Taking action to address health inequalities is an emerging priority for NHS trusts and we recognise that each trust will be at different stages of their development. In this section, we outline what good may look like for a trust that has embedded reducing health inequalities as core board business, to offer a vision to aspire to. From our work with trusts, we know that progress is achieved through leadership, enabling a strategic focus on inequalities, taking a data-driven approach, and is supported by public health expertise. We recognise that there are barriers preventing trusts from progressing, including ongoing operational and workforce pressures, lack of dedicated funding, limited access to data and the need for join up across systems. This vision for what good looks like is drawn from existing examples of good practice from trusts and we hope that the objectives in this guide will enable trusts to start embedding the reduction of health inequalities as core business.


Health inequalities: leadership

Appointing a board level executive lead for health inequalities is a requirement from NHSE, but this is just the first step in establishing leadership and accountability (NHS England, 2021a). The board has collective responsibility for championing and overseeing the reduction of health inequalities.

It is expected that the executive lead for health inequalities champions the agenda across the organisation and board-level discussions. Their role is to work with the board to establish a comprehensive governance structure for overseeing the trust’s work and strategy on health inequalities. It is also expected that the executive lead is linked into broader system working on health inequalities, taking a proactive approach to collaborating with ICS and local authority colleagues, alongside VCSE and wider community organisations. The executive lead should be aware of regional and national work on health inequalities.

Addressing health inequalities should be viewed as part of core trust business and the board’s leadership on this should foster a positive culture across the organisation. All executive and non-executive board members should take responsibility for the trust’s work in reducing inequalities and feel confident talking about this work, in the same way that they would talk about finance, quality or governance. Executive directors should have specific objectives relating to health inequalities, as set out in this guide, which are supported by developing knowledge and skills through training.

Inequalities should be understood and considered across all aspects of the organisation and best practice should be shared and replicated across the trust. The trust might also consider being active in campaigning and advocacy around health inequalities and should consider its role as an anchor institution and the contribution it could make to the wider determinants of health.


Health inequalities: strategic focus

Where leadership provides oversight, accountability, and a culture of addressing health inequalities, strategic vision and direction provides a governance framework for delivering on commitments. Overall commitment to reducing health inequalities should be set out within the trust’s organisational strategy and feature in all major trust strategies, recognising that this is core business for the trust.

The trust should develop a specific strategy or plan on health inequalities, which complements the trust-wide strategy. This should outline clear actions and outcome measures. The board should regularly review performance against the strategy, and progress should be publicly documented in the trust’s annual report. Delivering the strategy should be a collective responsibility of the board, with oversight from the executive lead for health inequalities. Practical delivery plans and governance structures should be in place to support implementation. Health inequalities reporting should be firmly embedded in the governance structure, via committees that report into the board.


Health inequalities: analysis and interpretation of data

Trusts need the necessary systems and digital infrastructure in place to support enhanced data capture and reporting on health inequalities. Trusts could use electronic patient records (EPR), or equivalent systems, to capture relevant data on health outcomes, access and experience. EPRs should be optimised to support population health analysis and be well implemented to ensure that staff can use them effectively. They should use their digital, data and technology teams to provide organisational capacity on population health data recording, reporting and analysis. Data analysts need the relevant training to support their knowledge and understanding of population health.

Data should be routinely available by deprivation, age, ethnicity and other relevant protected characteristics, and clinical staff should have the knowledge and confidence to use data to better understand their services and address health inequalities. Frontline staff should also understand the importance of accurately collecting and recording demographic data. The organisation should be able to demonstrate marked progress in data quality and completion, especially around ethnicity recording. Training should be implemented where staff need to build skills in data capture and recording.

Health inequalities data should be routinely incorporated into trust board papers and reporting processes, with data broken down by inequality related characteristics (for example deprivation and ethnicity). Staff should also be able to access the data they need easily, to use these data to inform their clinical and operational decision-making. Accessible methods, such as health inequalities dashboards, should be available and understood by staff. Clearly defined and outlined metrics or measures should be in place to monitor improvements. There should be the knowledge and experience required to translate the data into intelligence, to inform data-driven decision-making within board leadership.

Trust-level data could be enhanced by data-sharing among relevant wider system partners, such as primary care, ICSs, academia and local authorities, to better understand the broader population health needs and the intersection between health outcomes and the wider determinants of health. Trusts could also be engaged in health inequalities research to drive innovations in fairer service delivery. Trusts who are mature in this area should triangulate data from numerous sources, including qualitative data from communities and service users. Most importantly, they should have several examples, evidenced by their data, of how they reduced health inequalities across their services.

Health inequalities: building capacity through public health expertise

Some trusts have found that employing a healthcare public health team within the trust ensures dedicated resource on health inequalities, prevention, and health promotion. The team could be led by a public health consultant, bringing together public health analysts, registrars and other professionals with relevant expertise and skills. There should be opportunities for role development and progression within the public health team, with staff being encouraged to progress into senior leadership positions. Ideally, there could be public health representation within the board, either via executive directors and/or non-executive directors. The team should be sustainable in the long-term, supported by dedicated organisational funding.

The public health team could build capacity for the trust to take meaningful action on health inequalities and bring expertise in data analysis and interpretation to ensure that the trust is guided by understanding the needs of the local population and identifying the inequalities in care that exist. In addition, the public health team could work with clinical and operational teams to develop interventions, actions and quality improvement processes within the organisation. This could involve providing outreach services to teams to conduct health inequalities impact assessments. The public health team could also assist in identifying training needs among the workforce and potentially facilitating the training and learning for other staff members.