Moving from silos to system improvement: what healthcare leaders want to see from the health disparities white paper

Background

Improving population health outcomes and reducing health disparities across the UK is a priority for the UK government. As trailed in the levelling up white paper, the health disparities white paper presents an opportunity to set out detailed plans to tackle the differential health outcomes experienced by different people and places, and to improve healthy life expectancy. The role of the NHS and its partners is central to the success of any plan to tackle health disparity.

The aims of the white paper:

1. To understand the nature and magnitude of health disparities that arise from preventable ill health.
2. How local and national system partners, such as the government, NHS, local authorities and ICSs can collaborate to tackle the drivers of health disparities.
3. To increase healthy life expectancy and reduce the gap in healthy life expectancy between areas and groups.

We welcome the Office for Health Improvement and Disparities’ (OHID) extensive stakeholder engagement to inform the white paper’s development. This included a joint OHID/ NHS Confederation roundtable, which enabled local health and care system leaders to meet the OHID team and the deputy chief medical officer. It provided an opportunity for our members from across the breadth of the healthcare system to understand the plans from central government, as well as providing an opportunity for OHID to test early ideas and explore local system contexts and actions required for effective implementation of their proposals. We look forward to engaging further on the translation of the white paper’s ambitions.

In advance of the white paper’s publication, this briefing lays out four key priorities that we are asking the government to consider.

The view from healthcare leaders

The central message from healthcare leaders during our roundtable was for government to build on existing knowledge of what works in improving population health. That is, bringing together all the determinants of health when addressing disparities. Their view is that a system-wide approach is fundamental and that this requires breaking down siloed (primary or secondary care) ways of working within local systems.

Healthcare leaders urged OHID to lever change not only from health and local government, but also across Whitehall and industry. Involving a wider group of stakeholders could incentivise partnerships and collaboration that can better place individuals and communities at the centre of health improvement initiatives. Leaders agreed that only this broad and inclusive approach could improve health outcomes and reduce health outcomes inequity gaps.

Health equity in all policies

What we want to see:

• An obligation for public bodies to judge the potential mental and physical health effects of policy, programmes and projects, with particular consideration of the impact on vulnerable or disadvantaged groups.

Up to 80 per cent of what affects both mental and physical health is from outside of the health system. A person’s health is determined by the broader environmental and social context they live in. The COVID-19 pandemic highlighted that this relationship is symbiotic: the broader context (for example, the education system, transport system, economy etc) also depends on the health of the population.

To improve health outcomes and reduce inequities, the white paper must mandate that all government departments consider (and justify) the differential mental and physical health impacts of their policies by producing health equity impact assessments.

The need to adopt a cross-Whitehall approach to reduce health inequalities is widely accepted. The NHS Confederation, as a member of the Inequalities in Health Alliance ² , a coalition of over 200 healthcare organisations, is calling for a cross-government strategy to reduce inequalities.

Including a recommendation to adopt a ‘health equity in all policies’ approach will ensure that the white paper looks beyond the health sector to consider the drivers of ill health and promote those of good health and wellbeing. Further, embedding this within the levelling-up agenda will help to shift the focus to a longer-term sustainability and preventative approach to policymaking, which accounts for future generations in terms of its mental, social, environmental, economic and cultural wellbeing.

Progress and enablers

There is precedent for this approach and, in this area, England and Northern Ireland are lagging behind Wales and Scotland, which have already implemented legislation requiring policymakers to follow a health-in-all-policies approach through enacting the Socio-Economic Duty from the Equality Act 2010. The Socio-Economic Duty requires certain public bodies, including but not limited to NHS organisations to consider how their strategic decisions might help to reduce the inequalities associated with socio-economic disadvantage.

This provision has been implemented in Wales in 2021 and Scotland in 2018 but has not been brought into force in England. Evaluation by the Equality and Human Rights Commission shows that public bodies are positively engaging with it, although research suggests more support is needed to ensure its effective implementation ³  . We are joining the Inequalities in Health Alliance’s call for the white paper to set out implementation plans for the socioeconomic duty from the Equality Act 2010, and to oblige health equity impact assessments of all strategic decisions made by public bodies.

Another approach to embedding health inequity considerations across policy areas could be through the Health Impact Tool, which is already being explored by the Department of Health and Social Care in relation to mental health. The COVID-19 mental health and wellbeing recovery action plan, published in 2021, committed to exploring ‘the development of a policy tool which allows policymakers to examine the impact of their proposals on mental health ⁴ ’. Using the Health Impact Tool to evaluate both the physical and mental health impact of policies would be an efficient approach and would avoid siloed thinking around physical and mental health.

