Good intentions, risks and missed opportunities: What the NHS plan means for health and care inequalities

The long-awaited 10-year plan for the NHS has been published. It’s a huge, wide-ranging programme that touches on almost every aspect of health care. But what does it mean for health and care inequalities? Here’s our initial quick review.

Reducing health inequalities is clearly an underpinning driver of the plan, including phrases like “Social justice runs through this plan. We know everyday life poses greater health risks to the most disadvantaged in society, whether the price of healthy food, the level of pollution or the quality of jobs available.” However the challenge is translating rhetoric into action.

Key actions include, first, shifting more funding to areas of higher socio-economic disadvantage and inequalities we’ve been highlighting for years. However, it doesn’t include details of how this will happen other than undertaking a review of the Carr-Hill formula for general practice funding and support from the Advisory Committee on Resource Allocation (ACRA). We’ve previously published evidence supporting a capitation-first approach.

Second, there is targeting of risk factors strongly correlated with socio-economic disadvantage. The Tobacco and Vaping Bill will substantially reduce smoking rates; restricting junk food advertising will help reduce childhood obesity; and increasing the provision of free school meals will help children facing food insecurity. Evidence supports actions through legislation and community action rather than telling people what to do. Furthermore, there is more support for mental health through school-based programmes and mental health emergency departments, which are also more likely to help lower socio-economic groups. 

Third, there is a deliberate decision to start rolling out neighbourhood health centres in areas of higher socio-economic disadvantage to ensure benefits start with those with the greatest needs. If these neighbourhood health centres are truly co-designed with underserved communities, there could be significant opportunities to redesign services to meet those most in need. As part of neighbourhood health, there is also mention of evidence-based approaches to support underserved residents, such as community health workers. 

Finally, there is a continuation of the role of health and care services in helping people stay in work, and we know that employment is paramount to helping people, especially those in poorer areas, to have sufficient income to live healthy lives.

While many of these actions are to be applauded and welcomed by those of us who have researched health inequalities over the years, there are several other proposals which raise concerns from an inequalities perspective.

There are three key areas of concern. First, digital and the use of the NHS App. The plan sets out that the NHS App will be a full front door for healthcare by 2028, allowing patients to access advice, choose providers, manage medication, access health tools, and monitor long-term conditions. However, there is little concrete in the plan for those who can’t or don’t want to access care through the app, however there are plenty of evidence-based interventions to support those with limited digital access.

Second, many aspects of the plan promote more patient empowerment. Patient empowerment can promote equity if it helps underserved communities to receive flexible patient-centred care, but it may worsen inequalities if it means those with more resources and higher health literacy are better able to navigate the system. We know from research that services which require high patient agency (i.e., effort and resources) tend to increase inequalities. With the expansion of patent choice of provider, an increase in personal health budgets, and linking patient feedback to payment, it may be that some groups of patients are able to navigate and benefit from the new models of care better than others.

Third, the plan wants to drive increased productivity with a mixture of carrots and sticks. The carrots include the ability of hospitals to retain surpluses, increased autonomy for high performance, and more funding for high-performing clinical teams. However, the sticks are reputational damage through league tables, withholding payments for underperforming organisations, and missing out on payments linked to patient feedback. This combination of carrots and sticks means that organisations in dynamic, high-performing, innovative areas will do well, but those that aren’t will miss out. The pattern of high-performing organisations tends to be linked with socio-economic advantage – organisations in poorer areas tend to struggle to recruit staff, have fewer community assets to draw upon, and support people who often have a challenging mix of biopsychosocial problems. Therefore, this approach to improving productivity may mean that organisations in high-performing areas, which tend to be more affluent, can advance faster than those in lower-performing areas, which also tend to be poorer.

There are also some key omissions. First, there is no mention of a cross-government health inequalities strategy. We know that many of the drivers of ill health lie outside the control of health and care services and previous governments success in address health inequalities required cross-government action. While there are proposals on employment and food, there is no mention of supporting people financially in poverty, providing adequate housing, improving education in the poorest areas, ensuring people feel safe and have access to green space for exercise, or reducing the negative impact of social media on mental health. Our previous research has shown that cross-government working is essential to progress.

Second, there is little on culturally tailored care. We know that people who are Black African, Black Afro-Caribbean, Bangladeshi, and Pakistani have consistently worse health outcomes, with multiple underlying factors. There is consistent evidence that services are more likely to address health inequalities if they are tailored to the cultural values and norms of patients. Without adapting care for diverse groups, we risk widening ethnic inequalities in care and outcomes. 

Finally, the NHS has substantial assets as an employer. It has huge opportunities to address inequalities through changing procurement practices to support local businesses and empowering staff to take action on health and care inequalities. However, the plan appears to have missed an opportunity to fully leverage these resources to help address inequalities.

Just a final word on the use of private health care – we know there has been a substantial increase in private health care use since the pandemic. There is a real risk that we’re sleep-walking into a two-tier health system with those who can afford private health care being able to access quicker care and a wider range of diagnostics and treatments. Getting the NHS as good as it can be is paramount to preventing a two-tier healthcare system, but without substantial investment it is unlikely that this plan will be transformational to stem the ongoing rise of private health care. 

The plan covers a huge volume of proposals and in reality, is unlikely to be able to deliver them all without substantial investment, which seems unlikely. The true impact on inequalities is likely to depend on which elements of the plan are implemented and how they are implemented. There is an urgent need to build the evidence of what works to address health inequalities. The 10 year plan has a plethora of proposals and it’s imperative that we use this opportunity to monitor, evaluate and learn how to address health inequalities now and for future policy makers and practitioners. We at the Health Equity Evidence Centre are looking forward to playing our part in supporting evidence-based implementation of this plan and ensuring we learn from it.