Tackling health inequalities: seven priorities for the NHS

There is a wealth of evidence showing that some groups of people experience significantly poorer health, and significantly worse experiences of health and care services, than others. This is a longstanding injustice that has been further entrenched by the Covid-19 pandemic and cost-of-living crisis. These differences in health experiences and outcomes are avoidable, unfair and systematic, and yet they continue to widen (see box below).

Tackling health inequalities and improving health for the groups who typically experience the worst outcomes requires concerted action from across government. Yet the NHS clearly has a significant contribution to make. In this long read we outline how the anticipated 10-year health plan, which will set out a long-term vision for the NHS, can help to tackle this immense and salient challenge.

The state of health inequalities

Inequalities in health reflect the inequalities in society at large: they are closely related to personal and socio-economic factors, such as income, education, housing, gender, age, ethnicity, disability, geography and social inclusion.

Health inequalities are the result of differences in health status (eg, life expectancy), access to care, quality and experience of care, behavioural risks to health (eg, smoking), and wider determinants of health (eg, quality of housing). The groups who often experience the worst health include (but are not limited to) black and ethnic minority groups, people sleeping rough, people living in poverty, disabled people or long-term health conditions, and those who are part of the LGBTQ+ community.

To make matters worse, many of those most in need of health and care support often face the biggest barriers to accessing services. These barriers range from not feeling listened to or understood by health care staff to experiencing racism and discrimination (see box below). In addition, some groups are likely to face challenges specific to their life experiences. For example, without a fixed address, people who sleep rough often find it difficult to register with a GP.

Repeated negative experiences, often over generations, have led to a pervasive lack of trust in the health system and perceived uncertainty about worthiness of care among some groups. This acts as a further deterrent to accessing services, and in turn, widens inequalities.

The change we need

Tackling health inequalities and improving health for the groups who typically experience the worst outcomes requires a consistent and coherent focus on population health at a local, regional and national level, as well as targeted action to support change.

Our vision for population health is based on action across four interconnecting pillars:

• the wider determinants of health

• healthy behaviours and lifestyles

• the places and communities we live in

• the support of an integrated health system.

Delivering this kind of approach requires collective action from many systems, places, sectors and organisations. However, as a key actor in our health system, the NHS has a central role to play in delivering care equitably and working collaboratively with others to tackle health inequalities.

Alongside the moral case for action on tackling inequalities and the worst health outcomes, there is an economic case: a more equitable NHS is likely to be more efficient. Reducing the barriers to accessing services will prevent ill health, while tackling racism and discrimination will help to recruit and retain staff in the NHS. This will also support the government’s aim of helping more people out of long-term sick leave and bolstering economic activity.

The case for action to tackle health inequalities is clear and overwhelming, yet our analysis shows that attempts in recent decades have had mixed success. Despite strong legal and political frameworks that mandate this work and some pockets of success, our analysis suggests that overall there has been a lack of significant or sustained systemic progress in recent years.

A change in government presents an opportunity to do things differently and to generate the progress that is so desperately needed.

While meaningful progress requires much more than a written strategy, not least the capabilities and capacity to enable its effective implementation, devising a new national plan for the NHS is an opportunity to refocus and prioritise longer-term strategies for tackling inequalities and the worst health outcomes.

It is a positive step that the government’s health mission (published when the Labour party was in opposition) acknowledges the importance of prevention and a joined-up, long-term approach across government, alongside partnerships with local communities. These conditions are necessary for the success of the new 10-year health plan that tackles health inequalities and supports the health of future generations.

Our project

To understand how to move forward, we have looked back.

We reviewed more than one hundred reports, events and podcasts involving a variety of different people working in the NHS, local authorities, the voluntary sector and private sector, and people who experience the worst health outcomes. We also gathered insights from the organisational development professionals at The King’s Fund who work with individuals and systems.

Alongside this, we asked several individuals who were involved in the work that we reviewed about their experiences of the NHS and their views on what needs to change. This is because we know that in order to really understand these issues, we need to hear directly from the people affected by them. These stories and insights are shared as short video clips, included throughout this written piece.

