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King's Fund - Are integrated care systems making progress on tackling health inequalities?

We know tackling health inequalities is what motivated many leaders to step into integrated care system (ICS) hotseats. But was it worth it? A recent flurry of surveys and studies are starting shed some systematic insight on that question and in particular how ICSs are allocating resources to tackling health inequalities, and what they are actually focusing on.

The big picture is provided by South Central and West Commissioning Support Unit’s forensic audit of ICS strategies and Joint Forward Plans (JFPs) showing details for each ICS and comparing them to each other. Themes include striking ambitions on tackling the wider determinants of health (all 42 strategies and 38 JFPs include the wider determinants of health, with commitments to housing, education, poverty and green spaces) and the use of anchor roles. Most systems are applying NHS England’s Core20plus5 approach, and also often focus on inclusion health populations, for example . There are also positive signs that ICSs are investing in their own capability, including ‘academy’ models and staff training and development on health inequalities.

There is less progress on developing strategic outcomes frameworks, which are important to help cohere and hold partners to account on health inequalities. Of those systems that have, outcomes frameworks often draw on the Office for Health Improvement and Disparities public health outcomes framework indicators showing good understanding of what drives health inequalities at population level. Finally, there are often differences in focus around health inequalities between the strategies and JFPs for the same ICS; whether this is justifiable or a sign of inconsistency is not clear.

While the audit points to future plans, other studies are looking at what is happening right now. NHS Confederation zooms down from that big picture to focus on how specific funding for health inequalities from NHS England (£200 million ring-fenced in 2022/23, un-ringfenced and in baseline in 2023/24) was actually spent. The results show a lot of variation from funding specific interventions or pilots focusing on specific groups needs to developing wider system capability, to devolving funding to places and neighbourhoods directly. Interviewees for the study (ICS health inequalities leads) saw improving capacity and capability (including academy development, leadership development and deep-end general practice networks) as important to drive a shared understanding of what drives and tackles health inequalities, although there were differing emphases on whether the focus should be on health care access, or greater emphasis on the wider determinants of health.

Other insights highlighted in the work included the importance of wider and visible leadership, for example, the director of finance sitting on the population health transformation board, or the chief executive consistently calling health inequalities ‘the north star’; and having good governance that is wired into the wider system, including input from local directors of public health. However, some interviewees also criticised the dissonance and mixed messages from NHS England, especially the tightening focus on short-term and acute issues – a contributor to a very leaky ‘ring-fence’ (only half fully adhering to it in the year it was operating, the rest seeping into baseline spending which worsened in 2023-24) cutting across efforts to reduce health inequalities. And there was some disagreement on whether the focus should be on Core20plus5, NHS England’s approach to tackling healthcare inequalities, or whether it should be on making a wider contribution to the wider determinants of health. This is a reflection of the wider growing pains of ICSs, and the balance between their roles in working on health inequalities through sticking to NHS core business, or becoming bigger players in the underlying social and economic conditions that drive health inequalities in the first place. This evident tension resonates with The Health Foundation’s in-depth work with multiple leaders in three ICSs, finding that objectives on tackling health inequalities were being crowded out by work on hospital waiting times and finances, and that there was tension between Core20plus5 and the wider contribution to health inequalities that ICSs could make.

Zooming down to trust level, NHS Providers’ survey presents a mixed picture on progress since the last survey, two years ago. Almost six in 10 respondents reported that the trust board’s response to health inequalities was fairly or very well developed and since 2022 trusts report progress on data problems, on accountability and on access to public health expertise. But they also identified financial problems, lack of dedicated leadership time, the impact of the cost-of-living crisis and ‘conflicting priorities from national regulators’ as big factors that are hampering their work. Nonetheless most trusts report they are actively working in some way on addressing health inequalities in their own workforce, in specific clinical conditions (often tied to Core20plus5), race equality, working as an anchor institution and prevention. Again, survey respondents wanted their efforts to be part of a much stronger cross-government approach to health inequalities policy and action on the wider determinants of health.

What to take from all this? First, if (and that’s a big if) ICSs follow their own plans, they will be far more active on the wider determinants of health in future, and this could be transformative for health inequalities. Second, there are many great things happening, but key for me is to see ICSs investing in their own capability. Third, there is much more to do including on aligning national priorities, ensuring shared outcomes frameworks actually work for health inequalities, and in securing the time and energy for leaders to focus on health inequalities. Fourth – and this is a strong message from all the studies – progress depends on NHS England staying the course on health inequalities and aligning its own messages and efforts. Finally, there is a clear call from ICS and health care leaders for a strong, consistent wider government framework to work in and alongside. That includes a cross-government health inequalities strategy, targets and action on poverty. This final point is an encouraging sign of an active and mature leadership community that is taking its role on health inequalities seriously and seeking to live up to the founding principles of the NHS and of integrated care systems. An incoming government needs to do the same.

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