Key points

  • Health inequalities in England are vast and growing. Government has committed to ‘levelling up’ the country as it recovers from the pandemic and is also embarking on major reforms to the NHS in England. The Health and Care Bill 2021–22 could be used to help strengthen action to reduce inequalities.
  • The NHS has an important role to play in narrowing health inequalities, but progress has been slow in recent years and the pandemic has shown that more tangible action is needed. Yet the provisions outlined in the Bill amount to more of the same, transposing existing inequality duties onto the new NHS integrated care boards (ICBs). The duties placed on the health secretary and on NHS England are similarly unchanged.
  • The core inequalities duty could be broadened to acknowledge the NHS’s role in influencing wider social and economic determinants of health, and health inequalities could be incorporated into the new ‘triple aim’ duty for the NHS. Other public services that are vital for enabling everyone to lead a healthy life, such as housing and social security, will also require investment if inequalities are to be narrowed.
     
 

Introduction

The COVID-19 pandemic has exposed and exacerbated pre-existing health inequalities in England. Since 2010, improvements in life expectancy in England slowed more than in any other European country, and the gap in the number of years people can expect to live in good health widened between rich and poor.1 During the pandemic, this translated into higher death rates among people living in more deprived areas and for certain population groups, including people from ethnic minority communities. For people younger than 65, the COVID-19 mortality rate was almost four times higher for the 10% living in the most deprived areas as those in the least deprived.2 

Growing awareness of health inequalities has led to increased focus from NHS leaders and government about how to address them. In July 2020, NHS trusts were asked by NHS England to take forward eight ‘urgent actions’ to address inequalities in NHS care and outcomes – and told to increase ‘the scale and pace of progress’ to reduce inequalities.3 Government has upheld an existing ambition to extend healthy life expectancy in the UK by 5 years by 2035, while narrowing the gap between the richest and poorest.4 And the Secretary of State for Health and Social Care, Sajid Javid, has said that the country can ‘only level up economically if we level up in terms of health too’.5 

The Health and Care Bill 2021–22 offers a potential route to strengthen action on health inequalities. The Bill was published on 6 July and outlines a set of changes to NHS rules and structures in England. This includes measures to promote collaboration in the health system and strengthen the health secretary’s control over the day-to-day running of the NHS.6 Under the plans, England will be divided into 42 integrated care systems (ICSs). Each system will be made up of two bodies: integrated care boards (ICBs) – area-based NHS agencies that will control most NHS resources to improve health and care for their local population; and integrated care partnerships (ICPs) – looser collaborations between the NHS, local authorities and other agencies. 

When the Bill was introduced to parliament, then Chief Executive of NHS England, Simon Stevens, said that the reforms will ‘undoubtedly both help tackle health inequalities and speed the recovery of care disrupted by the COVID pandemic’.7 This long read examines what the Health and Care Bill says in relation to reducing health inequalities and compares this to the existing legal framework for the NHS. We explore how the Bill could be strengthened to support greater NHS action to reduce health inequalities in England and describe some of the wider policy decisions that will shape the NHS’s ability to do this.

 

What measures on health inequalities are in the Bill?

The Bill builds on and amends existing legislation for the NHS. The Secretary of State for Health and Social Care is already under a legal duty to ‘have regard to the need to reduce inequalities between the people of England with respect to the benefits that they can obtain from the health service’.8 While the Bill hands ministers sweeping powers to intervene in the day-to-day running of the NHS, there are no changes to the inequalities duty introduced via the Health and Social Care Act 2012.

The new ICBs – responsible for planning services and controlling most NHS resources for populations of around 1 to 3 million – will be given a statutory duty to ‘have regard to the need to reduce inequalities between patients’ in terms of access to and outcomes from health services.9  ICBs will also have a ‘duty to promote integration’ in certain circumstances, including where doing so is expected to reduce inequalities in access and outcomes.10  

These duties give ICBs considerable discretion to decide what action to take to reduce inequalities. But the Bill also includes requirements to make ICBs accountable for their plans and progress. Each year, ICBs – with their partner NHS trusts and foundation trusts – will be required to prepare a plan for the next 5 years, including how the duty to reduce inequalities will be carried out.11 There is also a requirement for each ICB to prepare an annual report that explains how effectively it has fulfilled its duty.12 When conducting its assessment of how well ICBs have undertaken their functions each year, NHS England must also assess how well they have worked to reduce inequalities.13 

When compared to existing NHS legislation, the Bill’s provisions to encourage action on health inequalities largely amount to more of the same (see Table 1). All are carried over from the duties and requirements that applied to NHS clinical commissioning groups (CCGs) (which will be scrapped under the changes and replaced by ICBs), and do not mark a change from the existing legal framework.

