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Reflections on developing practical, system level approaches to health inequality

Bola Owolabi, Director of the National Healthcare Inequalities Improvement Programme at NHS England, spoke at Public Policy Projects’ (PPP) latest breakfast event.

By David Duffy

Responsible for setting the national direction for tackling healthcare inequalities, NHS England’s Healthcare Inequalities Improvement Programme seeks to create a “positive improvement culture” which uses data to develop targeted action against health inequalities.

Overseeing this programme is Professor Bola Owolabi, who joined PPP and an audience of senior health and care stakeholders to provide an update on progress to date. Clear from the conversation that unfolded is a desire to move from hyperbole towards targeted, practical actions and to develop system level approaches that will shift the dial on health inequalities.

Inequality of access


Within the purview of NHS England’s Health Inequalities Improvement team lies a critical distinction between social determinants of health and healthcare disparities. While social determinants contribute significantly to health inequalities (and therefore require engagement with a diverse range of stakeholders beyond the health sector), healthcare disparities reflect unequal access and experiences within the healthcare system. This central distinction that often goes missing from debates concerning health inequalities.

Health systems must strive to establish effective spheres of accountability in order to drive more equal access to services. Citizens should not be waiting longer on an NHS waiting list on account of a learning disability or because they do not speak English as a first language, and yet this is an all too frequent occurrence for citizens accessing NHS services. Integrated care systems (ICSs) must harness their system wide view of services to address unequal access to healthcare.

Long-term inequalities


Addressing long-term inequalities rooted in social determinants and economic inequality will require a long-term strategic approach. But while the NHS cannot affect these inequalities alone, it must at least demonstrate progress.

ICSs should leverage their role as conveners to bring together public service provision beyond health and care, as well as industry and local private business. The latter have an important and often understated impact – both in terms of the services they can provide to health sector, but also their direct impact on local health issues as employers and local stakeholders.

This essence lies at the heart of many of the published integrated care strategies – the need to move beyond reaction and towards preventative healthcare, by finally plugging the health and care sector into community assets. The NHS and ICSs should not be employers of last resort, but rather a network of resources and a convener of public service provision.

It is the responsibility of health providers to seize upon citizen’s interaction with health and care services, in line with making ‘every contact count’ (NHS England’s approach to maximising support for population health behaviour change).

Actionable data insights


Health and care must embrace the idea of virtuous circles of data, driving actionable insights from data, formulating meaningful interventions and iterating these approaches according to data-driven evidence. There is, at times, a sense that the sector paralyses itself with data analysis, but it must move into the business of deriving insight from data and then deciding how that insight informs action.

If health systems find themselves without access to the necessary data to drive insight, then the question must be asked: why? Ultimately, proactive efforts to address data gaps and enhance data capabilities are essential for NHS organisations to effectively drive insights and inform targeted interventions aimed at addressing health inequalities and improving health outcomes.

Incentivising action


Fundamentally, resources must be reoriented to drive meaningful action on health inequalities. Addressing cancer outcomes in more affluent areas, for instance, will only service to exacerbate inequalities further if simultaneous efforts are not made to improve access to cancer screening and treatment in lower income areas.

By offering incentives, clinicians can be motivated to prioritise underserved populations, leading to improved health outcomes across all demographics. These incentives could take various forms, such as financial bonuses, professional recognition, or enhanced resources for clinics serving marginalised communities. Additionally, performance metrics tied to reducing disparities could be used by ICSs to reward clinicians who actively work to bridge gaps in care.

This is central to helping to empower local clinicians and help reestablish their agency – they often have more influence than they realise.

System level impact


Achieving meaningful progress requires a systemic approach that transcends individual initiatives. Leadership plays a crucial role in driving this systemic change. This should be seen as distinct from debates concerning governance, which can too often become bogged down with internal system politics.

There is also a clear need for a regulatory environment that enables action on inequalities. Embedded into CQC inspection regimes should be a mentality that providers and systems cannot achieve an ‘Outstanding’ rating without meaningfully impacting health inequalities in their areas, and at the very least, addressing inequality with regards to access to and experience of services.

Education also plays a vital role, with curricula and assessments needing to integrate a focus on health inequalities to better prepare future healthcare professionals. Health inequalities should be built into the undergraduate curricula, with every royal college assessing undergraduate examinations and employers introducing health inequality assessment into regular appraisals. Health inequalities should no longer be targeted by a ‘coalition of the willing’, but rather embedded into every trainee’s portfolio.

Moving beyond inequality inertia


These are interlinked issues, of course, but for too long systems have siloed their efforts to excuse a lack of progress in other areas. Health inequalities are certainly not new and yet systems are still having this conversation on the fundamentals. All stakeholders must embrace their agency and spheres of influence to enact meaningful change.


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