Addressing health inequalities is vitally important for trusts in providing equitable access to services and ensuring patients receive the same level of care. The covid-19 pandemic sharpened policy attention on tackling health inequalities, including highlighting the role that the NHS could play. In January 2021, the National Healthcare Inequalities Improvement Programme (HiQiP) was established in NHS England (NHSE) to ensure equitable access to services and optimal patient experience and outcomes. Later that year, we surveyed trusts to gain an understanding of how trusts were responding to the shift towards a focus on health inequalities (NHS Providers, 2022a). We found that there were high levels of board commitment to tackling health inequalities, but that trusts were at different stages of rising to the challenge. In response, we launched our health inequalities programme to support boards in their role in reducing health inequalities.
Since then, evidence suggests that disparities continue to widen. Individuals living in the most deprived areas were more than twice as likely to wait for a year or more for their elective care treatment, in comparison to people in the least deprived areas in 2022 (Jeffries, 2023). They were also twice as likely to attend A&E in 2022/23 (NHS Digital, 2023). These inequalities in access are likely to have translated into poorer health outcomes for patients. For example, women living in the most deprived areas are twice as likely to die during pregnancy, compared to those in the least deprived areas, and Black women are four times as likely to die during pregnancy compared to white women (MMBRACE-UK, 2023). Recent data from the Office for National Statistics reveal declining rates of life expectancy in England (ONS, 2024), with deprivation associated with shorter life expectancy and less time spent in good health (Hiam et al, 2024).
There has been a positive increase in attempts to address inequalities within the NHS in recent years. The Health and Care Act 2022 ushered in a wave of reforms to the NHS, including new legislation for tackling health inequalities. The Act placed a legal duty on NHS bodies to have regard to health inequalities and to report on the extent to which they have met this duty each year (NHS Providers, 2022b). The Act also established integrated care systems (ICSs) as statutory bodies. Tackling health inequalities is central to NHSE’s core aims for ICSs – including improving outcomes in population health, tackling inequalities in outcomes, experience and access, and supporting broader social and economic development (NHS England, 2021a).
Expanding on this, NHSE have set out five strategic priorities for addressing inequalities, which have been carried through NHS operational planning guidance documents:
- Restoring NHS services inclusively.
- Mitigating against digital exclusion.
- Ensuring datasets are complete and timely.
- Accelerating preventative programmes.
- Strengthening leadership and accountability.
There has been a growth in guidance on health inequalities from both NHSE and external organisations – including the Core20PLUS5 approach for reducing inequalities (NHS England, 2021b) and the statement on information on health inequalities (NHS England, 2023a). However, research has shown that the extent to which national policies have been successfully implemented locally has been variable and challenging for trusts and ICSs (Alderwick et al, 2024).
NHS services are facing huge operational pressures – including financial challenges, rising demand and ongoing industrial action – which limit the extent to which trusts can prioritise action on health inequalities. The cost-of-living crisis has also increased pressure on trusts and impacted people’s health – in our 2022 survey, 95% of trust leaders reported that the crisis had worsened inequalities in their area and created significant challenges for NHS staff members (NHS Providers, 2022c).
Alongside this, government focus on tackling health inequalities has diluted over time. The Office for Health Improvement and Disparities (OHID) was established in 2021, following the restructure of Public Health England. At the time of launch, a key aim for OHID was to "co-ordinate central and local government, the NHS and wider society to promote improvements in the public’s health", including working with partners inside of government to address the wider determinants of health (Foley et al, 2022). In 2022, the Levelling Up white paper outlined the government’s commitments to addressing regional inequalities and committed to narrowing the gap in healthy life expectancy by 2030 (Department for Levelling Up, Housing and Communities, 2022). To meet this commitment, OHID was expected to publish a white paper on health disparities, which would enable the Department of Health and Social Care (DHSC) to "work with the whole of government to consider health disparities at each stage at which they arise" (Department for Levelling Up, Housing and Communities, 2022).
A dedicated, national plan on health inequalities did not come to fruition. Instead, action on health inequalities has been incorporated into DHSC's upcoming Major Conditions Strategy, which will be published in full later this year. The case for change and strategic framework – published in 2023 – outlined addressing health inequalities as an overarching aim across each of the priority areas, which are targeted at the health sector (DHSC, 2023). A cross-government plan for addressing health inequalities and the wider determinants of health would provide tangible steps to addressing the root causes of health inequalities, rather than short-term policy solutions that focus action within the NHS.
About our research
The themes in this report are informed by a recent survey of NHS trusts and ongoing conversations with trust executive leads for health inequalities (referred to as 'executive leads' in this report).
Our recent health inequalities survey provided an opportunity to reflect on the extent to which trusts have made progress in tackling health inequalities between 2021 and 2024. The survey was open between February and March 2024 and was designed for respondents to share their work on health inequalities, considering: approaches and actions taken, what is working well, barriers to progressing work, and the policy levers needed to enable trusts to take meaningful action. The survey was comprised of a mix of quantitative questions, and open text boxes.
We received 80 responses from 72 unique trusts, accounting for 33% of the provider sector (209 trusts in England). There were four respondents that had a position which covered two trusts. Of these responses, 34% were from Non-Executive Directors, 24% from chairs, 21% from chief executives, 4% from health inequalities specialists, and the remaining from other job categories. All regions and trust types - including acute, community, mental health and ambulance - were represented in the responses.
This report is also informed by conversations with NHS trust executive leads for health inequalities to capture rich qualitative insights. These conversations took place between August 2023 and March 2024. In total, we met with 39 individuals from 32 unique trusts – 24 of these people held board level roles within their organisation.