What can be done to close the gap in healthcare inequality and improve the overall health of the population? Paula Vasco-Knight and colleagues consider the way forward
Health inequalities describe the “unjust differences in health, illness and life expectancy” experienced by different people from different groups of society.
‘The NHS cannot address all the health inequalities alone. The wider social determinants of health are all important’
In England, people living in the poorest neighbourhoods will on average die seven years younger than people living in the richest areas. The challenge for us all is how do we work together to create a fairer society?
The NHS cannot address all the health inequalities alone. The wider social determinants of health − housing, income, educational attainment and access to green spaces − are all important.
A recent report by National Audit Office estimated that only 15-20 per cent of inequalities in mortality rates can be directly influenced by health interventions that prevent or reduce risk. If the NHS is to help tackle these inequalities then it must work closely with all government bodies, Public Health England, local authorities and other local partnership such as health and wellbeing boards, CCGs and providers; to ensure the effective coordination of healthcare, social care and public health services. But we must also ensure our services mitigate these inequalities, positively working to reduce them at every opportunity.
We are aware the NHS cannot be successful in its overall mission to improve the health of our population without developing successful interventions in advancing equality and reducing health inequalities. These issues are central to NHS England in its policies, processes and functions, ensuring that disadvantaged and socially excluded communities and groups are not left behind in the improvements that are being made to health access, experiences and outcomes for the population.
‘We need to ensure that NHS organisations are inclusive workplaces, which enable staff to thrive and develop within supportive environments’
More than that, the NHS must, as the Marmot review said, “reduce the steepness of the social gradient in health, [with] action [that is] universal, but with a scale and intensity that is proportionate to the level of disadvantage”. This is called “proportionate universalism”, which means that closing the gap in health inequalities requires outcomes for the most disadvantaged to improve faster than the most advantaged.
Despite different accountability structures and legislation for promoting equality and for reducing health inequalities, our approach brings together the linked equality and health inequalities agendas. As we all know, improving access to health services is as much about reducing health inequalities as it is about eliminating discrimination. This will necessitate examining the experience of services.
That some minority ethnic communities take longer to re-engage with mental health services should give pause for thought − especially when the persistent ethnicity related mental health inequalities are considered. Currently there are twice as many GPs in the affluent suburbs than in the city centres − where there is the highest deprivation, the greatest health challenges and the lowest life expectancies.
Most valuable resource
For many of our communities we can see lower access, worse experience and poorer outcomes achieved by healthcare services alongside greater rates of illness and premature mortality.
At the same time, we know that the NHS’s most valuable resource is its workforce. We need to ensure that NHS organisations are inclusive workplaces, which enable staff to thrive and develop within supportive environments.
“To drive advancing equality and reducing inequalities in healthcare to be as important as the 18 weeks targets to chief executive officers” is the objective of Paula Vasco-Knight, chief executive at South Devon Healthcare Foundation Trust and national lead for equality at NHS England. Since April, NHS England has taken forward its legal obligations to advance equality in accordance with the public sector Equality Duty of the Equality Act 2010.
This is alongside its duties in the Health and Social Care Act 2012 to reduce inequalities between patients, with respect to accessing their health services and to the outcomes achieved for them by the provision of health services. The act also places duties on the national body to ensure that health services are provided in an integrated way where this might reduce inequalities.
Drivers for change
Key drivers for change are currently shaping priorities. First, the draft national equality and health inequalities strategy sets out the vision and direction of travel on this important agenda. The strategy delivers to the NHS constitution through improving lives, listening and learning from the public, patients, carers and communities; as well as underpinning key outcomes and deliverables that support compliance with the Equality Duty and the Health and Social Care acts.
‘The core objective is to develop an NHS leadership which is inclusive and reflective of the communities we serve’
The strategy’s objectives focus on two key areas: patients (improving lives) and staff (leadership and workforce), in both equality of opportunity and health inequalities.
Extensive consultation and engagement over the past 18 months resulted in these objectives and build upon the key recommendations from the Winterbourne View report, the Francis report and Keogh reviews.
In September, the Commissioning Assembly reducing health inequalities working group, co-chaired by GPs Sam Everington and Matt Kearney, was launched. The group will focus on developing practical tools and resources to support CCGs to meet their legal duties to commission services in a way that reduces inequalities in access and outcomes.
NHS England will be working with the NHS Leadership Academy in taking forward its national strategy on equality, diversity and inclusion. The core objective is “to develop an NHS leadership which is inclusive, reflective of the communities we serve and the workforce we lead and which systematically removes barriers to participation in leadership for talented people from all backgrounds, ensuring everyone counts’’.
A key focus is to address “underrepresented groups at the most senior levels and system alignment and changes” through a twin track approach of creating the right climate for diverse leadership and leadership development, one which supports the development for leaders with the right mindset, skills and capabilities, in order to create inclusive and diverse organisations.
Recent analysis of black and minority ethnic representation on the NHS Leadership Academy’s leadership development programmes for 2013-14 highlights a small level of increase compared to previous years, yet this is just the beginning.
“This agenda will only work if we all pull together to effectively implement the work and create an NHS we all want to see,” is Dr Vasco-Knight’s call to action.
Dr Paula Vasco-Knight is chief executive at South Devon Healthcare Foundation Trust and national lead for equality at NHS England; Ruth Passman is deputy director for equalities and health inequalities, Dr Matt Kearney is a GP and national clinical advisor on equalities and health inequalities, Ranjit Senghera is senior manager for equalities and health inequalities at Inclusion Health; Dr Habib Naqvi is senior manager for equalities and Christina Marriott is senior manager for addressing health inequalities at NHS England.