Table 1: Comparing existing health system inequality duties and proposed changes

  National Health Service Act 2006 (as amended by the Health and Social Care Act 2012)  Health and Care Bill 2021–22 (as introduced) 
Legal duties on inequalities  The secretary of state must have regard to the need to reduce inequalities between the people of England with respect to the benefits people can obtain from the NHS [section 1C]   No change 
NHS England/CCGs must, in the exercise of its functions, have regard to the need to reduce inequalities between patients with respect to access to, and outcomes from, health services [sections 13G and 14T]  For CCG, read ICB – otherwise no change [new section 14Z35 inserted by clause 19] 
Inequalities in other duties  Duty to promote integration: functions of NHS England/CCGs must be exercised with a view to health services, health-related services and social care services being provided in an integrated way where this would improve quality or reduce inequalities in access or outcomes [sections 13N and 14Z1]  For CCG, read ICB – otherwise no change [new section 14Z42 inserted by clause 19] 
Annual plans  NHS England’s business plan and CCG commissioning plans must explain how the duties to reduce inequalities are to be discharged [sections 13T and 14Z11]  For CCG commissioning plan, read ICB joint forward plan – otherwise no change [new section 14Z50 inserted by clause 19]  
Annual reports  NHS England and CCG annual reports must assess how effectively the duty to reduce inequalities was discharged [sections 13U and 14Z15]  For CCG, read ICB – otherwise no change [new section 14Z56 inserted by clause 19] 
Performance assessment  NHS England’s annual assessment of how well each CCG has performed must include an assessment of how effectively the CCG discharged its duty to reduce inequalities [section 14Z16]  For CCG, read ICB – otherwise no change [new section 14Z57 inserted by clause 19] 

 

Sources: National Health Service Act 2006 (as amended); Health and Care Bill 2021–22 (as introduced).

 

How could the Bill be strengthened?

The Bill could be strengthened in three main areas to support action to reduce health inequalities. 

1. Strengthening the existing core inequalities duty

The core duty in the Bill relating to the NHS’s role in reducing health inequalities – to ‘have regard to the need to reduce inequalities between patients’ in terms of access to and outcomes from health services – is unchanged from the existing legal framework for the NHS.14 Yet progress against national NHS commitments to reduce health inequalities has been slow in recent years.15  

Health outcomes are influenced most strongly by the social, economic, environmental, and other conditions in which people live.16 In addition to providing effective and equitable health care services, NHS leaders must therefore work with local government and others to help address the wider factors that shape health – such as food, housing, and economic development.17,18 NHS England’s interim guidance recognises this wider contribution, noting that each ICP must ‘address health inequalities and the wider determinants which drive these inequalities’ as part of its integrated care strategy.19 NHS England’s ICS design framework similarly expects ICSs to ‘influence the wider determinants of health and broader social and economic development’.20  

As it currently stands, however, the Bill’s core inequalities duty is narrowly focused on access to and outcomes from health services. The Bill misses an opportunity to recognise and encourage the wider role NHS organisations can play as ‘anchor institutions’.21 Due to their size, scale, and rootedness in local communities, NHS agencies have the potential to influence the social, economic, and environmental factors that shape health and inequalities in their area. This includes considering how buildings and spaces are used to support communities, widening access to quality work, and adjusting the way in which goods and services are purchased locally.22 The core inequalities duty could be broadened so that it specifies the need to act in partnership with local government and other agencies on wider social and economic determinants of health, and recognises the NHS’s potential as an ‘anchor’.

2. Boosting the ‘triple aim’

The Bill introduces a new duty on NHS agencies called the ‘triple aim’. Under the duty, NHS England, ICBs, and other NHS agencies must consider the effects of their decisions on the health and wellbeing of the population, quality of care, and sustainable use of NHS resources.23 The duty is designed to encourage action on a set of common goals that require collective action between NHS and wider agencies. Definitions of population health – the first part of the triple aim – typically include a focus on how health is distributed within the population.24 But currently the triple aim duty does not explicitly mention health inequalities. To send a clear signal to health and care leaders about its importance as a goal, the ‘triple aim’ could be amended to state the need to reduce inequalities. 

