Across systems, a range of different partners will hold information about the local population on the situations and circumstances which influence their health. For example, local government holds data on people’s access to statutory services, such as housing, benefits, work, education and social services, all of which contribute to population health. Emergency services such as police and fire services will also gain insights from their interface with the local community, and like ambulance services are often the first port of call in a crisis and therefore witness the impact of inequalities on people’s lives.

Delegates shared how they are coming together to identify their ‘shared cohorts’ – people who are coming into contact with a variety of services, and are in need of support, but whose needs are not being holistically met by any one service or in a joined up way by the wider system. This work often takes place in partnership with local health and wellbeing boards, or as joint audits of clinical pathways between NHS partners.

They shared the value of coming together to identify this shared group so that they could work better to understand the barriers they are facing to receiving support: for example one trust leader shared how vital services based in the town centre could exclude those who had been in contact with the justice system and were consequently banned from the local town centre. It was coming together for a discussion about these challenges that helped to identify the barriers faced by people in such situations.

In the NHS itself, other trusts, as well as primary care partners will have detailed information on management of long term conditions as well as playing a role in identifying and reducing inequalities in waiting lists and referrals. The voluntary sector has a wealth of insight on people’s lived experience and a holistic point of view about what is contributing to poor health among marginalised communities they support.

Some trust leaders describe information governance differences between system partners as a barrier to easily sharing information across organisational boundaries. Despite this, many felt that they had made progress in developing a shared vision of the system-wide evidence on health inequalities by coming together to discuss insights between organisations, reducing the distance between teams and facilitating real-time discussion of data.

Good relationships were described as an enabler of progress in this area. Bringing people together who trust each other into a forum to discuss the shared challenges for local people was described as a key to seeing ‘the art of the possible’, and successfully navigating differences in policies and ways of working. One delegate described having an away day with system partners to immerse themselves in the evidence about health inequalities, share good practice, and forge an agreed way forward together supported by mutually agreed goals.

Delegates described the importance of sharing insights across organisational boundaries to avoid the pitfalls of not knowing where the gaps are in their understanding of health inequalities. Some felt that their trusts are taking a piecemeal approach, seeking to identify inequalities in single services or pathways in order to develop and evaluate a model of improvement. Trusts also described a need to be mindful of those who fall through the cracks between services, who without a holistic approach to understanding local needs and service use, may not be captured in the data.

Some have tackled these gaps in insight by developing dashboards which give a snapshot of inequalities in access by deprivation, ethnicity and other characteristics prioritised via Core20PLUS5. At a system level, delegates described how integrated care systems or commissioning support units often act to bring together data sources to create a ‘single version of the truth’ across primary care, secondary care, mental health and community services can offer a ‘birds eye view’ of inequalities to then further investigate the drivers of inequality. Alongside this, trusts described a need to improve coding of data across services to ensure the picture of health inequalities is as complete and accurate as possible.

This is then followed by a ‘deep dive’ into the causal factors behind any inequitable access or outcomes identified in the data. For example, one trusts’ data identified differential access to services linked to breastfeeding status, and used it to develop a more differentiated service offer to improve equity of access. Another put a health inequalities lens to ‘did not attend’ (DNA) data, to delve into the reasons why people do not attend their appointments and put in place a personalised model. This is now being supported by an analysis tool which predicts which patients are likely to DNA and put in place support from the moment they are referred.

Delegates discussed how clinicians and frontline staff are at the forefront of reducing healthcare inequalities, because they help to shape the services people use and can play a key role in. However some described challenges in achieving the ‘hearts and minds change’ needed to ensure all staff have a good understanding of health inequalities and are bought into taking the actions needed to address them.

Attendees shared enablers of this cultural change. In particular, delegates felt that sharing a robust and clear evidence-base on inequalities in access, experience and outcomes can allow data to speak for itself and tell a clear story about where action is needed. One health inequalities lead described visiting each department’s clinical governance meetings to discuss inequalities in clinical terms, and felt that it was helpful to speak their language and identify what motivates a clinical focus on equity alongside other pressures. Another said that by describing the difficult choices patients have to make when taking time out of work for an appointment or treatment results in lost income, it helped to reframe their clinicians’ views on why some individuals do not access services as expected, and what can be done to help resolve this issue.

At board level, delegates described how health inequalities is often talked about at board conversations, but that this has not yet translated into a well-embedded or cross-cutting approach to looking at health inequalities as a factor in performance and quality. Embedding HEAT assessments into strategy documents and business case templates helps colleagues embed the issues across board-level conversations.