Can integrated care really eradicate health inequalities?

Eradicating health inequalities should be at the heart of every ICS agenda. But talk is cheap; given the complex challenges facing ICSs, is this really an achievable goal?

The four elements of the core purpose of every integrated care system, originally set out by NHE England in 2020, are to improve outcomes in population health and healthcare; to tackle inequalities in outcomes, experience and access; to enhance productivity and value for money; and to help the NHS support broader social and economic development.

In this week’s New NHS ICS Series webinar, speakers asked whether ‘tackling’ inequalities was enough. Shouldn’t we be aiming to eradicate them completely? But is that laudable goal realistic in the complex and resource-strapped environment in which England’s integrated care strategy is developing?

For Danielle Oum, chair of Birmingham and Solihull Mental Health NHS Foundation Trust and chair designate of the Coventry and Warwickshire ICB, eradication is exactly what we should be aiming for, despite the challenges. She said: “Yes, it’s difficult and challenging, but it’s our responsibility. We’re meant to be providing a universal service. That means a service that everyone has access to when they need it.

“We don’t have any other option. People feel this has been an area of focus for many years, but it hasn't. There have been initiatives and projects and programmes, but it hasn’t been a requirement […] We can seize this opportunity and make the most of it or say it’s too difficult. Yes, it’s hard but we’ve got to go for it.”

Not a nice to have

Danielle underlined why eradication is the target for Coventry and Warwickshire. She said: “Health inequality is life inhibiting, it’s costly and it’s still with us. The availability of good medical care tends to vary inversely with the need for it. We have an opportunity to reimagine ourselves as a health service rather than an ill health service. This is not just a nice to have – an optional extra. Our systems are facing unprecedented challenges and the way we respond is key to the sustainability of future services. So this is the purpose of ICSs, I would argue. […] Failing to address this will ultimately fail all of our communities.”

Turning to practicalities, she said a place-based approach supported by digital technology is key: “Digital services give us a real opportunity to ensure we’re using our resources efficiently.

“If you don’t understand your population – if you’re not in a position to gather data and analyse it in the right way – there’s no way to make sure you’re directing your resources and priorities according to need. It’s very easy to say but it’s something we’ve struggled with in the NHS, and we can learn a lot by the close working with our local authority colleagues.”

She added: “The urgent and the important must be addressed concurrently – addressing inequalities must be part of our core purpose, rather than something we get around to when everything else has been done. It must be embedded throughout governance, not as a separate workstream or committee. Like many ICSs, we have made a start on our journey towards eradicating inequalities and the focus now is less on hearts and minds and more on delivery and accountability.”

Download Danielle's slides here (3MB)

Avoidable unfairness

Our second guest speaker, Tom Cahill, national director for learning disability and autism at NHS England, described inequalities as ‘avoidable unfairness’. He said the pandemic shone a light on issues that were already there. He shared some sobering statistics about the impact of health inequalities on people’s lives, highlighting huge differences in life expectancy, in how much of life is spent in good health, and in the prevalence of mental health issues.

So, what do we do about it? Tom highlighted NHSE’s five priorities for recovering from the pandemic: restore services inclusively and minimise unwarranted variation, mitigate against digital inclusion – get back to face-to-face as quickly as possible – work on the data, accelerate prevention programmes, and strengthen leadership.

This, he said, is where ICSs have a crucial role. He said: “For the first time, everyone’s working together to achieve the same aim. There’s a big focus on population health. There’s an opportunity to work in a wider system, so with other health colleagues but also with social care, police, education, the voluntary sector… and the business sector too.

“The big challenge is that we don’t just move the deckchairs. We must have people with lived experience around the table, plus those from the commercial sector. Then I think it’s down to leadership. Think about who’s responsible for what. Don’t appoint a director for inequalities – we’re very good at process. This is about leading for vulnerable people; it’s about that leadership to ensure the most vulnerable in our communities are being looked after.

“We have a real challenge here, but we also have an opportunity to make a difference – but we have to do this collectively.”

We’ve been here before

Some of our 190+ guests remain unconvinced that eradication of health inequalities is a realistic prospect. One said: “The issues we’re talking about have been around for a very long time. There are long-standing, deep-seated systemic inequalities for all kinds of reasons that extend across the whole public sector. And there’s been lots of fine talk about doing something about it for many years. This mustn’t become yet another attempt that didn’t deliver. We must go much further than rhetoric and good intentions and make something different happen.

“That will require serious thought, strategizing, tactical awareness, political nouse, and long-term sustained commitment. There are no quick fixes; there are so many moving parts in the lives of the people we’re trying to help. And the NHS, much as we love it, is an institution that’s become almost wholly focused on treatment rather than prevention. If we’re going to address inequalities, we’re going to have to change the culture and mindset of the people responsible for leading NHS services to get them to adjust their focus towards prevention.”

Another said: “We’ve never had greater need and complexity. We need to be corralling our systems together. And I’m afraid there is some scepticism in the local government sector that this might just be yet another change in the NHS that will fizzle out in the next five years.”

Another guest said: “The systemic inequalities we’re dealing with are so great that I can’t see us being able to completely eradicate health inequalities without political will to reduce poverty. But I still believe ICSs offer an opportunity to listen more closely to voices within our communities and work on co-production.”

The last word goes to another guest, who said: “Eradication has to be the correct tone to set. Anything less than that is tantamount to accepting present reality and resigning ourselves to failure before we’ve even started.”

Next event – 23 March

The next event in this popular series will take place on Wednesday 23 March, when the topic will be population health management – one of the tools that might prove crucial in our efforts to eradicate health inequalities. Joining details will be shared on our events pages soon.