Organisation objective

• NHS Long Term Plan
• Statutory Item
• NHS Mandate from Government

Working with people and communities:

What approaches have been used to ensure people and communities have informed this programme of work?

• consultation / engagement
• qualitative data and insight, for example, national surveys; complaints
• partnership working with voluntary, community and social enterprise organisation

The Healthcare Inequalities Improvement programme involves people and communities in a number of ways. Development of the Core20PLUS 5 approach involved extensive engagement with a wide range of stakeholders, including Voluntary, Community and Social Enterprise (VCSE) partners. The Core20PLUS Connectors programme was co-designed with people with lived experience and with delivery partners including National Voices, Healthwatch England and the Health Creation Alliance. Frameworks for action have been designed with lived experience partners and voluntary sector partners.

Executive summary

NHS England (NHSE) and integrated care boards (ICBs) have a legal duty to have due regard to the need to reduce inequalities between persons with respect to their ability to access health services and the outcomes achieved by the provision of health services. This paper outlines the progress and impact NHSE’s Healthcare Inequalities Improvement Programme and NHS Race and Health Observatory (RHO) have made over the last year, for the NHS Board to note and discuss.

Action required

The NHS Board is asked to note the contents of this report, recognising the progress made by NHSE and RHO in 2023/24, and plans for 2024/25 and beyond. We aim to ensure a continued focus on health inequalities in all policies across NHSE and the wider NHS.

Background and policy context

1. The NHS has a crucial role to play in reducing health inequalities. Our primary area of responsibility lies in reducing inequalities in access to, experiences of, and outcomes from, health services. The NHS can also contribute to broader efforts to address the wider determinants of health that drive inequalities at local and national scale, working with other statutory and non-statutory bodies.

2. In 2020 NHSE created a dedicated programme to tackle inequalities in the delivery of healthcare. The agreed strategy was to:

• create conceptual frameworks to enable frontline healthcare delivery organisations and leaders to understand what action was needed on healthcare inequalities and why this activity was important
• build a consistent delivery network across the NHS to ensure that ICBs and trusts have the capacity and capability to tackle healthcare inequalities at a local level, including building appropriate strategic partnerships to create this infrastructure
• provide detailed guidance to support frontline NHS organisations to take action in the required areas of intervention
• undertake individual projects that require national action to tackle particular areas of healthcare inequality
• develop a clear accountability and measurement framework to assure delivery at a local level
• develop a partnership with the RHO to tackle race and ethnic inequalities

3. The paper sets our progress over the last year against each of these objectives.

Delivery and impact of work to date

Strategic framework for action on health inequalities

4. NHSE action on health inequalities continues to be driven through our five strategic priorities and the Core20PLUS5 approaches for adults and children and young people. These frameworks focus action on areas within the NHS’s direct influence that are major contributors to inequalities in life expectancy. They include the “big killers” (e.g. cancer, CVD, respiratory disease, smoking) and Long Term Plan priorities where stark inequalities are evident (e.g. maternity, severe mental illness, diabetes). Together, these provide a clear strategic framework for NHS action on health inequalities.

Expansion of networks to create a delivery infrastructure

5. We have made substantial progress on creating a national infrastructure to ensure consistent delivery of the Core20PLUS5 framework and our five strategic priorities at local level:

• our Core20PLUS Connectors programme supports community-based approaches to addressing inequalities through co-production and co-design. The Connectors programme now has 30 Connector sites across the seven NHS regions, with six of these sites onboarded over the last year. Over 540 connectors have been recruited (160 more than July 2023), working with over 70 voluntary, community, faith, and social enterprise organisations (VCFSE) and local Healthwatch delivery partners, an increase of 20 partners
• our Core20PLUS Ambassadors programme is an opportunity for people working in healthcare organisations to develop their skills, knowledge and ability to drive targeted action on healthcare inequalities. This year we have recruited an additional 245 Core20PLUS Ambassadors, an increase of 145 compared to wave 1. In addition, we onboarded 47 Healthcare Financial Management Association (HFMA) health inequalities finance fellows
• the collaboration between NHSE, the 7 Core20PLUS Accelerator sites and the Institute for Healthcare Improvement (IHI) has enabled all sites to build quality improvement capability to address healthcare inequalities

6. Taken together, these three initiatives have now ensured that all ICBs and trusts have the capacity and capability required to develop and deliver their local approach to tackling health inequalities.

