What do worsening health inequalities mean for the NHS?

This month, we published the second major report in our health in 2040 series. Based on current trends, our research shows that the 10-year difference in major illness-free life expectancy between the 10% most and least deprived areas of England will persist. 

Looking at ill health from early adulthood to old age, we project an increase in major illness across all age groups. Most of the increase in working-age adults living with major illness (80%) will be in the more deprived areas. This is clearly relevant to the current national policy debate about rising levels of economic inactivity linked to ill health.

But the implications of our findings extend beyond health and work. For the NHS there are three areas that particularly stand out: primary care, prevention, and financial and workforce planning. 

Primary care

There are five conditions driving health inequality: chronic pain, chronic obstructive pulmonary disease (COPD), type 2 diabetes, cardiovascular diseases and anxiety and depression. Most of these illnesses can be managed in primary care, at least in their initial stages. To do this well, primary care needs data, skills and capacity, with resources especially focused in more deprived areas. However, the ‘inverse care law’ means that the areas with the most need usually also face the greatest challenges in providing services such as GPs.

Funding for primary care was an explicit priority in the NHS Long Term Plan (2019), yet primary care now accounts for a smaller share of total NHS spending than was the case before the long-term plan. With the prevalence of these five health conditions only set to rise, it is critical that primary care is resourced and supported to deal with the increased demand, especially in deprived areas.

Prevention

While diagnosing and treating illness is important, the ultimate goal must be to reduce rates of illness in the first place. Over the last decade, the public health grant has been cut by 28% on a real-terms per person basis.  Post pandemic, while the waiting list for planned care makes headlines, the decline in performance for key prevention activities is also a major area of concern. For instance, childhood vaccination rates have fallen since their peak in 2012/13, fewer people are taking up health checks and cervical cancer screening rates have declined. These are among the most cost-effective services our health system can deliver, but in some well-established areas of prevention, we seem to be going backwards. 

Beyond these well-evidenced areas of prevention, our projections highlight that chronic pain and mental health conditions are set to increase substantially in the near future. The NHS will have an important role to play here, yet there are still big gaps in research and policy around prevention services for these conditions.

Financial and workforce planning

Our health inequalities projections clearly show that by 2040 more people will be living with major illness. Demand on health care services will increase, with more pressure on NHS funding and workforce. Our analysis of current plans for NHS funding indicates a planned real-terms reduction in total health funding compared with 2022/23, which will widen the funding gap between what is required and what is available. 

Beyond the current financial year, a new government will soon have an opportunity to set out a longer term, multi-year plan for NHS funding. To help inform that plan, we will soon publish projections of what trends in major illness would mean for demand for NHS care and finances. 

Likewise, how to staff the NHS is a big policy question that is not going away. By 2040, the number of people living with major illness will increase by 37%, but the working age population (from whom health care staff are drawn) will increase by just 11%. Over recent years, international recruitment has played a vital role, but the flow of health care workers is not just one way. Our recent analysis of nurse emigration highlights that for many international nurses, the UK may be a stepping stone to employment in countries such as the US, Australia and New Zealand. Labour-saving productivity gains, alongside effective policies to train and retain the domestic workforce, will be critical. We have just commissioned the University of Sheffield to look at the evidence on labour productivity.

Regional analysis is next on the horizon

Our health in 2040 series focused on England only (due to data availability). Because our projections did not cover the devolved nations, we could not provide a nuanced, regional picture of health inequality across the UK. This is what decision-makers have asked us for in order to make strategic and operational choices for better health across our cities, local authorities and integrated care systems. We will be addressing this gap in our future research programme, so watch this space.