At last! NHS England Report on health inequalities – but is it any good?

The NHSE board paper “Promoting Equality and Tackling Health Inequalities” is an important paper – it outlines NHS England’s obligations and strategic approach to promoting health and tackling health inequalities and it sets out the priority deliverables for advancing equality and tackling health inequalities.

I am only going to look at the outward facing elements of the paper – not those to do with NHS staffing Equality and Diversity issues.

Role of NHS England

The paper describes the NHSE role as threefold:

• a system leader
• a commissioner
• an employer

This is helpful – particularly the first point – I think that Clinical Commissioning Groups need to think of themselves in this way too – as local system leaders – not just as commissioners. This is expanded on later when it sets out the system leader role:

• collaborating with other parts of the health and care system
• convening debate
• brokering agreement
• holding up a mirror on performance to the whole of the NHS

Again, I find this confident description of system leadership really helpful – it is precisely the way in which Clinical Commissioning Groups will need to work at a local level if they are to make an impact – and if NHSE will let them! Old fashioned notions of achieving success purely through commissioning, tendering, contracting and performance management have utility but are not sufficient of themselves.

Inequalities

The paper recognises the persistence of inequalities in both health outcomes and service experience in two small sections (7 and 9) and gives some examples – in relation to geographical inequality, poor mental health, rough sleepers and lesbian, gay and bisexual people. It also makes reference to the variation in satisfaction by ethnic group. However, the paper does not place these examples into any wider framework to give a view about why such inequalities and injustice persist.

The paper makes no reference to the wider policy context for example:

• The impact of cuts to local government and social welfare
• Government intention to charge migrants for NHS services
• The impact of government re-calculation of the funding formula to give greater favour to areas with larger elderly populations at the expense of those with greater inequalities
• the impact of re-assessment of people with a disability to determine eligibility for Employment Support Allowance

Frankly its not acceptable for the key NHSE paper on health inequalities to ignore the impact of the current policy agenda on the most disadvantaged. As I have noted NHSE says that it is ‘the system leader’ here. Well, it needs to work out a way of honestly describing the policy context and its implications for addressing local need. If it cannot present a picture of the world that has some connection with the reality experienced at a local level then its plans will lack credibility.

NHSE needs to raise these issues in a way that recognises the challenge and helps the system navigate solutions and maintains its relationship with Government. I know this is hard – but pretending that this wider policy context does not exist is not the solution.

The report sets out a range of actions.

• Systematic adoption of the most cost-effective high impact interventions as recommended by NICE
• Diagnosing killer diseases earlier
• Improve access to health care for vulnerable populations
• Involve communities in design of services
• Integration of care and services
• Making every contact count – is this really still around? This seems to be one of those phrases that senior NHS and Public Health officials come out with when they are scraping around for a credible sounding action in a meeting.

What is the problem?

Where the paper is particularly poor is in setting out the reasons why the NHS continues to perform poorly in this area. After all this has been a concern for a number of decades – Julian Tudor-Hart – was talking about the inverse care law some 40 odd years ago and a range of agencies and institutions have already identified the challenges a number of which are mentioned in the National Audit Office Report that is mentioned in the paper.

I think some of the key ones are:

• Fewer GPs weighted for age and need in deprived areas – I would imagine this can be extended to other primary care services.
• Inconsistent quality primary care practice in deprived areas – including continued use of ineffective interventions.
• Poor relationships with patients from disadvantaged communities
• Poor integration of community based NHS services with other neighbourhood services be they VCS or Local Government

Actions

Here are the NHSE Actions with my comments:

• Robust and visible leadership…….. fairly obvious one this.
• Robust data – this will be made available for JSNA – nothing wrong with this, although we have much of this already – the Public Health Observatories have been doing this for many years. What would help though would be clear information on the quality of primary care services, range of services and level of investment per head at ward level.
• Resource allocation supports NHSE duties around inequalities – I have no idea whether the funding allocation agreed by NHSE England on the 18th of December 2013 is a clear indication  of commitment to this objective – can anyone enlighten me?
• Incentivise and prioritise improvements in primary care – these mainly seem to be financial mechanisms.
• Embed equality and tackle health inequalities in the CCG assurance regime – the main mechanism here is to develop a mortality indicator – I would have thought that a morbidity indicator is at least as important.
• Remove derogations that permit geographic variations in care standards – I have no idea how important this is – it does not feel that significant.
• Support the reduction of mental illness inequalities – I hope this does not get reduced down to trying to persuade people with a mental illness to stop smoking.

Comments

These actions  feel rather narrow, transactional and traditional – basically lets drive change through gathering information, tweaking funding allocations and performance management.

They ignore the need for energy, the need to share promising practice quickly, existing innovation and local diversity. I think we need actions that:

• support local leaders to drive and participate in powerful active programmes that share learning and experience with local government and the voluntary and community sector.
• help to develop coherent models of good practice at a neighbourhood level in disadvantaged communities and I think that the expertise for this is just as likely to rest in health and social care trusts, local neighbourhood organisations and local government as it is with CCGs.
• encourage dialogue and debate about what good might look like locally

What next

I think Clinical Commissioning Groups and Health and Wellbeing Boards need to take up NHSE on its commitment to debate and invite its officer to their meetings to consider the question “are the actions that NHSE have outlined here really the ones that are going to help take this agenda forward?”

What do you think?