The Integrator: Cutting the right things

Integrated care boards are challenged to do more to prioritise health inequalities, despite growing budget pressures, in a couple of timely new publications.

In particular, one report, from the national network Locality, along with Leeds Beckett University and researchers Social Life, says local community organisations are still usually “missing in health and wellbeing strategies” and the health system planning process. 

They highlight how such organisations must be key to improving health inequalities – ie improving outcomes at the bottom – because of their trust in and understanding of communities where these are often lacking. It was a lesson trumpeted in the covid vaccination drive, where religious groups in particular promoted uptake, but which is seemingly difficult to land elsewhere.

Community organisers report projects which have been predesigned by others and then “parachuted” on to them; “insufficient, inappropriate, and short-term funding and reporting mechanisms”; and community organisations having to subsidise public contracts. 

ICB leaders generally understand that their partnerships, including beyond statutory usual suspects, are pretty much the reason they exist, and, in most cases, they’ve put a lot of effort into reaching out. Many of them tell me they’re doing more – and planning to spend more – with voluntary, community and social enterprise organisations.

There’s also no shortage of examples of health initiatives aimed at targeting communities and seeking to work with them, to improve health (the Locality report shares some examples itself). 

That so many are still citing problems perhaps reflects the sheer scale of the work and cultural gaps; and of expectations on the NHS behemoth, which is pretty well resourced in relative terms, to do better.

ICBs would argue they’ve also been hindered by the seemingly relentless organisational turmoil, which is ongoing, and other priorities on their plate. It makes the case for giving them space and time to bed in.

Funding squeeze

But the barrier of tight finance is only going to get tighter for the short to medium term. The other recent report – from the NHS Confederation, also with Leeds Beckett – found half of ICBs in 2022-23 were effectively raiding what was meant to be a dedicated health inequalities funding pot, to help balance their books.

The report itself states: “There were some cases where the health inequalities lead had not been involved in the decision to use the funding to address deficits elsewhere in the system – usually acute or elective hospital care.”

My colleague and finance correspondent Henry Anderson adds: “Speaking in private, finance chiefs said they often have little choice but to do this, and that NHS England has turned a blind eye to the practice.”

Since 2022-23 was a time of plenty compared to 2024-25, prospects for those pots this year must be dire. Nearly all systems are now looking for drastic savings, including cash-releasing cuts to fund growing costs elsewhere.

Realistically, in this situation, mitigating health inequalities might be more about targeting cuts in the least bad place, rather than dwelling on scanty investment pots.

Often the right decisions in terms of value and fairness will be the most difficult and noisy, drawing the most resistance, both inside or outside the system. Engaging communities could make for better decisions (and make the case for them), but time will be tight.