Clause 4 of the Bill currently states that NHS England ‘may’ publish guidance about how to carry out this duty. But there is no requirement to produce guidance, or for any guidance produced to cover health inequalities. This could also be strengthened to ensure that details on action to reduce inequalities are published – for instance, against specific goals and metrics. 

There is good reason for NHS duties on health inequalities to remain broad and flexible, given the breadth of the NHS’s responsibilities and the wider policy action needed to improve health and reduce inequalities. Yet the performance of ICSs will still be assessed against the delivery of these duties. The way in which these duties are framed will therefore play a role in defining the focus of local efforts to address inequalities, and how they are measured and reported on. The NHS’s current ‘system oversight framework’ – used to define national priorities and monitor the overall performance of local systems – includes little in the way of concrete measures on health inequalities, with those that are included focused primarily on shorter term COVID-19-related equity impacts.25 

3. Proposed ICS structures: facilitating greater action on health inequalities?

ICSs are the centrepiece of the new NHS structure. Alongside ICBs, wider community partnerships – ICPs – will also be established across every ICS. Each ICP will include representatives from local government and must produce an ‘integrated care strategy’ to guide local decisions. Each ICP strategy must include details of how local health inequalities will be addressed.26 And ICBs must ‘have regard’ to the strategy developed by the ICP when developing their own plans.

Encouraging collaboration to improve health and reduce inequalities makes sense. But there is a risk that ICPs will have limited influence in the new system and be side-lined by more powerful NHS agencies. This is a major weakness given that local authorities have a central role in tackling social, economic, and environmental determinants of health and health inequalities. Local authorities have often not been treated as equal partners by NHS leaders.27 And the 5-year plans for improving health and care published by previous versions of ICSs in the NHS – sustainability and transformation plans – were often limited in in their approaches to preventing disease and reducing inequalities.28 For example, few plans described interventions to address social and economic determinants of health. To help give these wider community partnerships more teeth, the Bill could clarify how ICBs will be held to account for delivering key components of the ICP strategy.

There is also a risk of confusion on local plans and responsibility for reducing health inequalities. Multiple overlapping strategies will be produced by different partnership bodies in each ICS – including a 5-year ICB plan, an ICP strategy, and Health and Wellbeing Strategies and Joint Strategic Needs Assessments (both developed by Health and Wellbeing Boards at a local authority level). Government is also simultaneously embarking on a structural reorganisation of the public health system, with Public Health England being split into a new UK Health Security Agency and Office for Health Improvement and Disparities. As well as continuing to grapple with the pandemic, local government leaders will be faced with the challenge of navigating these two sets of reforms at once. 

Coordinated action is needed to influence the complex range of factors shaping health and health equity – and it makes sense that multiple agencies have responsibilities for tackling inequalities. But a clear narrative and vision will be required for how public health and NHS structures will work together regionally as well as nationally, to ensure alignment and minimise disruption.

 

Wider policy changes

Legislation can only do so much. The ability of local systems to tackle health inequalities will be shaped by a wide range of factors beyond the Health and Care Bill – including policy changes within the NHS and other public services. Making local collaboration work, for instance, depends as much on culture, management, resources, and other factors as it does on NHS rules and structures.29,30  National NHS bodies will need to provide a clear framework of priorities, potential interventions and measures of progress to guide local action on health inequalities.31 Current guidance is limited – and local plans for reducing health inequalities can often be vague and lacking a systematic approach.32  Changes in other areas of NHS policy, such as how resources are allocated between more and less deprived areas, could also be used to increase the NHS’s contribution to reducing health inequalities.33,34,35 

The NHS can also only do so much to tackle inequalities. Improving health and health equity depends on wider policy interventions at a national and local level – for example, government decisions about the level and distribution of public spending on income support, housing, education, and other services as the country recovers from the pandemic. Local government spending – which includes a range of services that contribute to health, such as parks, libraries, and sexual health services – has fallen significantly since 2010, with the biggest cuts in the most deprived areas of England. And despite strong evidence on the cost effectiveness of public health spending,36,37 the public health grant for local authorities is now 24% lower per person in real terms than it was in 2015/16.38  Continued underinvestment in local government and wider services that shape health will limit the ability of local systems to address social and economic factors that shape health and inequalities.

