There have been longstanding challenges in the way regulatory frameworks align with policy priorities. Trusts need an enabling regulatory environment to meet their health inequalities objectives. This should provide the right incentives to take the steps needed to reduce disparities and operate services in ways which help to reduce inequity in access and outcomes. Where financial requirements outweigh other objectives and are incompatible with wider system goals, ambitions which have not been embedded into regulatory models can easily fall by the wayside. To cement a long-term commitment to improving health inequalities as part of their 'day-to-day business', trusts will need a supportive infrastructure which measures and rewards progress on health inequalities as much as good operational and financial performance.

The impact of new regulatory models on health inequalities improvement

Care Quality Commission (CQC) published A new strategy for the changing world of health and social care in May 2021.The strategy outlines a commitment to supporting and enabling health and care providers and wider systems to reduce health inequalities within services and the wider population, for the first time. Running throughout is an ambition to improve people’s care by looking at how well health and care systems are working and how they’re acting to reduce inequalities. This marks an important shift in how CQC is thinking about its role as a quality regulator, including identifying progress and action on health inequalities as a key indicator of good culture, leadership and responsiveness to population need.

Similarly, NHS England and NHS Improvement’s new System oversight framework 2021/22 and accompanying metrics (2021) builds on their Integrating care paper and the intention for ICSs to focus on improving population health and tackling unequal access, experience and outcomes.. The new approach to oversight also aligns with the priorities set out in the 2021/22 operational planning guidance (NHS England and NHS Improvement, 2021) to address health inequalities in the first half of 2021/22. NHS England and NHS Improvement will take into account ICSs’ performance in tackling variation across the system and reducing health inequalities when it makes a decision about eligibility for entry into the highest performing segment, segment 1.


Trusts need an enabling regulatory environment to meet their health inequalities objectives. This should provide the right incentives to take the steps needed to reduce disparities and operate services in ways which help to reduce inequity in access and outcomes.


It is crucial that this focus on health inequalities within the new regulatory environment is supported by tangible metrics to ensure it does not unintentionally get side-lined by more immediate priorities and pressures that are easier to measure and quicker to improve. Some trusts have highlighted their concerns that while it is helpful to have this focus within their system boundaries, it can take years before changes have their intended impact and therefore it remains easier for regulators and local organisations to focus improvements on other measures, such as reducing waiting lists. NHS England and NHS Improvement’s system oversight metrics for 2021/22 include three welcome deliverables focused around preventing ill health and reducing inequalities:

  • restoring NHS services inclusively, measured at ICS, CCG and trust level
  • COVID-19 vaccination uptake for black and minority ethnic groups and the most deprived quintile compared to the national average, measured at ICS level
  • Ensuring datasets are complete and timely, measured at ICS, CCG and trust level.

These steps will help reassure providers that regulators intend to use this focus as a genuine opportunity to prioritise and address health inequalities. Alignment with the urgent actions listed in phase three of the response to coronavirus, and the planning guidance, offers helpful consistency in the national priorities. Measurement of these three outcomes at the relevant levels of scale provides a clear framework and incentive for progress, but the SOF aims to assess trusts against a wide-ranging set of outcome measures, and this creates a risk of conflicting priorities. Furthermore, where metrics are being assessed at multiple levels – for example at both ICS and individual trust level, it may ultimately become unclear who is accountable.

Most of the metrics relating to health inequalities in the system oversight framework will be assessed at the ICS level, with trusts asked to focus on restoring services inclusively and ensuring data is collected about patients’ ethnicity. Systems will be assessed on their progress to accelerate preventative programmes. Many of these are delivered through primary care but trusts will also expect to be asked by their systems to contribute – metrics which are being measured at ICS level will undoubtedly filter down to their component organisations as the unit of delivery.

There are still unanswered questions around the role of non-NHS organisations, such as local authorities, social care and voluntary organisations, as well as the independent sector partners supporting with the backlogs, which play a vital role in addressing the complex factors driving health inequality. Where regulators and national bodies need to make an effective judgement on the performance of ICSs and trusts in how they are addressing health inequalities, they will need to take into account the role of non-NHS organisations to ensure providers are not measured on outcomes that are not wholly within their control. It is, as yet unclear what intervention from regulators will look like where progress on health inequalities is insufficient.