Since the height of the pandemic, national policy development on health inequalities has moved beyond broad ambition, to measurable and actionable reality. Trusts and systems acknowledge the impact of COVID-19 on some of the most marginalised communities in England and are now taking steps to address these inequalities as part of the recovery task.

This shift in mindset is now being supported by a shift in policy direction. National leaders have recognised that to drive a wholesale change in the NHS’s approach to health inequalities, the underpinning infrastructure and funding mechanisms need to act as an enabler. By aligning the ambitions, objectives and responsibilities of trusts and systems so that no single imperative draws trusts’ attention away from the task of addressing health inequalities, systems and their component organisations can build on constructive relationships to meet this shared aim.

Measuring impact

Understanding and measuring health inequalities and the impact of COVID-19 on disparities in access to care lays the foundations for concerted action and improvement. The national bodies are committed to making a transformational change in the way health inequity is treated in the health service.

There will be a need for this to be underpinned by clear accountability at the right level. Where metrics collected by NHS England and NHS Improvement, or thematic analysis of health inequalities by CQC, identifies disparities in access and outcomes for populations facing health inequalities, there should be a defined outcome of such findings including clarity on what measures national bodies may take to support progress, and what further support may be offered to trusts and systems. Where progress is made, this should be celebrated and built upon so that the wider system can learn from what works to act on inequalities elsewhere. Without this, the potential of clear direction-setting by national leaders in key policy documents will not be fully realised.

Evidence of the impact of recent measures taken to address health inequalities, including commitments made in the long term plan, as well as shorter-term interventions to tackle inequalities in the wake of the pandemic, is scarce. There is a role for NHS England and NHS Improvement to monitor and report on national progress, support the sharing of learning about what interventions work well, and continue to provide an enabling environment for strong and effective collaboration at place, and the health inequalities improvement dashboard in development by NHS England and NHS Improvement will be pivotal in understanding the impact of the interventions set out in this report. It will take a consistent impetus and focus from all parts of the system to maintain progress, such that in several years’ time there will be evidence of sustained improvement attributable to initiatives being developed now.

Recommendations for national leaders

It will be necessary for national bodies to consider how ICSs will be able to prioritise tackling health inequalities, and what support will be available to trusts to make progress while continuing to manage the immediate operational pressures. The risk of confused accountabilities and its potential impact on systems’ ability to act effectively in partnership should not be underestimated – national bodies must measure the right outcomes at each level and set out clearly how these interact.

Policy frameworks, political imperatives, and funding streams must be aligned to enable a focus on health inequalities without financial or operational targets taking precedence. Interventions aimed at improving the financial or operational position should not be structured in a way that widens inequalities. National bodies should learn from historical evidence of how policy interventions to shorten waiting times, increase sustainability of services or control volumes of activity may have widened inequalities in the past, and act to ensure that the health inequalities impact of any new approach is positive.

Finally, the five key priorities developed by NHS England and NHS Improvement are a valuable starting point for a focused and intensive effort on health inequalities. They set out a clear course of action to begin embedding a health inequalities improvement approach into the COVID-19 recovery. The inclusion of health inequalities in the planning guidance and regulatory frameworks gives weight to the notion that health inequalities will be front and centre as the service recovers from the pandemic.