This article was first published in Healthcare Leader on 25 May 2023.
Can you give an overview of the current state of health inequalities in England?
Health inequalities in England were already stark before the COVID-19 pandemic, and the impact of the rising cost-of-living on people’s mental and physical health risks increasing them further.
The COVID-19 pandemic brought increased public awareness to these unfair, systematic and avoidable differences. People from minoritised ethnic groups and those living in neighbourhoods with greater levels of socio-economic disadvantage were more likely to get seriously ill or die from COVID-19. The impact of the pandemic, both directly and indirectly, was greater for people from minoritised ethnic groups, children and older people, people on lower incomes, and disabled people.
The rising cost of living means rising rates of poverty. Around eight children in a class of 30 are being brought up in poverty. Poverty in communities means cold homes, means skipping meals and taking the cheapest route to feeling full – often high fat, salt and sugar foods. This, of course, has a negative effect on health. And ‘money worries’ isn’t just a glib turn of phrase – cost of living pressures are having a significant impact on the nation’s mental health, too: one in four adults living in the most deprived areas of England are experiencing moderate to severe depression.
The term ‘health inequalities’ has become more prominent in policy in recent years. Why is this?
General practice clinicians have long seen the effects of the social determinants of health in the patients that arrive in their surgeries. Factors like where we were born, where we work, the neighbourhood where we live and the air we breathe – all of these contribute to our health. This is health inequalities in action – the unfair, avoidable and systematic differences in health between different groups of the population.
…it’s not just our individual choices that guarantee how healthy we are
Now, it’s not just clinicians who understand this. The unequal impact of the COVID-19 pandemic laid bare to the public, the press and to policymakers across the political divide, that it’s not just our individual choices that guarantee how healthy we are. Many of the levers to create a healthy society rest with government and policymakers from across Whitehall. For example, taxing high fat, salt and sugar food to subsidise nutrient-rich options; supporting active travel; and implementing air quality regulations.
The NHS Long Term Plan has reducing health inequalities at its core, and primary care networks (PCNs) form a key part of this as the ‘building blocks of ICSs’. Lots has happened since 2019, but the aim and direction of travel is laudable. We need to make sure we don’t lose momentum, keep what has worked well (such as PCNs) and continue to translate policy into action.
Does that reflect a real impact for patients?
Translating policy ambitions into real impact for patients is critical. In fact, it’s the whole point. For example, the NHS Long Term Plan (2019) outlined plans to support smoking cessation in pregnancy, given the extensive evidence on the harms for mothers and their babies. In the year after the plan’s publication, smoking rates at the time of delivery dropped fastest in the most deprived areas in the country – showing that the approach was targeted where it was needed most. To meet the plan’s ambitions, targets need to be supported by adequate long-term funding.
Reducing health inequalities isn’t only about creating impact for ‘patients’, but about creating health across the whole of society – before people even become patients
Reducing health inequalities isn’t only about creating impact for ‘patients’, but about creating health across the whole of society – before people even become patients. So preventative activity that stops people from becoming patients in the first place is just as important in tackling health inequalities. A health in all policies approach across government will be critical to creating a healthy society and preventing ill health.
How important is primary care in addressing inequalities in access?
Firstly, I would like to thank GP colleagues for their work in delivering care up and down the country, especially under the incredible strains the NHS has faced in recent months.
We know that primary care does not cause inequalities in access in the same way that a hospital doesn’t cause inequalities in access
We know that primary care does not cause inequalities in access in the same way that a hospital doesn’t cause inequalities in access.
Primary care is the front door of the NHS. Many patients access the NHS through primary care and that’s why primary care has a key role in identifying and working to end health inequalities.
Primary care can address the barriers to access that are within its control, like the rest of NHS. Outreach initiatives during the vaccination programme, which primary care administered 70 per cent of, prove just how effective primary care can be when empowered and enabled to care for its patients.
These barriers can be split into two groups. One being that barriers that occur prior to interaction with an NHS service include their circumstances, such as insecure employment, meaning they are unable to take the time off work to attend an appointment or pick-up a prescription during standard hours. Some areas are also underserved by doctors, including more deprived and rural areas, which makes it comparatively more difficult to access primary care. Primary care has no control over the cause of this but can help address the barriers to access, for example, opening weekday evenings and Saturdays, which has been rolled out across England by PCNs since October or having secure lockers for picking up prescriptions 24/7, such as in Peterborough.
The government can address issues with the funding structures that lead to some areas being under-doctored and/or provide incentives for doctors to work in these areas.
Finally, the second group of barriers is what occurs when the patient has made contact with the service. This can include the channel, such as telehealth versus in-person. What is a barrier for one person may be a convenience for another. For example, younger people are broadly more comfortable with remote consultations, but some young people don’t have access to the requisite devices. Older people, in general, prefer in-person consultations but older people are more likely to be housebound. The other barrier is the sheer demand for services, which people experience equally, and means people can’t access services.
