COVID-19 had a rapid and significant impact on the health service, which had already dealt with several years of substantial annual rises in demand, outstripping growth in available resource. Although trusts continued to provide cancer services, and urgent and emergency care (including for mental health), from the beginning of the first wave and in subsequent waves, the pandemic has severely limited trusts’ ability to deliver elective and outpatient services.
The pressures created by COVID-19, and the need to reconfigure services, redeploy staff and delay planned care to enable the NHS to respond to the virus, meant that by May 2021, there were 5.5 million people waiting to begin hospital treatment (NHS Providers, 2021) – the highest figure since records began.
Within this backlog is an underlying picture of substantial inequality between those living in the most and least deprived areas. The Strategy Unit, for example, carried out analysis of the drivers of inequality in access to planned hospital care (May 2021). It found that rates of access to planned care overall are higher among those living in the most affluent areas. When adjusted for levels of need, however, activity was skewed towards the early stages of care pathways for the most deprived communities - for example primary care management – for each of four common conditions (chronic obstructive pulmonary disease, heart failure, arthritis of the hip and cataracts). Meanwhile, secondary care treatment including surgery was skewed towards the most affluent areas. In some cases, the report notes that levels of emergency hospital spells and deaths in hospital are higher among those living in more deprived areas and suggests that intervention earlier in the care pathway had not necessarily had the impact of reducing unplanned care.
Although trusts continued to provide cancer services, and urgent and emergency care (including for mental health), from the beginning of the first wave and in subsequent waves, the pandemic has severely limited trusts’ ability to deliver elective and outpatient services.
In exploring the drivers of this imbalance, the research found that the skew in type of activity between the most and least deprived populations emerged in recent years and may have been driven by policy initiatives introduced to improve or control access to secondary care treatments. Similarly, while waiting times reduced overall between 2000 and 2014, before starting to lengthen again, a disparity emerged wherein the most deprived areas had longer waiting times for elective care. The report suggests that policies which may disproportionately impact those living in the most deprived areas include referral management and lifestyle-based eligibility criteria, while waiting time targets and patient choice policies, as well as NHS-funded access to private treatment, may have disproportionately benefited the least deprived populations.
NHS England and NHS Improvement has, through a series of interventions over the past year, set out an expectation that the NHS will address this backlog with health inequalities at the forefront of its mind. For the first time, the planning guidance stipulates that people at risk of poorer outcomes due to the inequalities that they face should receive priority for treatment, setting the bar for how systems should use the concerted effort to reduce the care backlog as an opportunity to narrow gaps in access and outcomes.
Trusts are considering how to restore their services equitably and take advantage of opportunities to reduce inequalities facing those from deprived backgrounds, minority ethnic groups, autistic people and people with learning disabilities, and other protected characteristics. This includes carrying out analysis to identify disparities in access, outcomes and experience, and committing to narrowing these gaps through their prioritisation of their waiting lists.
While waiting times reduced overall between 2000 and 2014, before starting to lengthen again, a disparity emerged wherein the most deprived areas had longer waiting times for elective care.
National policy drivers
NHS England and NHS Improvement phase three letter - Urgent actions to address inequalities in NHS provision and outcomes
As the NHS began to plan its recovery from the impact of coronavirus, the letter setting out measures for the third phase in the NHS's response to COVID-19 (NHS England and NHS Improvement, 2020) in July 2020 set out urgent actions to address inequalities in NHS provision and outcomes. It asked trusts to work collaboratively with their partners on eight steps to restoring NHS services inclusively, and increase the pace of progress in reducing health inequalities:
- Protect the most vulnerable from COVID-19, by ensuring those who may be clinically extremely vulnerable to COVID-19 were identified and supported to follow shielding recommendations. This was underpinned by a call to consider risks associated with people’s protected characteristics and demonstrate their insight into the risks faced by their communities through population health management and risk stratification approaches.
- Accelerate their return to near-normal levels of non-COVID health services, with a focus on doing this inclusively, including supporting people with unequal access to diagnosis and treatment, with proactive outreach to those at risk. Monthly reporting will include measures of performance in relation to patients from the 20% most deprived neighbourhoods and compare service use and outcomes to develop metrics on clinical need, activity and outcomes to identify and address disparities between groups.
- Develop digitally enabled care pathways in ways which increase inclusion, including reviewing who is using new primary, outpatient and mental health digitally enabled care pathways.
- Accelerate preventative programmes which proactively engage those at greatest risk of poor health outcomes; including more accessible flu vaccinations, better targeting of long-term condition prevention and management programmes such as obesity reduction programmes, health checks for people with learning disabilities, and increasing the continuity of maternity carers.
- Particularly support those who suffer mental ill health, as society and the NHS recover from COVID-19, underpinned by more robust data collection and monitoring.
- Strengthen leadership and accountability, with trusts and systems asked to identify a named executive board member responsible for tackling inequalities.
- Carry out work to ensure datasets are complete and timely to underpin an understanding of inequalities, with a particular focus on the accuracy and completeness of ethnicity data.
- Collaborate locally in planning and delivering action to address health inequalities, including outlining in local plans how systems will: better listen to communities and strengthen local accountability, deepen partnerships with local authorities and the voluntary and community sector and maintain a focus on implementation of these actions, resources and impact.
These eight urgent actions are the underpinning for the national position on tackling health inequalities and restoring services inclusively. They lay the foundations for further action, including work to address challenges across the wider determinants of health and enhance prevention.
Develop digitally enabled care pathways in ways which increase inclusion, including reviewing who is using new primary, outpatient and mental health digitally enabled care pathways.
