Quality improvement approaches to health inequalities, December 2022

Health Inequalities peer learning forum, held on 5 December 2022.

This interactive online peer learning forum explored:

Find the presentation slides here.

About the event 

In the pursuit of providing equitable healthcare services, it is important to recognise the relationship between quality improvement (QI) approaches and health inequalities. QI in healthcare has shifted from a focus on individual performance to a broader perspective encompassing systems thinking and patient-centered care. 

Despite QI approaches, there are still disparities in healthcare access and outcomes which stem from factors such as socioeconomic status, race, ethnicity, and geographic location. Designing quality improvement initiatives with a focus on addressing health inequalities ensures equitable access to care.

Tackling health inequalities requires targeted strategies within QI initiatives. This may involve focusing on vulnerable populations, improving cultural competence, enhancing health literacy, and promoting community engagement. Collaboration between healthcare professionals, policymakers, and community organisations is vital for effective interventions. By integrating health equity as a core principle in QI approaches, health inequalities can be mitigated. This approach ensures that every individual has equal opportunities to achieve optimal health outcomes, regardless of their social or demographic background.

Accurate and disaggregated data play a crucial role in identifying and addressing health inequalities. Prioritising the collection and analysis of data across diverse demographic groups helps identify disparities in healthcare access, outcomes, and patient experience. This information guides targeted interventions and policy changes.

By targeting health inequalities through tailored strategies, embracing health equity as a core principle, and leveraging data-driven decision-making, a healthcare system can be created that is both high in quality and equitable in its delivery. Incorporating these considerations into decision-making processes empowers leaders to shape a future healthcare system that ensures equal access to quality care and improved health outcomes for all individuals, regardless of their social circumstances.

Key themes from the event

This peer learning forum was aimed at those who contribute to or lead work on health inequalities in their trust. It offered an interactive discussion space to share the use of quality improvement as a mechanism for reducing health inequalities in services, and share actionable insights and improvement as a practical means to advance work in health inequalities through the means of QI.

Themes from the breakouts are outlined below:

Understanding the inequalities experienced by the local population through data analysis

In order to design QI responses to inequalities, delegates highlighted data as a key starting point for understanding the needs of the local populations that trusts serve. Data is vital for showing which groups require targeted interventions. This includes identifying the “plus” groups from NHS England’s Core20PLUS5 framework for reducing health inequalities, which could include groups that share protected characteristics or inclusion health groups.


There is a need for greater understanding within trusts about what data are needed to interpret local health inequalities. Linking data from multiple systems is a challenge – particularly for provider level data, ICS data and public health data. It was acknowledged that data can be deceptive, in that overall improvement trends for a trust can mask inequalities experienced by individuals or groups.


Delegates shared examples of good practice in data collection and reporting on health inequalities. In one setting, the trust appointed a multi-disciplinary team to analyse local data, including an analyst, health economist, data scientist and a matron. This allowed for in-depth discussions over particular issues, informing more personalised care. A different trust have produced a local “inequalities score” as a relative measure of inequality, which is used in their data analysis. It was recognised that what works for one trust may not work for another as every local context is unique.

Involving local communities in developing solutions

Hearing from local communities about their experiences of accessing services must sit alongside data analysis in order to understand the local health inequalities. Delegates shared that patient stories provide a powerful narrative and help increase understanding on certain issues, such as high DNA rates among groups from more deprived areas. Discussions explored the different ways that patient and community voice can be incorporated into service level change. This ranged from patient feedback forms to co-production of solutions with local communities.


There was agreement that patients should be involved, although a number of challenges were raised. This included how to appropriately and meaningfully engage with local communities in ways that avoid tokenism, over-consulting with the “usual suspects” and engagement fatigue among staff. It can be particularly difficult reaching those who are most likely to experience health inequalities, as their interactions with health services are typically reactive (via A&E departments). There may be specific digital barriers that prevent engagement with some individuals. Finally, there may at times be a conflict between patient need and business need.


Delegates stressed the importance of working in partnership with community-based organisations to effectively engage with local communities. A number of good practice examples were shared among the group. One trust has established a mental health and learning disability alliance of 200-300 members of the community, which has provided a sense of shared ownership for improving mental health in the local community. A different trust has adopted a peer-to-peer approach by using volunteers to ask patients why they aren’t attending appointments and feeding back issues around costs and transportation.  It was suggested that it would be good practice for patients to be routinely involved in the development of feedback forms and surveys to make sure trusts are asking patients the right questions.

Embedding a culture of understanding health inequalities across trusts

Delegates stressed the importance of embedding an organisational culture that recognises and prioritises health inequalities. This includes training staff to increase their understanding of health inequalities and what their role is in addressing the issue. It was suggested that clinicians have a duty of care to enquire about the wider determinants of health by making every contact count and asking patients about their wider lives, not just their health status. Examples of this included asking patients about transport costs for travelling to the hospital and asking about fuel poverty. It is important that staff are appropriately trained in having these conversations so that they know where to signpost patients to. Training to increase understanding should be available to all staff, particularly data colleagues who are responsible for reporting on health inequalities.


Alongside staff training, delegates recognised the importance of setting strategic priorities around addressing health inequalities. Although aligning trust priorities with the needs of the local population and the ICB priorities was identified as a challenge.


Delegates acknowledged that it takes time to create organisational change, especially when building relationships and networks around advocacy for reducing health inequalities. The following networks were recommended as useful for building relationships in this space:

  • The Q Network – a special interest group on QI and equity
  • Equality and Health Inequalities on Futures NHS Collaboration Platform.


There was an awareness among delegates that any health inequalities experienced in the wider community will be reflected among staff within the trust. Delegates discussed the impact of the cost of living crisis, which had increased levels of staff sickness. It is important for trust leaders to keep equity in mind when devising all-staff interventions or schemes, linking into the Equality Diversity and Inclusion (EDI) agenda. One trust has recently started providing mini health check ups for staff over the age of 40, via their public health team.

QI approaches for reducing health inequalities

Delegates recognised the value of taking a QI approach to reducing health inequalities. The QI methodology provides a solid staring point: designing the aim and understanding the problem, how to involve the community, how to measure whether something is working and how to standardise the intervention. However, delegates felt that national guidance was needed to support trusts in how to take a health inequalities approach to QI, alongside more examples of good practice. Examples shared among the group included using AI to identify patients and predict non-attendance, prioritising health inequalities within strategies and business plans, and developing a health inequalities toolkit.


Chair: Jenny Reindorp, interim director of funded programmes, NHS Providers