Based on a review of our work, we have identified seven areas for action that we believe the new 10-year health plan should prioritise in order to ensure the NHS can better tackle health inequalities and the worst health outcomes.

1. Develop a cross-government health inequalities strategy for the 10-year health plan to feed into.

2. Reorientate the NHS to focus on prevention.

3. Radically change the relationships the NHS has with people and communities, from ‘power over’ to ‘power with’.

4. Tackle racism and discrimination in the NHS and cultivate a culture of compassion.

5. Enable staff to identify and act on health inequalities and capture learning.

6. Empower place-based partnerships to take more decisions about how NHS money is spent.

7. Actively support local voluntary, community and social enterprise (VCSE) organisations through changes in financial planning and commissioning.

Seven priorities for the new 10-year health plan

1. Develop a cross-government health inequalities strategy for the 10-year health plan to feed into

What are the key issues?

The root causes of health inequalities need to be addressed by multiple sectors and organisations. Progress relies on co-ordinated action across the public sector and beyond. Responsibility for tackling health inequalities, therefore, is shared among many actors. This can make it challenging to monitor progress and to hold systems and organisations to account.  

In addition, there is currently no cross-government approach to addressing health inequalities. The lack of progress in this area is illustrated by the previous government shelving its anticipated health disparities strategy.

However, it is important to note that there have been some specific efforts in relation to the health and care system, such as the Core20PLUS5 model for targeting efforts to reduce inequalities, the setting up of the NHS Race and Health Observatory, and integrated care systems (ICSs) being set a core goal to address health inequalities.

In recent years, the signal from government about the importance of this work has not been strong enough. Leaders in the NHS have told us that efforts to address health inequalities have been hampered by national targets and performance monitoring that predominantly focus on finance and elective activity as opposed to quality and inequalities. Limited practical support from national bodies on how to improve, coupled with harsh consequences for failing to meet targets, creates a culture of fear and fragmentation between different parts of the system that is further hindering change.

Even where ICSs are able to commit time to this work, and despite pockets of great practice, progress is not always systematically monitored and learnings are not always shared as widely as they could be – a crucial tool for system-wide change.  

What would help?

Concurrent action is needed at multiple levels: an enduring national goal to tackle inequality; a renewed partnership between national bodies and local organisations to create the conditions for system success; and local leadership to nurture the disruption needed to sustain success.

• The government must develop and implement a cross-government strategy to address the interlocking nature of the root causes of inequalities eg, in education, employment and housing. The mission board (which has been set up to deliver the government’s health mission) is well placed to develop and lead this cross-government strategy on health inequalities. It should include high-level goals to signal the importance of this work, and bring together efforts across government departments, sectors, organisations and systems. The 10-year health plan must take every opportunity to align with the goals set out in the health mission and its strategy for tackling health inequalities. 

• NHS England should ensure that outcomes and process measures around tackling health inequalities are embedded within integrated care boards’ (ICBs) performance management structures. This will signal the critical nature of this work and help to ensure long-term transformation is not subsumed by more immediate work. These measures need to go beyond monitoring the numbers of people accessing services to account for people’s experiences of using them, the quality of the care received, and the inequalities in these. Crucially, these measures must also go beyond measuring NHS activity: they also need to cover the NHS’s contribution to tackling the wider determinants of health. Thoughtful metrics (see area 2) will enable systems to collect data, measure progress, share learning and ensure accountability for improvement.

• Alongside performance management, the NHS needs to develop a system that provides more support to help systems, places and neighbourhoods progress their work on health inequalities. Improvement is dependent on both clear and transparent accountability and the right level of support. National bodies need to consider what additional support and guidance is needed to enable the delivery of this work. Teams also need the space to work independently to design and deliver services for their local populations in the best way (see area 5). The approach to health inequalities improvement support developed in the 2000s provides one possible model (see below). 

2. Reorientate the NHS to focus on prevention

What are the key issues?

The NHS is currently facing exceptional challenges. In attempts to tackle these challenges, funding is very often allocated to the most pressing and time-critical issues. Although addressing health inequalities and focusing on prevention are core purposes of ICSs, longer-term priorities risk being subsumed by immediate pressures on the NHS. This has contributed to a system that is focused on acute care over other areas.

