Transforming health systems to reduce health inequalities

John Ford, clinical lecturer , A Sarah Sowden, clinical lecturer , B Jasmine Olivera, researcher , C Clare Bambra, professor of public health , D Alex Gimson, consultant transplant hepatologist , E Rob Aldridge, professor of public health data science , F and Carol Brayne, professor of public health medicine G

John Ford

A University of Cambridge, Cambridge, UK

Sarah Sowden

B Population Health Sciences Institute, Newcastle-upon-Tyne, UK

Jasmine Olivera

C University of Cambridge, Cambridge, UK

Clare Bambra

D Population Health Sciences Institute, Newcastle-upon-Tyne, UK

Alex Gimson

E Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK

Rob Aldridge

F Institute of Health Informatics, London, UK

Carol Brayne

G University of Cambridge, Cambridge, UK

Address for correspondence: Dr John Ford, Forvie Site, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge CB2 0SR, UK. Email: ku.ca.mac.lhcsdem@356fJ Twitter: @johnford1849

ABSTRACT

Never before in history have we had the data to track such a rapid increase in inequalities. With changes imminent in healthcare and public health organisational landscape in England and health inequalities high on the policy agenda, we have an opportunity to redouble efforts to reduce inequalities.

In this article, we argue that health inequalities need re-framing to encompass the breadth of disadvantage and difference between healthcare and health outcome inequalities. Second, there needs to be a focus on long-term organisational change to ensure equity is considered in all decisions. Third, actions need to prioritise the fundamental redistribution of resources, funding, workforce, services and power.

Reducing inequalities can involve unpopular and difficult decisions. Physicians have a particular role in society and can support evidenced-based change across practice and the system at large. If we do not act now, then when?

Introduction

For the first time in history we have the empirical data to witness a rapid compounding of existing inequalities due to the COVID-19 pandemic, particularly for lower socio-economic and minority ethnic groups. 1,2 In the UK, deaths in the most deprived areas are double those in the least deprived (age–sex standardised rate in the least deprived areas are 350 deaths per 100,000 compared with 669 in the most). 3 In the USA and UK, deaths are up to three times higher in minority ethnic groups. 4 The current crisis represents a syndemic pandemic; the intertwined, interactive and cumulative effects on health and wellbeing of the COVID-19 pandemic combined with substantial existing socio-economic inequalities across life courses and in communities. 2

Despite the policy prominence and various frameworks focusing on health inequalities, healthcare leaders still do not feel they have the skills and knowledge to reduce health inequalities. 5–9 The underlying reasons for this may include a failure of researchers to provide accessible evidence on how to translate evidence into practice as well as a lack of a systematic and logical approach to inequalities for healthcare systems. 10–12 Physicians have a particular role in society and can support evidence-based change across practice and the system at large. Here, we first discuss the current policy and research context, then argue it is time for a re-framing of inequalities within healthcare systems, with a concerted effort to build a long-term organisational change to tackle inequalities head on, along with a wider redistribution of resources, funding, workforce, services and power across healthcare and wider society.

Policy, research and legislative context of health systems in the UK

In England, for the first time, key national and local NHS decision-making bodies were required by law to address inequalities in access and outcomes under the Health and Social Care Act 2012. 13 This was the result of a growing body of literature showing sustained stark health outcome inequalities, dating back to the Black report, with inequalities in waiting times, patient experience and hospital admissions. 14–17 The Health and Social Care Act also shifted power from ministerial departments to NHS England with a decentralisation of decision making to local health systems. Despite the statutory responsibility, the years after the enactment of the Health and Social Care Act were dominated by reorganisation with considerable fragmentation of previously aligned services. Reforms were undertaken in the name of efficiency with poor evidence of their impact, rising costs to the health system and little progress on health inequalities, despite the clear negative health and wellbeing impacts of austerity and welfare reform. 18,19 Public health professionals classified the risk of this reorganisation to widen health inequalities as ‘extreme’. 20

In 2019, the NHS in England was asked to develop its own plans for a £20 billion funding injection. High-level policy objectives and initiatives were outlined in The NHS Long Term Plan and, in turn, local healthcare systems were asked to develop their own local response plans. 21 Health inequalities were a prominent feature of the national The NHS Long Term Plan among other priorities, such as primary care workforce, integration, prevention, cardiovascular disease and cancer. The plan set out to establish a ‘more concerted and systematic approach to reducing health inequalities’ alongside a number of specific inequalities initiatives such as supporting minority ethnic groups. However, the plan and its subsequent supporting documents failed to outline how local and national systems could systematically approach health inequalities with an expectation that local healthcare systems would each develop their own approaches. Our own previous research has highlighted that this is challenging for local systems, resulting in local plans being vague and lacking a systematic or joined-up approach. 12 Furthermore, the lack of a national health inequalities strategy (like that successfully pursued between 2000 and 2010) makes it harder to effect change across local health systems. 22,23

