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

NHSE Inequalities

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:

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:

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.


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:

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.

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:


Here are the NHSE Actions with my 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:

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?

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