- The COVID-19 pandemic has played out against a backdrop of multiple inequalities, driven by a range of factors including levels of poverty and deprivation, safe and healthy housing, education, employment and access to healthy food and green space. Despite a gradual move towards embedding health inequalities and the wider determinants of health as a key responsibility of the health and care system, the NHS' potential to contribute towards a comprehensive approach to population health and narrowing health inequalities has not yet been fully realised.
- The 2021/22 operational priorities and planning guidance stipulates, for the first time, that people at risk of health inequalities must be prioritised for treatment as trusts work through their backlogs of elective care. The presence of a "gateway criterion" for the elective recovery fund, requiring trusts to address health inequalities to be eligible for additional funding, is evidence of the national bodies’ increasing commitment to reducing health inequalities: financial incentives and operational requirements focused on addressing inequalities did not exist at the same level of priority before the pandemic.
- Forthcoming legislation firmly positions integrated care systems as the primary level at which partners will come together to make plans, including to address health inequalities. Meanwhile guidance issued by NHS England puts a welcome emphasis on the role of place-based arrangements in identifying and narrowing inequalities. It will be necessary therefore to avoid confused and conflicting accountability in this new system-wide focus on health inequalities.
- There is a risk that, if shorter-term financial and operational pressures dominate integrated care boards’ attention, a focus on health inequalities could be lost, while valuable partnerships could be undermined in being drawn into transactional conversations about the distribution of scarce resources. A statutory duty upon integrated care systems to reduce inequalities may therefore strengthen the argument for interventions to be funded and supported. This will only be possible if integrated care systems (ICSs) themselves are given a realistic task.
- It will be crucial for national policymakers to enable and support trusts and systems to prioritise this focus on inequalities. Improvement in this area may take time, may bring additional costs, and could slow down broader efforts to reduce the size of waiting lists or return to expected productivity levels. Trusts need a policy environment in which targets for service recovery and objectives to reduce health inequality complement, rather than conflict with, each other.
- Evidence of the impact of recent measures taken to address health inequalities is still scarce. Where data collected by NHS England and NHS Improvement or Care Quality Commission reveal disparities in access and outcomes, there should be a defined outcome of such findings including clarity on what measures national bodies may take to ensure progress is made, and what further support may be offered to trusts and systems. There will be a need for data collected as part of new obligations on trusts to share metrics on their progress towards tackling health inequalities to be used to monitor impact and share learning on what works.
- The inclusion of health inequalities in the planning guidance and regulatory frameworks gives weight to the notion that health inequalities will be front and centre as the service rebuilds from the pandemic. New legislation, with its focus on collaboration between a broader range of partners within systems and at place level, appears to offer a genuine opportunity to create momentum. However, national leaders will ultimately need to set out a long-term framework for taking these actions further in a way that sustains improvements made in health inequalities.