In response to COVID-19 inequalities data, NHS England and NHS Improvement (NHSE/I) published eight urgent actions to address health inequalities, including directives protecting the most vulnerable, improving recording, strengthening leadership and increasing preventative measures. 24

The structure of the NHS has moved substantially from its inception, through many re-disorganisations and, lately, the statutory bodies established under the Health and Social Care Act 2012. More recently, integrated care systems have been established, which are likely to merge with clinical commissioning groups. 25 It is likely that further health and social care legislation, under the advice of NHSE/I, will be passed in the near future to catch up with the organisational evolution. 26

Only 7 years after its formation, Public Health England (PHE) is already being disestablished. PHE was set up to protect and improve the nation's health and reduce health inequalities. 27 One action of the Health and Social Care Act was the extraction of public health skills from leadership roles within the NHS, something that was an obvious gap immediately after revealing a lack of understanding of the key role of public health leadership and skills in health and social care systems. This has become critical during the COVID-19 pandemic, as more public health leadership in the health and social care system may have improved the response.

Health inequalities have been a common thread across PHE activities. While trying work across organisational boundaries, these have included the provision of data on health inequalities, guidance, evidence-based tools for local health systems, advice to national government and focused action on inequalities in screening and immunisations. 5 , 28–31 PHE have particularly promoted a place-based approach to inequalities. 5 Under current plans PHE's health protection functions will be taken over by the National Institute for Health Protection, but the future location of the other PHE functions is still under discussion.

The research community has been driving forward the inequalities' agenda. The Academy of Medical Sciences published their report Improving the health of the public by 2040 promoting a health of the public research approach with a strong emphasis on health equity. 32 In response to this, the Strategic Coordination of the Health of the Public Research committee (SCHOPR) was established and has set out its guiding principles on population research, including a priority of focused investigation into how interdisciplinary research can reduce inequalities. 33 Furthermore, the Academy of Medical Sciences has recently written to the secretary of state outlining the need to prioritise prevention and improvement to reduce inequalities. 34

More recently, the Royal College of Physicians have convened a coalition of over 140 organisations to campaign for a cross-government strategy to reduce inequalities, the commencement of the socio-economic duty in the Equality Act and prioritising child health in public policy. 35

With the healthcare and public health reform afoot, inequalities highlighted due to the pandemic are thus high on the policy agenda, and a mobilised research community, it is time to rethink our approach to inequalities within and beyond the healthcare system. Without clarity, sufficient prioritisation and leadership any actions are at risk of only ever having a marginal impact.

Framing inequalities to ensure a systematic and logical approach in health systems

Framing is a way of structuring or presenting a problem and can be helpful, potentially vitally so, to ensuring action. 36 How we discuss and present inequalities must be developed with and for any audience it is hoped might contribute to effective changes; for example, NHS staff are more likely to engage if inequalities are framed around healthcare and the specific services for which they are responsible, such as inequalities in chronic disease management or non-elective admissions alongside concrete actions, rather than high-level more abstract health outcome inequalities, such as differences in life expectancy. 37 A lack of adequate framing brings risks. Focusing only on high level inequalities with healthcare staff, such as life expectancy, may lead to a sense of fatalism because these inequalities are primarily driven by geo-political factors outwith the influence of local health systems and their leaders; or a belief that downstream individual actions targeted at the social determinants of health will reduce inequalities. 38–40 In turn, these may lead to a health inequalities fatigue where motivation for action on inequalities wains due to short-termism and a perceived lack of progress.

A broad framing of inequalities highlighting how multiple different aspects of disadvantage lead to substantial differences in healthcare and health outcomes is needed to allow decision-makers to develop their own systematic and logical approach to doing what is within their power and advocacy to reduce inequalities. Without this systematic approach, there is a risk of an unequal focus on certain groups at the expense of others, such as focusing on the so-called ‘deserving poor’ at the expense of the ‘undeserving poor’. 41 Our review of local NHS plans revealed that systems focused more on people with learning difficulties and autism, but less so on undocumented migrants, people who are transgender or those with justice service involvement. 12 This creates inequalities within inequalities.

Inequalities must be framed and measured to include both healthcare (eg risk factor management, access, diagnosis, treatment and experience) and health outcome (eg morbidity and mortality) inequalities (Fig ​ (Fig1). 1 ). Key components across the spectrum of health and care include the distribution of health system resources (namely funding, workforce and research distribution, and training), access to and quality of healthcare, major drivers of mortality and morbidity (eg cardiovascular disease, respiratory disease, cancer, mental health and musculoskeletal conditions) and conditions which are intrinsically associated with inequalities (such as drug and alcohol abuse).