing it routinely and publicly is important for tackling health inequalities. It will stimulate action and allow scrutiny by communities, health and wellbeing boards and regulators alike. Public awareness of inequalities increased during the pandemic, yet understanding of inequality remains a complex area and not always one that mobilises support for the most effective actions.
NHS England has produced a national health inequalities dashboard (currently only available to public sector organisations), adding to an extensive body of data held by the Office for Health Improvement and Disparities, local government and many others. Integrated care systems (ICSs) and regional public health teams should create a single view of this data that organisations in each local area rely on.
Data must be grounded in accuracy and completeness. The pandemic revealed a legacy of incomplete ethnicity coding being tolerated, while inclusion health groups are currently under-represented in datasets, as the Office for Health Improvement and Disparities has recognised.
Data-sharing is central to population health management. There remains work to do to support primary care, social care and community teams to have visibility of common live datasets to direct their efforts. Primary care networks do not need just analytical data, they need the real-time information that proved so crucial during Covid-19.
Distilling what works and sharing it
A systematic approach to sharing evidence and implementing best practice is needed.
The action needed to tackle health inequalities is well evidenced. For example, we know that the Sure Start model of supporting families with children under five has been successful in reducing hospitalisations, as well as improving child health and reducing inequalities. The current government’s focus on strengthening the support provided by family hubs is therefore welcome. The housing-first model of providing homeless people with access to stable housing as a starting point for tackling their wider health, care and social needs has also shown promising results. At a local level, work to address differences in cardiovascular services are a crucial step to changing outcomes, making best practice commonplace and challenging unwarranted variation.
However, capability and capacity to design and implement effective interventions are not evenly distributed across or within systems and sharing knowledge will be critical. This sharing can take different forms: peer support models are common in local government and now public health, while more nationally led support has often been used in the NHS. Current initiatives such as the National Institute for Health Research collaborations between local government and academic researchers on the wider determinants of health will be important. Those insights explicitly draw on lessons from different sectors, whose structured learning networks remain unintegrated at present across health and local government.
A large-scale, co-ordinated programme of peer support could aid local partners’ efforts to tackle inequalities. Directors of public health, and system health inequalities leads, will be important in anchoring approaches tailored to local circumstance.
Tackling health inequalities should be business as usual for the NHS
Making tackling health inequalities central to the work of the NHS requires a shift in what is prioritised, valued and regulated.
The NHS alone is not best placed to lead health inequality reduction, but it is an essential partner. The service needs to be mobilised to see inequalities as a priority and to stay the course of a long-term effort to address inequalities. During the 2000s this was not necessarily the case, while many local government systems sought to keep attention on equity and inclusion. The creation of ICSs, aiming to transform health and care delivery to a population health model, with a focus on those who are in need not simply those presenting, is a vital opportunity to align purpose.
Structural change is a start. But the transition to more upstream care has been a theme of health strategy for some time. It faces some inherent challenges. Parity of esteem between physical and mental health, central to many elements of health inequalities, has not yet been achieved. Addressing ethnic health inequalities demands specific action and urgency. Hospital care continues to dominate expenditure, attention and leadership hierarchies. Within this context, preventive care, and in particular a focus on excluded communities, can take second place.
The crucial ‘carrot’ required is to support and engage frontline professionals in finding their role in the effort on inequalities. Organisations, including colleges, universities and professional regulators, for example, the General Medical Council, will need to support health professionals to do this work from early training and as their careers progress, so tackling health inequalities becomes a career-long practice. System health inequalities leads must play a role in developing local academies and other knowledge-sharing models to promote this frontline translational work.
There is a role for proportionate regulatory and performance management. ICSs must be regulated, including by the Care Quality Commission, with an emphasis on inequality as an part of an effective and responsive approach. If finances and waiting lists come with external monitoring , and inequalities does not, then history suggests that long-term transformation will be subsumed by the more immediate, urgent ask.
A local leadership role to nurture the disruptive capability to sustain success
Moving money and changing outcomes
All NHS organisations, including hospitals, need to challenge themselves to both push care upstream and tackle the underlying causes of inequality.
Spending on inequalities work is too often considered additional or novel, directed at specific groups or one-off projects. In many cases, notably when focused on preventive measures, this funding is expected to meet a higher value-for-money threshold than other spend. For work on inequalities to endure, there must be a shift in the way baseline funding is spent. This means treating inequalities spending as part of the mainstream and not as short-term funding.
Most importantly, tackling health inequalities requires a local shift in expenditure patterns to address some of the underlying causes of inequality. This does not need to wait for any national change in funding formulas, although reviewing workforce distribution to prioritise the most-deprived areas may be considered. It can be done now on a local whole-system integrated basis, with ICSs offering local partners the flexibility to think differently about how funding is spent.
In particular, health institutions need to consider how to support the work of others in prioritising interventions in areas such as housing, employment and even food supply. Supporting early adopters of these changes and encouraging radical action can help build momentum for places to be disruptive in their approach.
NHS expenditure at a local level tends to reflect historic trends. ICSs and provider collaboratives can now re-balance allocation of resources within a local system. Previously moving funding was dependent on commissioners ‘pulling’ back funding, for example, from hospitals. Increasingly provider collaboratives may be asked to vertically commission for pathways or disease groups. Such arrangements seek to draw providers into a shared responsibility, asking them to proactively ‘push’ their resources upstream.
Prioritise building community capability
Asset-based approaches and primary care should be at the heart of integrated care system’s plans to tackle health inequalities.
The pandemic has illustrated the power of new models of provision in reaching communities historically excluded by services. Community capability has long been recognised as being central to supporting neighbourhoods to overcome inequality, either by directly narrowing the inequalities gap or by creating resilience to manage its effects. There is a need for a mindset that values the role of informal care and the volunteering work that builds trust and relationships between communities and state provision.
It is within these hyper-local settings, at neighbourhood level, that primary care plays a pivotal and essential role in co-ordinating help and offering continuity of care. In the most deprived communities, there is a pressing need to consider how to sustain general practice and to overcome the flaws in the Carr-Hill funding model that have been acknowledged for more than two decades.
Deliberate action is needed to nurture these assets, in community partnerships and within health. Anchors should build on the strength of their communities before looking to new statutory services. Integrated care systems have renewed responsibility to pay attention to the voluntary sector’s contribution and resilience, and one of their four aims is to prioritise economic and social value. This brings health into line with local government’s traditional role in community wealth building. This alignment of responsibility has to be maximised if local community efforts are to thrive.
Past attempts illustrate how preventable inequalities can begin to be tackled. But they also show how easily gains can fall away or attention can shift. This apparent pattern could reduce commitment from professionals and leaders to disrupt the status quo, mindful that ambitions change.
A mission to make tackling health inequalities business as usual must nurture the experimentation that shifts the dial on how money is spent and how capabilities within communities are developed. The learning around the role of communities in responding to the pandemic must not be lost as health equity becomes an overwhelming focus for local partnerships.
Hard-wiring health inequalities into the way that systems work requires a deliberate design that acknowledges endurance, partnership and disruption as fundamental. The seven specific steps we have outlined here are not just desirable criteria for change, they are essential criteria.
The authors would like to thank colleagues Sally Warren, Patrick South and Richard Murray who contributed to this work, acknowledge the advice provided by Dr John Ford and Ian Holdroyd, and the insights provided by Professor Kate Ardern, Matthew Kershaw and Tom Riordan CBE who both commented on drafts and attended a roundtable held by The King’s Fund in December 2021 that helped shape and challenge our thinking.