The development of the government's ten-year, cross-government mental health and wellbeing plan also presents an opportunity to reduce health inequalities through a health-in-all policies approach. The NHS Confederation's Mental Health Network will be responding to the consultation on the plan, pressing the need for it to focus on groups most at risk of poor mental health, be outcomes-focused and be adequately resourced.

It is encouraging to see the formation of the Health Promotion Taskforce within the Cabinet Office, chaired by the Secretary of State for Health and Social Care, with a remit of driving a cross-government effort to improve the nation’s health, supporting economic recovery and levelling up. However, more transparency is needed on the progress of this taskforce on informing policy decisions across Whitehall.

Incentivise prevention

What we want to see:

• ICS governance and funding structures that incentivise prevention by allocating resource according to need and deprivation.
• Long-term integrated funding for evidence-based public health activities.
• Commitment to funding for primary care networks (PCNs) and their services beyond 2024.
• The use of structural and regulatory levers to create a healthy society, for example as suggested in the food and tobacco reviews ^{5   6} .

Investing in prevention at the earliest stage is crucial. For example, research shows that evidence-based parenting interventions are one of the most cost-effective interventions that can be made to promote mental health, prevent the development of mental health problems and physical health problems, given the strong link between the two. ⁷

The white paper must outline sustainable, long-term integrated funding programmes to address conditions with drastic inequalities in outcomes. These include health checks for cardiovascular disease prevention; sexual health services; and obesity and tobacco interventions. These interventions are supported by local public health teams and PCNs. However, the public health grant has been cut by 24 per cent in real terms per capita since 2015/16. During this time, inequalities in outcomes have continued to increase, and the healthy life expectancy gap is now nearly 20 years between the most and least deprived areas of the country ⁹ . In addition, PCNs are currently facing an uncertain future, with their funding currently not secured beyond 2024.

The recent Spending Review failed to commit to a real-terms increase in the public health grant ¹⁰  and soaring inflation rates (currently standing at 9 per cent) mean the Spending Review’s commitments represent a significant real-terms cut in funding. The white paper must reinstate real-terms funding increases at the level seen before 2015/16 to restore the crucial support offered by public health experts at a local level to address health inequalities.

The white paper must also include a commitment to funding for PCNs and their services beyond 2024. These services play a key role in the provision of upstream preventative interventions which begin in primary care.

Long-term funding for evidence-based public health interventions will allow local leaders to prioritise tackling health inequalities and shift the focus towards prevention and away from acute and crisis care. It is by shifting focus to prevention at population level, and applying system-level levers such as levies, nudges and taxes, that the underlying causes of health inequalities can be addressed.

Progress and enablers

Although many individual ICSs are working to tackle the upstream drivers of ill health and strategically prioritising reducing health inequalities, the goals of different parts of systems are often insufficiently aligned to prioritise early intervention and prevention.

The ICS structure provides a fresh opportunity for central government and local leaders to share power using a subsidiarity model whereby power is channelled in a flexible and dynamic way, rather than through pyramid-style top-down or bottom-up hierarchies ¹¹ . Via integrated care partnerships (ICPs), local leaders can ‘embrace community power’ and have a mechanism to coproduce services according to the priorities of their local communities ¹² .

The subsidiarity model of ICSs must be underpinned by clear principles for governance and funding that take into account deprivation. Healthcare and workforce funding should be allocated according to the principle of proportionate universalism, whereby resources are allocated to populations proportionate to the degree of need. In this way, the system will be set up to shift money towards preventative care instead of towards reactive or acute services.

Robust governance and accountability structures are required to enable collaboration between the organisations that will need to deliver change together, including the NHS; local and national government; industry; the voluntary sector; and academia. Among other key enablers, interoperable data and information systems are also essential to facilitate collaboration and enable learning to be shared across these partners.

In order to accurately allocate funding according to deprivation, the white paper must also outline its plan to modernise the Carr-Hill formula. This funding allocation formula has been used for almost two decades to allocate funding to general practices, but the GP Forward View published in 2016 found it to be outdated and in need of revision ^{13   14} . This revision did not materialise, and the Health Foundation reported that by 2020: ‘practices serving more deprived populations receive[d] around 7 per cent less funding per need-adjusted registered patient.’ More recently, at the NHS ConfedExpo event in June 2022, reform to the Carr-Hill formula was promised by NHS England’s medical director for primary care, but timelines have not been given ¹⁵ . The formula as it currently stands is not compatible with a whole-system approach that incentivises prevention. Therefore, the government must set out its proposals (backed by funding and evaluation) and act without further delay to reform the Carr-Hill formula so that funding is allocated consistently according to need and deprivation, across the whole system and across the whole country, equitably to tackle the elective backlog and reduce health inequalities.

