Policy and guidance documents

In recent years, there has been a growth in guidance on the role of the NHS in addressing health inequalities, from NHSE, CQC and external organisations. Some of these provide statutory actions that trusts must take, while others are recommendations of good practice. In this guide, we have collated actions relevant to health inequalities from within NHSE policy and guidance.

Operational planning guidance

In the first half of 2021/22 systems were asked to focus on five priority areas outlined in the NHSE priorities and operational planning guidance (NHS England, 2021a). These were distilled from the eight urgent actions outlined in guidance with respect to the ‘phase 3’ response to the Covid-19 pandemic.

The eight priority actions were refined into five priorities:

1. Restoring NHS services inclusively.
2. Mitigating against digital exclusion.
3. Ensuring datasets are complete and timely.
4. Accelerating preventative programmes.
5. Strengthening leadership and accountability.

These five priority actions on health inequalities should continue to be addressed by Integrated Care Boards (ICBs) currently. NHSE also states that trusts should have a nominated executive lead for health inequalities, while also implementing national initiatives such as Core20PLUS5.

The 2023/24 operational planning guidance states that ICBs and system partners should continue to address health inequalities and deliver on the Core20PLUS5 approach (NHS England, 2023b).

NHS Long Term Plan

Published in 2019, NHSE’s Long Term Plan provides a 10 year vision for NHS services, with actions and commitments required to provide “services fit for the future” (NHS England, 2019). The plan was developed by frontline NHS staff, patient groups and national experts. Chapter two of the plan sets out specific commitments to deliver “more action on prevention and health inequalities” - with a targeted focus on smoking, obesity, alcohol, air pollution, and anti-microbial resistance.

Core20PLUS5 for adults and children and young people

Core20PLUS5 is NHSE’s approach to reducing healthcare inequalities at a national and system level (NHS England, 2021b). “Core20” represents the population living in the most deprived quintile identified by the Index of Multiple Deprivation (IMD). Nationally, this represents 20% of the population, but the proportion will vary depending on the catchment area of the trust. ‘PLUS’ represents population groups who are at risk of social exclusion, such as inclusion health groups, and others sharing protected characteristics – this may include people experiencing homelessness, people with learning disabilities and people who may have language/communication barriers. 'PLUS’ groups should be defined locally, according to need. Lastly, ‘5’ represents five clinical priorities that require accelerated improvement. For adults these are: maternity, severe mental illness, chronic respiratory disease, early cancer diagnosis and cardiovascular disease prevention. For children and young people the five clinical priorities are: asthma, diabetes, epilepsy, oral health and mental health (NHS England, 2022a). The five clinical priority areas guide clinical focus, but the ‘Core20’ and ‘PLUS’ elements can be applied to all clinical areas.

There are specific clinical targets that ICBs are expected to reach as part of the Core20PLUS5 approach. ICBs are encouraged to create Core20PLUS5 Ambassador roles to embed the framework locally.

Statement on information on health inequalities

NHSE’s statement on information on health inequalities (duty under section 13SA of the National Health Service Act 2006) sets out the powers available to trusts around data, provides a list of data indicators that trusts will be expected to report on, and identifies opportunities for how trusts could make use of these data (NHS England, 2023a). The purpose of the statement is to help trusts and ICBs to identify key data and information on health inequalities and outline how they have responded to this information within their annual reports.

NHSE requires foundation trusts to include information on the extent to which it has exercised its functions consistent with the statement within their 2023/24 annual report (NHS England, 2024b) and this expectation will continue on an annual basis. It is expected that the legal duty on trusts to include information on health inequalities within their annual reports will encourage better quality data, increase transparency, and provide a tool to monitor improvements in reducing inequalities.

The statement prioritises a small number of data indicators and a limited number of expectations on how the information should be used - so as not to place a high demand on NHS bodies. These indicators are:

• Aligned to NHSE’s five priority areas for addressing healthcare inequalities set out in the operational planning guidance and Core20PLUS5.
• Already available on existing dashboards (or will be within the timeframe of the statement).
• To be disaggregated by a limited number of variables (age, sex, deprivation and ethnicity), where available.

Our NHS Providers briefing on the statement provides more information on the data indicators that trusts are expected to respond to in their annual reports (NHS Providers, 2023b).

Long Term Workforce Plan

The NHS is one of the largest global employers. NHSE’s long term workforce plan, released in 2023, sets out a strategy to grow, retain and reform the workforce over the next 15 years (NHS England, 2023c). This includes plans to:

• Increase the specialist public health workforce by 13%.
• Embed public health core skills and knowledge across the wider NHS workforce.
• Equip the NHS workforce with the right skills and knowledge to shift care towards prevention and early intervention.