An important enabler of delivering a prevention agenda is investment in community-based care, as local provision can reduce access barriers for those most in need. In addition, primary and community care staff are best placed to identify and address health issues early. Examples include heath centres that are situated on the high street, and ‘one-stop-shops' where multiple services (health and other welfare services) are housed under one roof.

Despite successive governments repeating a vision of health and care services focused on communities rather than hospitals, that vision is very far from being achieved. If this shift in focus does not happen, more expensive hospitals will need to be built to manage people with acute needs that could have been prevented or better managed in the community.

The cost of failing to put prevention first can be seen across all areas of public services – and results in higher acute demand for other public services, not just the NHS. Failing to invest in prevention not only costs the economy, it also results in loss of opportunities for people and loss of life.

These losses are not evenly distributed across society; many preventable diseases disproportionately affect some groups of people (eg, cardiovascular disease is among the largest contributor to health inequalities, accounting for one-fifth of the life expectancy gap between the most and least deprived communities), and so work to refocus the NHS on prevention is a critical step in tackling health inequalities.

Without comprehensive action to prevent ill health, the pressures on health, care and other public services will only increase. Without supporting working-age people with ill health back into the workforce, inequalities will widen and opportunities to build a prosperous future will diminish.

What would help?

There is currently remarkable consensus across think tanks, health institutions and political parties that a move towards a preventive state is key to creating a healthier nation.

An approach that focuses on primary, secondary and tertiary prevention (ie, to prevent ill health, to reduce the impact of ill health, and to support people living well with ill health) offers potentially huge benefits for the nation’s health and prosperity, but the rewards will not be reaped immediately. An investment of this kind requires courageous and strong leadership, accompanied by investment in other areas, eg, bolstering the public health grant.

If implemented, these recommendations will help to support the big ‘shifts’ the government hopes to achieve in moving more care into the community and improving preventive measures.

• Government decisions about the allocation of capital and revenue spending must support the wider ambitions to shift the health service towards prevention.

• National bodies should implement longer-term planning cycles to enable ICBs to deliver a prevention agenda. The government should implement the recommendations set out in the Hewitt review. Namely, ‘funding should be largely multi-year and recurrent’ so that ‘systems can more cohesively plan their local priorities over a longer time period’. This is particularly important for prevention initiatives that tend to deliver impact over longer time periods.

• ICBs need to invest in – and make progress on – prevention and be held to account for this. NHS England should work in partnership with ICBs to prioritise strategies that focus on prevention and developing care in the community. This needs to be fully reflected in the published national priorities and operational planning guidance. Specifically, the framework used to assess and hold ICBs accountable needs to include more detailed metrics around prevention, health inequalities and delivering care in the community. Alongside this, ICBs need support and guidance from national bodies on how to deliver against these targets (see area 1).

• To facilitate a more systemic approach to prevention, NHS England needs to support a wholesale shift to delivering care in primary and community settings. Moving care into the community will involve directing a greater proportion of the NHS budget to primary and community care, incentivising people to take up leadership roles in community settings, and giving local health and care leaders more flexibility to meet local needs.

• NHS organisations should continue to develop their role as ‘anchor’ institutions to contribute to the health of the population. This includes creating healthy workplaces, reducing their environmental impact and supporting active travel (eg, cycling to work schemes) among staff and patients. They should consider joining the health anchors network to support their work.

3.   Radically change the relationships the NHS has with people and communities, from ‘power over’ to ‘power with’

What are the key issues?

As described above, some groups of people face a range of barriers to seeking support and accessing services.

For some individuals and communities, these barriers negatively impact their experiences of using health and care services, cultivating mistrust and leading to worse health outcomes, all of which deepen the existing inequalities. For the health system, this cycle results in duplication and inefficiency. 

One of the NHS’s core values is to put the patient at the heart of everything it does, and ICBs have a legal duty to involve patients and the public in their services. For some ICSs, improving ways of working with their local populations is a key priority; however, there is significant variation across the country. In many places, people and communities are still largely seen as recipients of health services as opposed to active partners, and are not genuinely considered a key constituent of the health system.   