The government must make use of the structural and regulatory levers at its disposal to create a society where the healthy choice is the easy choice for everyone, regardless of their socio-economic, ethnic or cultural background. These structural changes can in turn support preventative activities. For example, as outlined in the National Food Strategy Part Two, the government could incentivise the healthy choice and fund preventative activities such as providing low-income families with fresh fruit and vegetables, by enacting a sugar and salt reformulation tax ¹⁶ . Similarly, The Khan Review: Making Smoking Obsolete, suggested a polluter pays levy whereby additional taxes on tobacco companies would fund the additional investment required into stop-smoking services ¹⁷ .  The health disparities white paper must outline implementation plans for the salt and sugar reformulation tax and the polluter pays levy, as well as other preventative regulatory and structural measures and nudging policies, for example in areas such as alcohol control. This will incentivise prevention at every level.

Inclusive innovation, integration and access

What we want to see:

• Government to enable inclusive access to healthcare by closing the digital gap and providing ‘health on the high street.’
• Integrated patient data systems to flag high-risk individuals.

The COVID-19 pandemic accelerated progress towards the NHS Long Term Plan’s 2019 targets to increase the availability of digitally enabled care. For instance, remote consultations more than doubled from 30 per cent of all GP appointments pre-pandemic, to 70 per cent during the first lockdown of 2020 ¹⁸ . However, the change did not happen equitably. Around 1.7 million households in the UK do not have internet access ¹⁹  and digital services must be safeguarded against driving further inequality. To close this digital gap, the government must outline funding to provide internet to those without access, so that the benefits of a digital NHS are available to all ²⁰ .

Innovation must not come at the price of patient choice and remote care is not the only innovative mode of delivering care post-COVID-19. Providing health services on the high street creates a more easily accessible option in addition to remote care and traditional clinical settings, particularly for those with limited means or mobility issues. This initiative should be expanded with a focus on the country’s most deprived wards to improve access to services, while minimising travel costs and maximising convenience ²¹ .

The government must also set out its refreshed plan to engage the public and industry to implement a population health management approach to data, which begins in primary care. An integrated general practice dataset will provide a single, secure system to identify and protect high-risk individuals before symptoms begin, but previous iterations have been scrapped after industry experts flagged privacy flaws. In addition, a failure to meaningfully engage citizens from the outset of the project led to widespread public mistrust in the GDPR system ²² , despite many citizens feeling positive about their health data being used for innovation ²³ . The government must prioritise building trust through transparency and co-development with the public, if it hopes to achieve the benefits of an integrated general practice secure dataset. This will be critical to addressing health inequalities by targeting care to early clinical need rather than acute demand, and thus creating a health system with prevention at its core.

Progress and enablers

Equitable innovation will require a commitment to community co-production, as well as ongoing monitoring and evaluation. Meaningful partnership working with the voluntary, community and social enterprise sector will also provide valuable links into communities. Rapid outcome feedback loops must be developed to identify context-specific success factors and scalability.

Action on the cost-of-living crisis for communities

What we want to see:

• Cost-of-living support to be targeted to people with the greatest need.
• Tackle in-work poverty to improve health.
• A 4 per cent pay rise for the lowest paid NHS staff and a national care worker minimum wage of £10.50.
• Bespoke support for communities living in the most deprived areas of the country.

Low-income families face a double challenge of recovering from the COVID-19 pandemic and coping in the midst of a cost-of-living crisis. Inflation currently stands at a 40-year high of 9.1 per cent and energy bills rose by an average of 54 per cent this April. This has resulted in the number of working families in poverty hitting a record high.

The link between poverty and ill health is well-evidenced: for babies born between 2018 and 2020, the healthy life expectancy gap between the best- and worst-off areas of the country stands at 19.3 years for girls and 18.6 years for boys ²⁴ .

One in five Britons is currently struggling or unable to make ends meet, with 5 per cent (up from 1 per cent last year) often having to go without essentials like food or heating ²⁵ . Government support on the cost of living to date has been insufficiently targeted. For example, the Energy Bill Support Scheme, costing the government £15 billion, provides all domestic energy customers with a £400 grant towards energy bills. Better targeted support to those who need it most in our communities will be essential to ensuring that the resources are spent where they are needed the most, so that no one has to choose between eating and heating. Government interventions on the cost-of-living crisis must be targeted to those who need it most in our communities.