The plan recognises the pivotal role of frontline staff, who engage in over a million patient interactions daily. Specific training goals involve enhancing capabilities in Making Every Contact Count (MECC), smoking cessation, the use of screening tools, and the recognition and care of individuals with co-occurring mental health and substance use conditions. Collaboration with local authorities and the promotion of relevant e-learning modules are crucial elements in achieving these workforce development objectives.

Equality, Diversity and Inclusion Improvement Plan

NHSE’s equality, diversity, and inclusion (EDI) improvement plan was published in 2023 (NHS England, 2023d). The aim of this plan is to improve EDI and to enhance the sense of belonging for NHS staff to improve their experience. The improvement plan identified six high impact actions for trusts, two of which are particularly relevant for this guide:

• Chief executives, chairs and board members must have specific and measurable EDI objectives to which they will be individually and collectively accountable.
• Develop and implement an improvement plan to address health inequalities within the workforce.

Equality Delivery System

The Equality Delivery System (EDS) is a system that helps NHS organisations improve the services they provide for their local communities and provide better working environments (NHS England, 2022b), while meeting the requirements of the Equality Act 2010 (UK Gov, 2010). The EDS was developed by the NHS, for the NHS, taking inspiration from existing work and good practice. An updated version of EDS was developed in 2023, which aligns with the NHS Long Term Plan and implementation is mandated for providers through the NHS standard contract (NHS England, 2023e).

The EDS consists of 11 outcomes organised into three domains:

1. Domain 1 – Commissioned or provided services.
2. Domain 2 – Workforce health and wellbeing.
3. Domain 3 – Inclusive leadership.

Actions within the EDS related to health inequalities have been included in this guide, but actions related to workforce have not.

Inclusion health framework

Inclusion health is an umbrella term to describe socially excluded groups, including:

• People who experience homelessness.
• People with drug and alcohol dependence.
• Vulnerable migrants and refugees.
• Gypsy, Roma, and Traveller communities.
• People in contact with the justice system.
• Victims of modern slavery.
• Sex workers.

Social exclusion involves extreme inequality and multiple interacting risk factors for poor health. Although there is limited data collection obtained regarding inclusion health groups, existing national evidence identifies various barriers in accessing healthcare services and multiple risk factors resulting in poorer health.

NHSE’s inclusion health framework, published in 2023, sets out action on inclusion health across the system (NHS England, 2023f). The key action for trusts is to ensure inclusion health groups can access the best possible healthcare.

Digital inclusion framework

The adoption of digital technologies by both patients and staff has significantly increased over the last few years, however the benefits are not yet accessible for everyone. Digital exclusion can compound health inequalities by exacerbating challenges with access to healthcare, skills and capability to navigate and use services, and the general resources needed to lead a healthy life.

NHSE’s digital inclusion framework, published in 2023, identifies the following groups as being at higher risk of digital exclusion (NHS England, 2023g):

• Older people, especially people over 75 years old.
• People in more socio-economically disadvantaged groups, such as people that have lower incomes or who are unemployed.
• Inclusion health groups.
• Disabled people and people with life-impacting conditions.
• People living in areas with inadequate broadband and mobile data coverage – more likely in rural and coastal areas.
• People less fluent in understanding the English language.

The key action for trusts is to consider and take steps to address the digital barriers to healthcare that some groups of people may face.

Advancing mental health equalities strategy

NHSE’s advancing mental health equalities strategy aims to provide systems and trusts with the tools they need to address inequalities in mental health services (NHS England, 2020). The strategy highlights actions and goals within the following areas:

• Supporting local health systems.
• Data and information.
• Workforce.

Implementation of the strategy is overseen by the Advancing Mental Health Equalities Taskforce at NHSE.

Patient and Carer Race Equality Framework (PCREF)

NHSE rolled out the Patient and Carer Race Equality Framework (PCREF) as mandatory for all mental health trusts and service providers in 2023 (NHS England, 2023h). PCREF provides an anti-racism framework for trusts to co-produce actions that reduce racial inequalities within their services. The framework supports improvement in three main areas:

• Leadership and governance.
• Data.
• Feedback mechanisms.

This framework is applicable to mental health trusts only.

Anchors and social value

NHSE have collated guidance and resources for NHS services to fulfil their function as anchor institutions within their local communities (NHS England, 2021c). Anchor institutions are large organisations whose long-term sustainability is tied to the wellbeing of the populations they serve. NHS services can deliver their role as an anchor institution through:

• Widening access to quality work.
• Purchasing for social benefit.
• Using buildings and spaces to support communities.
• Reducing environmental impact.
• Working closely with communities and local partners.

UCL Partners have developed an anchor institution measurement toolkit for NHS trusts and their partners to assess their current level of anchor related activity, with examples and case studies of anchor measurement in action (UCL Partners, 2023).

Equality and Health Inequalities Impact Assessment

NHSE have provided a template Equality and Health Inequalities Impact Assessment for NHS trusts to complete and use within their own services (NHS England, 2022c).