One example of the way in which people and communities are excluded is that they are not routinely or meaningfully involved in the design of services. As a result, services very often do not meet their needs.

What would help?

People and communities need to be at the centre of the new 10-year health plan. Building the plan in this way will send a strong message to NHS organisations about the importance of this work.

• The NHS needs to transform the way it works with people and communities by focusing on listening, building trust and sharing power. This ethos needs to be central to the way the 10-year health plan is developed to signify the importance of this approach. Progress requires this approach to be rooted in the conviction that communities are assets and understanding lived experience is essential to improving services and tackling health inequalities. Genuine partnership working (which may involve methods such as co-production and deliberative public engagement) needs to be built into systems and processes that drive how services are developed, eg, planning, monitoring, decision-making and funding. This will require people at all levels of NHS organisations to foster meaningful and sustained partnerships with people and communities. Listening to communities and dismantling hierarchical ways of working by sharing decision-making power will help to rebuild trust between the NHS and communities, inform the design of person-centred, culturally sensitive services, and in turn, reduce barriers to accessing care. 

• The NHS must learn from past failures. Some groups of people are systematically not listened to by authorities. This can have significant, and sometimes deadly, consequences. The devastating fire at Grenfell Tower is one such example: residents repeatedly raised concerns about health and safety that the authorities did not listen to and so opportunities to prevent the tragedy were missed. The story behind the introduction of Martha’s rule is another example of the tragic consequences of health services ignoring the concerns of patients. All voices need to be heard and concerns need to be consistently taken seriously. This requires a recognition of the history of structural racism in the NHS (see area 4) and an ongoing commitment to transparency, particularly around the allocation of health service funding.  

4.   Tackle racism and discrimination in the NHS and cultivate a culture of compassion

What are the key issues?

Systemic racism and direct and indirect discrimination permeate NHS services just as they do wider society. They affect the NHS in multiple ways, including the experience of staff in the workplace, the way the NHS designs and delivers services, and the health of the people and communities who use those services. The NHS cannot tackle health inequalities meaningfully without prioritising work to tackle racism and discrimination in all its forms.

This means NHS leaders must purposely focus on tackling racism and discrimination in all aspects of how it operates – for their staff and for the communities they serve. This includes understanding and engaging with communities and different groups who experience discrimination to ensure services are accessible and delivered in a way that is appropriate for all (see area 3). It also includes efforts to make the NHS a better place to work, eg, by reducing preventable stress. This is part of developing a culture of compassion in which leaders hold crucial conversations about inclusion, where they hear and reflect deeply on what staff are telling them and then take necessary action to help address inequities and discrimination in the workplace.

What would help?

The first step is for organisations and staff to admit that there are issues and work to understand them – including the nuance of how staff experience and patient experience and outcomes differ between different ethnic groups and other groups who experience discrimination. Staff must then take action to bring about change, including:

• NHS England should implement existing policy recommendations for improving leadership and equality, diversity and inclusion in the NHS (like those contained in the Messenger review and the NHS’s equality, diversity and inclusion improvement plan), which include actions to embed inclusive leadership practice as the responsibility of all leaders and promoting equal opportunity and fairness standards.

• The NHS must invest (rather than disinvest) in staff roles that help to drive change – such as those focused on diversity and inclusion – that support the development of an inclusive and compassionate culture in organisations.

• NHS England must prioritise staff and patient experience and reflect this in its approach to performance management. This means changes to performance conversations between NHS organisations and NHS England (which currently focus predominantly on activity and finance), and using the Care Quality Commission’s Well-led framework to support this change. This should address how NHS boards understand and act on data about staff and patient experience and the diversity of its leaders.

• While structural change is essential, our research suggests action is needed by individuals in local teams, departments and organisations so that there is an onus on individuals to make their own commitments and take action, alongside structural change (see next area).

5. Enable staff to identify and act on health inequalities and capture learning

What are the key issues?

Our research found that NHS staff are sometimes not aware of how health inequalities affect their work area or how to identify and act on them.

Making work to tackle health inequalities mainstream and making it everyone’s business, rather than the purview of a small group of specialists, is a key part of accelerating progress. Our work has shown that all staff have a role to play in tackling health inequalities through awareness, action and advocacy (the ‘three As’).