2021/22 operational planning guidance and elective recovery fund
Building on the actions set out in the Phase Three letter, the 2021/22 priorities and operational planning guidance (NHS England and NHS Improvement, 2021) identified five key priorities for trusts to focus on in the first half of the 2021/22 financial year. These develop the urgent actions from phase three and guide systems on how to embed them into their day-to-day operational working:
- supporting the health and wellbeing of staff and taking action on recruitment and retention
- delivering the NHS COVID-19 vaccination programme and continuing to meet the needs of patients with COVID-19
- building on what we have learned during the pandemic to transform the delivery of services, accelerate the restoration of elective and cancer care and manage the increasing demand on mental health services
- expanding primary care capacity to improve access, local health outcomes and address health inequalities
- transforming community and urgent and emergency care to prevent inappropriate attendance at emergency departments, improve timely admission to hospital for ED patients and reduce length of stay.
Among these, the guidance emphasises the importance of ensuring health inequalities are tackled throughout plans to address the longest waiters and working collaboratively across systems to deliver on these priorities.
The letter sets out how systems which achieve activity levels above the levels funded from core system envelopes would have access to the elective recovery fund (ERF). Acute providers need to meet 'gateway criteria', including addressing health inequalities, transformation of outpatient services, implementing system-led elective working, tackling the longest waits, and supporting staff.
The presence of a gateway criterion for health inequalities in the ERF 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.
However, the ERF has only been made available to acute providers, and so as systems take stock of the health inequalities across their patch, there is a risk of an undue focus on elective care recovery and focus on acute services when in reality all sectors face unique challenges and unprecedented levels of demand. It is crucial to recognise the complexity of the task of addressing health inequalities, particularly for people who may require support from multiple services, have mental health needs, receive care from community services, or who more frequently need ambulance services. The ERF is a non-recurrent pot of funding for a defined purpose and is therefore not a suitable long-term lever for permanent change in the way systems think about health inequalities. It does, however, have the potential to help galvanise a focus on health inequalities in trusts’ operating model.
It is crucial to recognise the complexity of the task of addressing health inequalities, particularly for people who may require support from multiple services, have mental health needs, receive care from community services, or who more frequently need ambulance services.
Opportunities and challenges
Trusts now have an opportunity to use the challenge of tackling waiting lists and high levels of demand to find, and address, disparities in access and outcomes for people who endure health inequalities. Trusts are asked to prioritise according to which groups of patients face the greatest inequalities, either in how long they have waited for care or who may be at risk of the poorest outcomes due to the broader inequalities they face. This will need to be balanced with an approach which ensures all those in the greatest clinical need receive care as a priority.
National leaders will need to consider the equalities impact of policies to improve access to elective care given the evidence suggesting previous attempts to do so have disadvantaged people living in the most deprived areas. With ICSs increasingly taking on responsibility for planning care according to population need, national leaders should bear in mind the impact of local decision making introducing the potential for variation across the country and how to mitigate against the risk of widening health inequalities while also adapting to meet local needs.
Trusts initially need a means of identifying these disparities (if they do not have them already), so they can understand the characteristics of their waiting lists, and identify any unintended consequences caused by how their services are designed. For example, patient data must be coded by their index of multiple deprivation (IMD), ethnicity, and other protected characteristics such as learning disability or LGBTQ+ identity so waiting list data can be analysed by those characteristics and disparities identified. Analytical capacity can be a barrier to trusts, with variation across the sector in how much analytical resource is available to attach IMD or ethnicity data. The planning guidance asks trusts to focus in particular on strengthening the robustness of their data, but the effect will take time to be seen in full and the availability of accurate, national level data for comparison may be limited until all trusts meet this target.
NHS England and NHS Improvement is developing a national health inequalities improvement dashboard to support systems to improve their intelligence on health inequalities in their areas, and some trusts have already identified ways of prioritising patients for care based on health inequalities data. For example, Calderdale and Huddersfield NHS Foundation Trust reviewed waiting list data and found “unexplained variation” in waiting times for surgery between different ethnic groups, and also took into account health inequalities faced by people with learning disabilities. In light of this analysis, the trust made the decision to prioritise people with learning disabilities and people from Black, Asian and minority ethnic backgrounds for elective treatment.
National leaders will need to consider the equalities impact of policies to improve access to elective care given the evidence suggesting previous attempts to do so have disadvantaged people living in the most deprived areas.
Trusts then need to understand where these disparities arise: a patient with a learning disability may be referred to a service in a more advanced clinical state than someone without, due to problems with the referral pathway which prevented them from being identified sooner, leading to worse outcomes. Similarly, people living in more deprived circumstances may find it difficult to accept elective surgery if they are unable to afford to take time off work prior to admission to self-isolate, causing them to wait longer.
When trusts have identified whether structural factors are influencing inequality among their patients, they can take steps to address those inequalities, as part of a wider system effort to tackle to wider determinants of health. Trusts are clear that this takes visible, committed leaders who are able to have important conversations with their service managers and consultants about how they can work as a trust to reduce inequalities when they arise. Trust leaders say that compassionate leadership and avoiding blame culture is fundamental to creating a shared understanding of the drivers of inequity in their services and make progress on these. It also requires robust and consistent capacity for the type of analysis required to identify inequities hidden within their datasets.
It will be essential for national policymakers to enable and support trusts and systems to prioritise this focus on inequalities. It will be particularly important to remember that improvement in this area may take time, slow down broader efforts to reduce the size of waiting lists or return to expected productivity levels or cost more. Trusts need a policy environment in which targets for service recovery and objectives to reduce health inequality complement, rather than conflict with, each other.