Primary care has some control over the first of these. We know that one size does not fit all so we need to have multiple options available, like remote and in-person services and adequate home visits provision.
In the face of falling GP numbers, we’ve been consistently calling for investment in primary care capacity. It is good to see additional roles reimbursement scheme (ARRS) roles in place, but we need it to equip primary care with the training and technology to ensure we can make the most out of them.
Are PCNs the best vehicle for addressing health inequalities in primary care, or is there a better way?
We know that the only way to get a grip on addressing health inequalities is when we have addressed capacity issues. The longer they continue, the worse health inequalities will become.
The rising demand and declining GP numbers mean that primary care needs to work together to benefit from economies of scale and have a better chance of meeting demand.
Primary care networks are one example of this, federations are another, as are primary care provider collaboratives and networks of networks. A merger of two practices is even an example of this.
We cannot say something is the ‘best vehicle’ without knowing what the other options are but PCNs were introduced with an objective of addressing health inequalities. Since 2019, when they started, they have contended with a lot of extraordinary events – pandemic, vaccination programme, rumours about their future when they’ve barely been given the chance to start, but they have achieved a huge amount in this time. Their services are up and running, thousands of ARRS staff are in place and they led the vaccination programme, which did a great deal to reduce health inequalities and their outreach initiatives, from buses to everyday conversations, were remarkable. They have a lot to commend them.
What is expected of general practice in regards to health inequalities?
PCNs are the vehicle with the objective of reducing health inequalities and general practice is expected – not mandated – to be a part of one. A specific PCNs service is Tackling Neighbourhood Health Inequalities, which excellent progress has been made against, especially with annual physical health checks for those on the learning disability register.
We need to go back to those core aims and learn from primary care about what works and what does not
Future contracts must give PCNs the ability to focus on what matters for their communities and what primary care does best – caring for their patients in their communities. A lot has happened since the NHS Long Term Plan and primary care networks were first introduced. We need to go back to those core aims and learn from primary care about what works and what does not.
Reducing health inequalities is a tall order with the social determinants being a large factor(s) in outcomes. Not a single part of the NHS nor the NHS itself can reduce health inequalities. This means that all parts of the NHS must work together with the aim of reducing health inequalities – secondary care can’t expect primary care to be solely responsible and vice versa. ICSs provide an opportunity to work together towards the aim, as well as to deliver on ICSs’ fourth purpose, which can have a great impact on the nation’s health, which our recent work with the IPPR Health and Prosperity Commission demonstrates.
What about the NHS at-large?
The NHS has a key role to play in reducing health inequalities. One of the four core aims of integrated care systems is to tackle inequalities in outcomes, experience and access. ICS leaders are committed to tackling inequalities and recently published their strategies which included their actions to tackle health inequalities.
While health inequalities are present across the country, often they are defined at a super-local level and require highly targeted approaches. For example, the NHS trust in Lewisham and Greenwich used a population health management system to identify patients at-risk of developing type 2 diabetes in near real-time using data from primary, secondary, community and mental health care. They identified and tested these at-risk patients and offered support; both to reduce the risk of developing diabetes, and to manage the conditions of those that received a positive diagnosis. Lots of innovative work to tackle health inequalities is happening across the NHS within primary, secondary, community and mental health care.
Is the NHS sufficiently focused on reducing inequalities among those it serves?
When I speak to NHS leaders, I hear resoundingly that they are focused on and committed to reducing inequalities.
The NHS alone cannot ‘solve’ health inequalities – central policy change is needed, too
The NHS alone cannot ‘solve’ health inequalities – central policy change is needed, too. NHS leaders were looking to the health disparities white paper to address the national, structural causes of health inequalities. This white paper was shelved last summer, and has now been folded into an upcoming major conditions strategy. To address health inequalities, NHS leaders are clear that the major conditions strategy must address the drivers of inequalities across people’s life course in the conditions, such as racial inequality and socio-economic deprivation. It must outline a preventative approach and cannot narrowly focus on treating the conditions once they have arisen. This will require a cross-government ‘health in all policies’ approach.
Also, policy needs to be translated into action and this requires capacity. At present, primary care – and all across health and social care – demand is outstripping supply. It’s difficult for the NHS, both management and clinicians, to do what’s needed to help reduce health inequalities when they’re understaffed and demoralised. In primary care, the annual increase within the GP Contract is nowhere near inflation while investment – and permissions – to improve estates have not been forthcoming. A fully funded workforce plan and investment that at least keep pace with inflation, as well as vital capital investment would help alleviate these pressures. As well as this, paying a premium to GPs working in a challenged area, as well as covering all training exam costs with GPs expected to work in the NHS minimum of three years in return or pay back exam and practice training in full. This in turn would help retention and the recruitment of GPs and relieve a lot of pressures primary care currently face today.
Victor Adebowale is chair of the NHS Confederation. You can follow Victor on Twitter @Voa1234