Tricky Times – tackling health inequalities in the NHS

Excelsior – with thanks to Henry Wadsworth Longfellow – haha!

Last year I wrote a blog which looked at how 3 Integrated Care Boards (ICB) had used ring fenced health inequalities funding. Following this the NHS Confederation asked me to undertake a wider review of a more representative sample – in the end this was 20 of the 42 ICB.

A team of us at Leeds Beckett University interviewed the Health Inequalities leads from each ICB.

The final report is here

Empathy with ICB

Health Inequalities is a wicked issue – it exists due to complex reasons to do with power, culture, prejudice and the economy. The situation is getting worse not better.

ICB have only been in existence for 2 years – so actions are not going to lead to a quick fix – so lets have some empathy for health inequalities leads in ICB. Their job was made harder when year two NHSE cut 30% of their management budget.

A strategic system level approach to address health inequalities is needed.

The funding we looked at was ring fenced in year one specifically to address health inequalities – and went into the baseline for subsequent years. £200m -sounds a lot – but it pales into insignificance against an NHS budget of some £168bn. The ICB have a duty to address health inequalities (highlighted in text here)  – it should be the case that ALL NHS funding is stress tested to take account of its impact on reducing inequality not just the £200m. In our interviews some respondents were clear – this health inequalities funding is a catalyst to help them influence the spending of this much larger allocation.

It was clear given the time pressures particularly in year one that health inequalities leads tried to get the money out of the door before the end of the financial year in the most responsible way possible. 

These decisions were made without an explicit overarching plan – the first Joint Forward Plan was only required to be produced by the end of the first financial year.

The real test going forward is whether this ‘catalyst’ funding model helped to bend NHS spend to reduce health inequalities more effectively – at this stage we just don’t know.

Third, Leadership is more important than ringfencing

Ringfencing really did not protect this funding. If a leader in the Integrated Care Board wanted to take the money to use it to pay off a deficit they could and in a number of cases did. We found that among half of our interviewees some or all of the money was used for purposes other than health inequalities. In some cases Health Inequalities leads never saw the funding at all – it was spent on deficits and never came to them.

More positively of course, half of ICB used the funding specifically to tackle health inequalities … so it is possible!

Cultural Change in ICB

Many ICB changed the governance architecture of the organisation – changing its culture through establishing high level accountable committees that usually reported to the Board. These involved wider stakeholders and were called things like population health and integration committees, health and equalities boards, population health management and health inequalities groups

NHSE still treats inequality as a second order issue

It was clear that the influence of NHSE is crucial here. Their top priorities remain things like hospitals performance in terms of finance, waiting times and service quality.

To paraphrase one respondent:

“We get must attend high level calls from NHSE holding us to account for our performance on topics waiting times or financial balance, we have never had a call from NHSE saying we want to speak to about your performance on reducing health inequalities”

This is not to denigrate the work of the NHSE National Healthcare Inequalities Improvement Programme led by Professor Bola Owolabi which was generally viewed positively by interviewees. Both for the development of the CORE20PLUS5 framework and for fighting for this catalytic funding.

Final thoughts

• Strong leadership in ICB is crucial to giving space to address inequalities
• Cultural Change such as changing the ICB Committee structure is essential to develop a shared analysis and action plan AND to empower ICB leaders take a different path to national priorities
• The real challenge is using the smaller health inequalities pot in a way that enables strategic change in the NHS system as a whole.

What do you think?