Healthcare should be equally accessible to all, but this is not yet a reality. In England, the gap in health inequalities looms large, laying bare a nation divided by access and outcomes. Official statistics show that in healthcare, a child born in the most deprived areas is still expected to live, on average, nine fewer years in good health than their counterparts in the wealthiest regions.
The pandemic intensified these disparities, with mortality rates from Covid-19 found to be 2.5 times higher in the most deprived areas compared to the least deprived. Health inequalities – defined as systematic differences in health status between different socio-economic groups – not only reflect societal injustices but also undermine the very foundation of public health principles.
Across the country, trusts are working hard to tackle these unjust disparities in healthcare and outcomes – and in many cases, are making vital progress. To support trusts' efforts, NHS Providers has published a guide for NHS board members.
We know the task of reducing health inequalities has never been more urgent. As well as being a moral imperative, it's a strategic necessity for the NHS – aligning with the legal duty to consider the health and wellbeing of people and the quality of services provided to all. NHS England's new planning guidance emphasises the need to tackle inequalities and focus on prevention in the year ahead, in line with the Core20PLUS5 approach.
There is also, of course, the strong economic case for tackling health inequalities: it leads to productivity and efficiency benefits for trusts by contributing to broader priorities such as reducing Did Not Attend rates and high demand in A&E, as well as promoting inclusive elective recovery.
NHS Providers' guide recognises that the causes of health inequalities are complex, with various social determinants – such as where people live, their education and access to employment – at play. Inequalities are also driven by the ways in which health services are designed, delivered, funded, and by the quality of clinical care received. The resource sets out a comprehensive framework comprising four key components: leadership, strategic focus, data analysis, and building capacity through public health expertise. Let's look at why these are important – and how trusts are implementing them.
Leadership: setting the tone for change
Since 2021, NHS England has required that all NHS trusts appoint a health inequalities executive lead. However, this is just the first step in establishing leadership and accountability.
Effective leadership at all levels is pivotal in driving change, with dedicated commitment across the board. This involves visible and engaged executive leaders who champion health equity and integrate it into the trust's mission, vision, and strategic goals.
Trusts should also establish robust accountability mechanisms to ensure that health equity remains a central focus. This means setting clear objectives related to reducing health inequalities, actively tracking progress, and leaders being held to account for achieving these goals.
Great Ormond Street Hospital for Children has established a dedicated health inequalities committee and steering groups that report to the board. With an executive lead and an operational lead overseeing these efforts, they're effectively advocating for change and collaborating with wider system partners.
Strategic focus: tailoring interventions to local needs
Where leadership provides oversight, accountability, and a culture of addressing health inequalities, strategic vision and direction provides a governance framework for delivering on commitments. Trusts should have a comprehensive strategy that explicitly prioritises reducing health inequalities and integrate it into all major strategies and operational planning.
Developing a specific strategy or plan on health inequalities – outlining clear actions and outcome measures – is key. The board should regularly review performance against the strategy and document progress in the trust's annual report. Practical delivery plans and governance structures should also be in place to support implementation, while health inequalities reporting should be firmly embedded in the governance structure, via committees that report into the board.
Central London Community Healthcare Trust has developed a comprehensive strategy on the back of data analysis and community engagement. The strategy is split into four campaign areas: access to services, workforce equality, understanding communities and their role as an anchor institution. There are then dedicated internal leads for each campaign area to drive implementation and ensure accountability. The trust also makes health inequalities part of everyday practice, including through practices such as mandatory staff training.
Data analysis: leveraging insights for informed decision-making
Trusts can boost efforts to reduce health inequalities through robust data collection and analysis. By collecting and disaggregating data based on demographic and socioeconomic factors, trusts can gain valuable insights into the nature and extent of health disparities within their communities. Leveraging these insights, trusts can make evidence-based decisions when developing and implementing interventions.
The Dorset Intelligence and Insight Service (DiiS) is an excellent example of this. The programme is a collaborative project set up to deliver a near real-time health and social care dataset – presented in easily digestible visual dashboards – across the Dorset Integrated Care System. DiiS is core to the system approach to population health management, with data analytics enabling the team to group the population by medical, mental health, demographic and socio-economic markers and therefore identify points of earlier intervention in a pathway.
This comprehensive approach, as demonstrated in the Altogether Better programme, provides actionable insights for addressing health inequalities. These include to support the delivery of better health and wellbeing outcomes for the local population to support proactive, as opposed to reactive, healthcare.
Building public health expertise: using dedicated knowledge and skills
Prioritising the training and development of the trust workforce in public health approaches is crucial. The NHS Long Term Workforce Plan commits to increasing the number of public health practitioners, including nurses, by 73% by 2036/37 to meet the ambition of delivering more preventative and proactive care. NHS Providers has previously published a framework setting out principles for a population health approach that can be taken by NHS provider organisations, working as part of an integrated health and care system.
By working closely with public health colleagues, The West Yorkshire Provider Collaborative draws upon trusted relationships across a wider area, meaning trusts can access additional support from public health agencies. This enables them to implement initiatives aimed at reducing disparities and target the factors that cause some people to experience significantly worse health.
Conclusion
Trusts are at the forefront of tackling health inequalities, with many making important progress using innovative strategies. As we have seen, prioritising leadership and accountability, strategic focus, data analysis, and building capacity through public health expertise, can lead to significant strides in reducing disparities in health outcomes. Embracing and further developing these strategies is vital to ensure equitable access to high-quality care for all individuals, regardless of their background or circumstance. Alongside NHS trusts' demonstrable commitment, we need to see a whole-government approach that includes a long-term strategic focus on addressing the wider determinants of health as well as prevention and early intervention.
This blog was first published by National Health Executive.
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