The NHS is the largest employer in Europe ²⁶ , and good work has strong links to improving health outcomes. We urge the Department of Health and Social Care (DHSC) to give a higher pay rise than last year to health service staff on the lowest full-time pay ²⁷ . NHS leaders want to see the Department of Health and Social Care commit to a 4 per cent pay rise for all NHS staff at Band 2 contracts (~£18,870 per year) and for staff on similar salaries in primary care, such as general practice receptionists.

This funding increase must be fully funded by government and is essential for two reasons: firstly, health and care staff must be protected from the worst effects of the current cost-of-living crisis. Secondly, failing to increase pay for those staff could lead to a mass exodus of vital support staff into better paid jobs in the private sector, exacerbating the existing health and social care staffing crisis and ultimately risking the health service’s ability to function.

Social care staff are crucial to a functioning healthcare system and must also be protected from the rising cost of living. Vacancy rates in the care sector are at 10 per cent, with staff leaving for better paid roles in other sectors ²⁸ . Healthcare leaders are increasingly concerned about the impact on the whole health system of workforce shortages in social care. We are calling for the immediate implementation of a national care worker minimum wage of £10.50 an hour. This has already been introduced by the Scottish government ²⁹ .

Progress and enablers

As anchor institutions (large organisations whose assets and value are inextricably linked to their local areas and communities), NHS organisations have significant roles to play in developing their local economies. Therefore, more bespoke support for communities living in the most deprived areas of the country could be achieved by the government reducing the bureaucratic burden associated with the Apprenticeship Levy. Each year, the NHS is forced to return over half of its levy funds. Empowering local leaders to use this money flexibly and with a widening participation approach will provide a cash injection into local economies and succeed in getting more people into good work, which is linked to positive health outcomes and has a protective effect on health.

As a short-term measure, following the pandemic, the COVID-19 Mental Health and Wellbeing Recovery and Action Plan allocated £15 million in 2021/22 for a Prevention Stimulus Fund for local authorities in the most deprived areas, to help stimulate and boost prevention, and early intervention mental health support services. Analysis of the funding is currently being undertaken, although the short-term nature of the funding means impact is difficult to measure. In light of the cost-of-living crisis, and the impact that this will have on mental health in the worst-off communities, we are calling on government to provide a long-term promotion and prevention fund.

Viewpoint

Through action on four key priorities, the health disparities white paper can tackle the increasingly disparate health outcomes experienced across the country to create the conditions for a healthier population, with no one left behind.

Health equity in all policies

Up to 80 per cent of what affects health – both physical and mental - is from outside of the health system, so if the white paper fails to outline a cross-government approach that looks beyond the remit of the Department of Health and Social Care (DHSC), its impact will be drastically constrained.

Incentivise prevention

Using structural levers will be essential to sustainably addressing health disparities in the long term. The white paper must incentivise integrated care systems (ICSs) to allocate resource according to deprivation. The government must make use of the structural and regulatory levers at its disposal, such as taxes and levies, to create a society where the healthy choice is the easy choice for everyone. The government must also outline its plan to reinstate real-terms funding increases to the public health grant at the level seen before 2015/16. Without regulatory levers that incentivise prevention, and proper resource for public health, the white paper’s plans to reduce health disparities will remain theoretical.

Inclusive innovation, integration and access

The COVID-19 pandemic opened the door to innovative modes of delivering services, such as remote appointments, but without action to ensure these reach the country’s most deprived areas and communities, they risk exacerbating inequalities. The white paper must set out funding proposals to ‘close the digital gap,’ and a strategy for the provision of health services on the high street, beginning with the country’s most deprived areas. The government must also set out its plan for a population health management approach to general practice data to enable prevention to begin in primary care.

Action on the cost-of-living crisis for communities

The COVID-19 pandemic, combined with the cost-of-living crisis, has pushed a record number of working families into poverty, which risks undermining any strategy to reduce health disparities. Government support on cost of living must be targeted towards those who need it most in our communities. In terms of health and care staff, DHSC must fund a higher pay rise than last year for healthcare staff on the lowest pay, and a national care workers minimum wage of £10.50 should be introduced immediately. The white paper must also encourage a flexible approach to the Apprenticeship Levy, using widening participation principles, to enable more people from disadvantaged or excluded communities to get into good work.