 

Conclusion

COVID-19 has exposed vast and unjust differences in health between different social groups in England. Government has committed to levelling up the country as it recovers from the pandemic – and is also embarking on the biggest legislative overhaul of the NHS in a decade. The Health and Care Bill offers an opportunity to strengthen NHS action to reduce health inequalities – including by bolstering and expanding health inequalities duties and ensuring data are collected and published to monitor progress. But legislation alone can only play a partial role, as can the NHS. Wider public policy changes and investment will be needed to support local whole system efforts to tackle health inequalities. These should be underpinned by a cross-government strategy to improve health and reduce inequalities in England.39

  1. Marmot, M et al. Health Equity in England: the Marmot Review 10 Years On. Institute of Health Equity (IHE); 2020 (www.health.org.uk/publications/reports/the-marmot-review-10-years-on) (p 13).
  2. Suleman M, Sonthalia S, Webb C, Tinson A, Kane M, Bunbury S, Finch D, Bibby J. Unequal pandemic, fairer recovery: The COVID-19 impact inquiry report. The Health Foundation; 2021 (https://doi.org/10.37829/HF-2021-HL12) (p 12).
  3. NHS England. Implementing phase 3 of the NHS response to the COVID-19 pandemic. NHS England; 7 August 2020 (https://www.england.nhs.uk/wp-content/uploads/2020/08/implementing-phase-3-of-the-nhs-response-to-covid-19.pdf) (p 2).
  4. Department for Business, Energy & Industrial Strategy. The Grand Challenges. Department for Business, Energy & Industrial Strategy; 2019 (https://www.gov.uk/government/publications/industrial-strategy-the-grand-challenges/industrial-strategy-the-grand-challenges).
  5. Rt Hon Sajid Javid MP. Key note speech by Secretary of State for Health and Social Care; 16 September 2021 (https://www.youtube.com/watch?v=ib-2T0hQSzE&ab_channel=TheCentreforSocialJustice). 
  6. Alderwick H, Gardner T, May N. England’s new health and care bill. BMJ; 2021 (https://www.bmj.com/content/bmj/374/bmj.n1767.full.pdf) (p 1).
  7. UK government. Health and Care Bill introduced to Parliament. UK government; 2021 (https://www.gov.uk/government/news/health-and-care-bill-introduced-to-parliament).
  8. House of Commons. Health and Social Care Act 2012: Chapter 7 (https://www.legislation.gov.uk/ukpga/2012/7/pdfs/ukpga_20120007_en.pdf) (p 3).
  9. House of Commons. Health and Care Bill Part 1 — Health service in England: integration, collaboration and other changes; 2021 (https://publications.parliament.uk/pa/bills/cbill/58-02/0140/210140.pdf) (p 16).
  10. Ibid (p 17). 
  11. Ibid (p 21).
  12. Ibid (p 46). 
  13. Ibid (p 25). 
  14. The King’s Fund. Briefing: Health and Care Bill House of Commons Second Reading. The King’s Fund; 2021 (https://www.kingsfund.org.uk/publications/health-care-bill-house-commons-second-reading-briefing) (p 6). 
  15. Thorlby et al. The NHS Long Term Plan and COVID-19: Assessing progress and the pandemic’s impact. The Health Foundation; 2021 (https://doi.org/10.37829/HF-2021-P08) (p 20). 
  16. The Health Foundation. Evidence hub: What drives health inequalities? The Health Foundation (https://www.health.org.uk/evidence-hub).
  17. Whitehead M, Dahlgren G. What can be done about inequalities in health? The Lancet. 1991; 26(338)8774: 1059–1063.
  18. Elwell-Sutton T et al. Creating healthy lives: A whole-government approach to long-term investment in the nation’s health. The Health Foundation; 2019 (https://www.health.org.uk/publications/reports/creating-healthy-lives).
  19. NHS England. Interim guidance on the functions and governance of the integrated care board. NHS England;  2021 (https://www.england.nhs.uk/wp-content/uploads/2021/06/B0886_Interim-guidance-on-the-functions-and-governance-of-the-integrated-care-board-August-2021.pdf) (p 11).
  20. NHS England. Integrated Care Systems: design framework. NHS England; 2021 (https://www.england.nhs.uk/wp-content/uploads/2021/06/B0642-ics-design-framework-june-2021.pdf) (p 8).
