The NHS will have a better chance at tackling health inequalities if it does so with local government, other partners and communities. By David Buck

Joined up

As we all know most of the drivers of health and health inequalities lie outside the NHS, which of course is partly why the public health reforms gave more responsibility for public health to local authorities, albeit with the sting in the tail of an ever-shrinking budget. But that still leaves the NHS considerable influence on our health: who it treats, and how it does that has an impact on health inequalities.

Beyond this, through its economic size and its employing power it influences our health in ways many of us never think of. For example, the provision of free health care affects income inequalities, which are highly correlated with health inequalities. The Organisation for Economic Cooperation and Development estimated that through simply being free at the point of use the NHS narrows the income gap between those at the top and bottom of the scale more than any other public service.

The OECD estimated that through simply being free at the point of use the NHS narrows the income gap between those at the top and bottom of the scale more than any other public service

So when Simon Stevens talks about inequalities in health it’s worth listening. And, to be fair, he’s talked about it a lot. But in the past few years that’s been with a very specific focus – namely, how representative (or not) the NHS workforce is of the general population and how this affects patient care and outcomes as well as staff. While there’s a long way to go, there has been some really good progress in this area for which NHS England deserves a lot of credit.

But with inequalities in health widening, other worries on general life expectancy and the added impetus – perhaps – of NHS England’s new mandate – which states “NHS England must ensure commissioning focuses on measurable reductions in inequalities in access to health services, in people’s experience of the health system, and across a specified range of health outcomes, which contribute to reducing inequalities in life expectancy and healthy life expectancy” – he is taking a fresh look.

Scope for improvement

In my view this has been too long a time coming, but as a sign of intent it’s very welcome. There is not enough room here to go into detail about what NHS England could do to really make good on that intent, but here are some high level thoughts.

First, NHS England needs to turn the clock back and rediscover and repurpose all the work that was done under the auspices of the last Labour government in support of its health inequalities target – and work with Public Health England to do so.

PHE has refreshed some of that material but not the delivery support to make it happen. The approach was practical, powerful, cheap and systematic, and it was mostly about commissioning “the obvious” at scale and consistently across social groups, including diabetes, cholesterol and hypertension control and smoking prevention and cessation, in the context of local places.

It’s clear that the NHS will have a better chance at tackling inequalities if it does so with local government, other partners and communities

Critically, in retrospect, it also appears to have worked based on recent analysis of how inequalities in life expectancy fell in those parts of the country where the strategy was most active, compared to those where it wasn’t.

Second, we need to step back and think about the goals of integration. If you look into the bowels of the Health and Social Care Act 2012 you will find that the stated reason for the duty on the NHS Commissioning Board (now NHS England) to promote integration apart from improving quality is tackling inequalities in health. There is a very good reason for this. 

Despite the fact that we have known for years that the onset of multimorbidity and all its health and wider social consequences occurs 10 to 15 years earlier in poorer populations we have done little about it. In my view system leaders and commentators have all been collectively blind to this duty and to this knowledge. Surely tackling inequality should now be one of the core objectives of any integrated care system or sustainability and transformation partnership?

While the NHS picks up the costs of inequality and poverty, it can do much more than it thinks to prevent and mitigate them

Third, it’s really good to hear that NHS England is examining the Social Value Act and the role of NHS bodies as anchor institutions. This reflects a growing interest in understanding the social and economic power of the NHS and how it helps shape and influence the wider determinants of health, including poverty.

While the NHS picks up the costs of inequality and poverty, it can do much more than it thinks to prevent and mitigate them. In a welcome sign of a shift in thinking the NHS Confederation has been increasingly active on this issue, and the NHS can also learn much from local government.

And that brings me to my final point. It’s clear that the NHS will have a better chance at tackling inequalities if it does so with local government, other partners and communities. We have just published a short paper on how the housing sector can contribute to STPs.

So, as the NHS heads towards its 70th birthday, the gift I would give it would be the rediscovery and reshaping of its role in tackling inequalities in health. That’s about access to care based on need not ability to pay. But it is far more than that.