As systems evolve, staff change and projects complete, it is also critical that ICBs develop skills in capturing and acting on learning to create a virtuous cycle of learning and improvement that can be applied across their system.

As the NHS develops more community-based services (see area 2), there is an opportunity to plan and train a workforce skilled in understanding and working with the complex needs of many individuals and communities in a way that supports people with the worst health outcomes and reduces inequalities.

What would help?

• ICBs should develop a cross-system strategy for supporting all staff to develop the skills they need to work with communities, understand their needs, identify inequalities, and design services that support them. There are promising examples of ICBs using their system-wide reach to set up an academy and other staff training and development models for NHS and wider system staff (see resources below). These models require sustainable recurrent funding from ICBs.

• NHS England and ICSs must also support health inequality leads on NHS boards who were appointed in every NHS organisation in the wake of the Covid-19 pandemic and can play an important role facilitating action throughout their organisations and systems.

6. Empower place-based partnerships to take more decisions about how NHS money is spent

What are the key issues?

ICBs were created to support integrated planning between system partners across relatively large areas. At the same time, there was an intention that ‘place-based partnerships’, which cover smaller areas, would take decisions where more localised insight is needed.

The extent to which decision-making power has been delegated to ‘places’ (that often mirror local authority boundaries) varies. This matters because much of the NHS’s work to tackle inequalities requires a nuanced understanding of local needs and strong local relationships across the NHS and local government. Therefore, this work is best co-ordinated at ‘place’ level and led by place-based partnerships that include the NHS, local authorities and local VCSE organisations.

What would help?

• ICBs must empower place-based partnerships to take decisions about how funding is spent. This includes ICBs delegating budgets and decision-making power to place-based partnerships where possible, eg, for all decisions other than those that are best taken at system or regional level. Place-based partnerships should identify opportunities to devolve power to neighbourhoods and co-commission services with communities to ensure they meet local needs (see area 3).

• ICBs should be held to account by NHS England and the Care Quality Commission for the extent to which they are making best use of local decision-making at place and neighbourhood level.

7.   Actively support local voluntary, community and social enterprise (VCSE) organisations through changes in financial planning and commissioning

What are the key issues?

Local VCSE organisations that support people who experience the worst health outcomes are key partners to the NHS in work to tackle inequalities. They provide tailored services that support health and access to health care in these communities and are based on deep connections with them and understanding of their needs.

However, local VCSE organisations find it difficult to work with the NHS. The problems stem in part from the NHS commissioning in a way that is more suited to large public sector organisations, as well as a lack of knowledge and understanding within statutory bodies of the role and contribution of the VCSE sector at a local level.

Problems include short-term contracts, complex or time-consuming tendering processes that take significant time and resource to engage with, and disproportionate monitoring requirements. These factors mean that small VCSE organisations are often left holding a lot of financial risk (eg, by having to set up services without a long-term guarantee of funding) that public sector bodies would be better equipped to hold themselves.

What would help?

• Embed the VCSE in NHS strategic planning at national and local level. This includes ways of working that involve the VCSE early and often using an iterative and developmental approach to working together. It also means implementing a clear framework for the role of the VCSE within the ICS.

• Implement three to five-year financial planning cycles that include the flexibility for ICBs to move money from one year to the next. This should facilitate a longer-term approach to commissioning services from the VCSE (as well as other benefits, such as encouraging investment in prevention – see area 2).

• Develop a more collaborative approach to commissioning the VCSE based on new ways of working between the public and VCSE sectors.

Conclusion

It is deeply unjust that some groups of people have significantly worse health and worse experiences of the NHS than others – it is also preventable.  

As a key pillar of our health system, the NHS has a central role to play in delivering care equitably and working with others to tackle health inequalities. To do this, the NHS must radically transform the way it works with communities and staff, while reorientating services to focus on prevention.

A change in government and the development of the 10-year health plan offers a real opportunity to facilitate the significant change that is so desperately needed. The King’s Fund is committed to supporting the NHS and its partners in this task.

This kind of transformative work is difficult, but the potential rewards for us all – both now and in the future – are immense.