  21. Reed S, et al. Building healthier communities: the role of the NHS as an anchor institution. The Health Foundation; 2019 (www.health.org.uk/publications/reports/building-healthier-communities-role-of-nhs-as-anchor-institution). 
  22. Allen M, Malhotra A M, Wood S, Allwood D. Anchors in a storm: Lessons from anchor action during COVID-19. The Health Foundation; 2021 (www.health.org.uk/publications/long-reads/anchors-in-a-storm). 
  23. House of Commons. Health and Care Bill Explanatory Notes; 2021 (https://publications.parliament.uk/pa/bills/cbill/58-02/0140/en/210140en.pdf) (p 17).
  24. Alderwick H, Gottlieb L M. Meanings and misunderstandings: a social determinants of health lexicon for health care systems. Milbank Q. 2019 Jun;97(2):407-419 (doi: 10.1111/1468-0009.12390).
  25. NHS England. NHS oversight metrics for 2021/22. NHS England; 2021 (https://www.england.nhs.uk/wp-content/uploads/2021/06/B0693-nhs-oversight-metrics-for-2021-22.pdf). 
  26. NHS England. Interim guidance on the functions and governance of the integrated care board. NHS England; 2021 (https://www.england.nhs.uk/wp-content/uploads/2021/06/B0886_Interim-guidance-on-the-functions-and-governance-of-the-integrated-care-board-August-2021.pdf) (p 11).
  27. Alderwick H, et al. Sustainability and transformation plans in the NHS: how are they being developed in practice? The King’s Fund; 2016 (https://www.kingsfund.org.uk/publications/stps-in-the-nhs).
  28. Briggs A, Göpfert A, Thorlby R, et al. Integrated health and care systems in England: can they help prevent disease? Integrated Healthcare Journal 2020;2:e000013 (doi: 10.1136/ihj-2019-000013).
  29. Alderwick H, Hutchings A, Briggs A, et al. The impacts of collaboration between local health care and non-health care organizations and factors shaping how they work: a systematic review of reviews. BMC Public Health 21, 753 (2021) (https://doi.org/10.1186/s12889-021-10630-1).
  30. Perkins N, et al. What counts is what works’? New Labour and partnerships in public health. Polit Policy 2010;38:101-17 (https://www.ingentaconnect.com/content/tpp/pap/2010/00000038/00000001/art00006).
  31. Thorlby et al. The NHS Long Term Plan and COVID-19: Assessing progress and the pandemic’s impact. The Health Foundation; 2021 (https://doi.org/10.37829/HF-2021-P08) (p 20). 
  32. Ford J, et al. Transforming health systems to reduce inequalities. Future Healthc J Jul 2021, 8 (2) e204-e209; DOI: (10.7861/fhj.2021-0018) (p 204).
  33. Barr B, et al. The impact of NHS resource allocation policy on health inequalities in England 2001-11: longitudinal ecological study. BMJ 2014; 348  (https://doi.org/10.1136/bmj.g3231).
  34. Levene L S, et al. Socioeconomic deprivation scores as predictors of variations in NHS practice payments: a longitudinal study of English general practices 2013-2017. Br J Gen Pract. 2019 Aug;69(685):e546-e554 (https://pubmed.ncbi.nlm.nih.gov/31208972/).
  35. Fisher R. ‘Levelling up’ general practice in England: What should government prioritise? The Health Foundation; 2021 (www.health.org.uk/publications/long-reads/levelling-up-general-practice-in-england).
  36. Masters R, Anwar E, Collins B, Cookson R, Capewell S. Return on investment of public health interventions: a systematic review. J Epidemiol Community Health 2017; Mar 29. (https://jech.bmj.com/content/71/8/827). 
  37. Owen L, Fisher A. The cost-effectiveness of public health interventions examined by the National Institute for Health and Care Excellence from 2005 to 2018. Public Health April 2019 169:151-162 (https://www.sciencedirect.com/science/article/abs/pii/S0033350619300356?via%3Dihub).
  38. The Health Foundation. Has government grasped the full enormity of the country’s public health challenges? [Press release]. The Health Foundation; 2021. (https://www.health.org.uk/news-and-comment/news/has-government-grasped-the-full-enormity-of-public-health-challenges).
  39. Dixon J, Everest G. The government’s levelling up agenda: An opportunity to improve health in England. The Health Foundation; 2021 (https://doi.org/10.37829/HF-2021-C07). 

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