The NHS must set a mission to tackle growing health inequalities, with waiting lists growing faster in the most deprived areas.
The NHS is at a critical juncture. Lord Darzi, who was tasked by the government to conduct an 'immediate and independent' investigation of the NHS, highlighted growing waiting lists – currently over 6 million individuals – as a key part of the challenge. In response, the budget is set to provide an extra £25bn for the NHS, with reducing waiting lists a key priority for the cash injection. Alongside the three big shifts, the government has committed to returning to meeting the 18 week performance standard by the end of their first term. This is no mean feat - but is this policy missing something?
Health inequalities are growing. Individuals from more deprived areas, and those from ethnic minority groups, are likely to have higher levels of acuity and multi-morbidity. Waiting lists are increasing at a faster pace in the most deprived areas, rising by 55%, compared to just a third (36%) in the least deprived areas, and they may not be able to afford to wait longer. Existing levels of illness and broader personal circumstances impact upon an individual’s ability to "wait well", how they are able to navigate healthcare appointments, and the rates at which their illnesses deteriorate.
Yet conversations about waiting lists are largely focused on speed and volume – the bigger the reduction in the overall figure, the greater the success. Yet nearly 71% of trust leaders who responded to our State of the Provider sector survey think it is unlikely that the NHS will meet constitutional standards, such as the 18 week standard, over the next five years. Questions about fairness, equity and inclusion should not be overlooked in the haste to make progress. We cannot restore the nation's health and truly achieve a shift to prevention without improving outcomes equitably.
We can’t afford to simply talk about addressing health inequalities, without embedding practical actions to sustain real change.
Policy Advisor, NHS Providers
Strategically, the 10 year health plan can prioritise action on inequalities, placing it at the heart of policy-making. Specifically, NHS England's new upcoming plan on elective recovery is where we expect to see the detail. Both provide an opportunity to combine the dual aims around improving NHS performance and tackling health inequalities. There should be an inclusive approach to elective recovery, with more detail within the elective recovery plan on how systems and providers can prioritise this approach within the broader operational context. This would mark a step change away from addressing waiting lists via clinical need and time spent, to considering the wider impacts of waiting on specific population groups and re-prioritising lists by demographic factors – such as ethnicity and deprivation - alongside clinical need. This targeted action will ensure fewer individuals are waiting for treatment, more people are in good health and so able to work, boosting economic growth.
National prioritisation enables tangible change. While there was a post-pandemic push to adopt an inclusive approach to recovery, with NHS England urging action to reduce waiting lists at "an equal pace across all groups," the extent to which this has been prioritised over time has waned. Annual operational planning guidance documents have not set specific actions on inclusive recovery. The 2022 recovery plan mentioned a "fair recovery" and the need to understand variations but did not go further. The 2024/25 guidance for the elective recovery fund does not mention inequalities or inclusive approaches at all. This lack of national focus means that progress on inclusive recovery has been squeezed out by other priorities at trust and system level, such as meeting stretching efficiency plans.
Research by the King's Fund found that inclusive recovery has not been systematically prioritised among NHS trusts, citing operational issues related to data and analytic capabilities as key barriers. In a survey of NHS Providers members, only 50% of trusts indicated that they are considering health inequalities in their waiting lists. While there are examples of progress among trusts that have prioritised patients on waiting lists, such as using AI tools, we know that trusts are keen to learn from others about approaches they have taken, but the absence of national prioritisation prevents widespread action. Tackling inequalities can easily fall to the bottom of the to-do list, especially when there are many operational pressures facing trusts. But, an inclusive approach to waiting lists can, and should, be part of the solution.
There are indications that this approach may be filtering through. Latest announcements indicate that funding will be provided to the 20 NHS trusts in areas with the highest levels of economic inactivity. But this needs to go further and faster. We need to guarantee that every patient, from no matter what background, gets the right care.
At this crucial policy juncture, equity and inclusive recovery needs to be placed at the heart of both the 10 year health plan and the elective recovery plan – to ensure that all trusts can target their recovery work by deprivation and ethnicity. Trusts need clear guidance, funding and a framework for action to support them to take the necessary next steps. We can't afford to simply talk about addressing health inequalities, without embedding practical actions to sustain real change. Investing in tackling health inequalities now, will support the government's shift to preventing ill health and wider ambitions to drive economic growth in the long-term.
This blog was first published in Public Sector Focus on 18 December 2024.
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