Strategic partnerships

7. We are enhancing system capability to tackle health inequalities through a series of strategic partnerships:

• a multiyear strategic partnership with the Royal Society of Medicine (RSM) for a healthcare inequalities education programme has been agreed, with an annual summit delivered each January
• NIHR Core20PLUS5 Research Grant Challenge: we have launched a £50 million research call into maternity health inequalities to support efforts to improve care and outcomes
• we partnered with the Accelerated Access Collaborative to deliver the Innovation for Healthcare Inequalities Programme (InHIP), which involved a £3.9M investment across 39 ICSs to identify, address and minimise healthcare inequalities through projects to improve access to the latest health technologies and medicines
• we worked with the NHS Innovation Accelerator (NIA) programme on a health inequalities callout, of which two successful candidates made it onto the full NIA programme, including C2-Ai, which uses artificial intelligence and machine learning to provide granular risk stratification and prioritisation of the waiting list, integrating factors such as ethnicity and social determinants of health
• we continue to work closely with His Majesty’s Prison and Probation Service (HMPPS) around healthcare inequalities experienced in the criminal justice system. This includes a suite of evidence reports based on surveys conducted with adults in the criminal justice system; national Prison Radio campaigns in adult male, female prisons and youth offending institutions to raise awareness of health risks and encourage healthy behaviours; an interactive poster campaign for adults under supervision of probation services with information on common health issues for the population; and a report based on a survey of prison officers to provide data on how best to engage young people in prisons
• Turning The Tide: Addressing Health Inequalities in Coastal Towns through the lens of Employment” Breaking Barriers report, commissioned by Suffolk and North East Essex (SNEE) ICB with support from NHSE and building on the CMO coastal communities report
• we worked with The Health Foundation and NHS Providers to deliver an Improving Equitably programme to support Provider Collaboratives to use quality improvement approaches to tackle health inequalities
• we partnered with NHS Horizons to deliver School for Change Agents with a focus on healthcare inequalities, 2261 people signed up to participate 
• we have committed to continue the work of the NHS RHO for a further 3-year period covering 2024-2027 

Publication of resources

8. We have developed a set of resources to guide system action on our five strategic priorities, including:

• publication of a framework for NHS action on inclusion health in October 2023, to help drive increased focus on securing good access to and experiences of healthcare among socially excluded groups
• publication of ‘Inclusive digital healthcare: a framework for NHS action on digital inclusion’ in September 2023, to ensure that the growing use of digital technology in the NHS does not widen healthcare inequalities
• publication of health inequalities requirements in NHS priorities and operational planning guidance for 24/25 requiring systems to publish joined up health inequalities action plans by the end of June 2024

National action to tackle particular healthcare inequalities

9. In 2021 the All Party Parliamentary Group (APPG) on Sickle Cell and Thalassaemia published a report – ‘No One’s Listening’ – which detailed the inequalities in access to healthcare, racial inequity, sub-standard care, and stigmatisation experienced by patients with Sickle Cell Disease. NHSE has subsequently established a programme of work to improve clinical pathways and care. The programme has also delivered Sickle Cell symptom awareness and prescriptions campaigns, emergency department bypass pilots, digital care platforms and funding for blood group genotyping to reduce adverse reactions to blood transfusions in people with SCD, These interventions followed an end-to-end clinical pathway review of care for people living with Sickle Cell Disorder (SCD). We have also worked to ensure Voxelotor will be funded via the Innovative Medicines Fund to treat sickle cell anaemia after it was recommended by NICE.

Development of system accountability mechanisms

10. Since its inception in 2021, the programme has focused on input measures related to building a delivery architecture. In the next phase, there will be greater emphasis on monitoring progress on reducing actual healthcare inequalities through a set of outcome measures, such as those seen in the Targeted Lung Health Check programme which tracks Early Cancer Diagnosis by deprivation. These will be embedded as part of routine organisational assurance processes and will, in turn, inform course correcting actions if the expected progress in reducing healthcare inequalities is not achieved.

11. We have therefore developed, agreed, and published accountability mechanisms to assure local delivery of action on healthcare inequalities, including:

• the NHSE ‘statement on information on health inequalities’ in November 2023, which sets out the health inequalities data that systems and trusts should publish alongside their annual reports in line with health inequalities legal duties
• a set of metrics and indicators within a Health Inequalities Monitoring Framework to support action on health inequalities. (See annex 1, annex 2 and annex 3)
• undertaken a robust, health inequalities led, review of ICB Joint Forward Plans, to ensure each ICB’s five year plan contains appropriate action to tackle inequalities 

The NHS Race and Health Observatory

12. To better understand and address the stark health inequalities experienced by Black and minority ethnic communities, NHS England established the NHS Race and Health Observatory(NHS RHO). Over the last 3 years the NHS RHO has (i) developed a significant evidence base, (ii) overseen major policy change based on this evidence, and (iii) initiated new and innovative implementation and improvement interventions. Activity over the last 12 months includes:

Evidence and insight

• published robust evidence across the domains of maternal and neonatal health, mental health, learning disabilities, sickle cell disease, genomics, the NHS workforce and COVID-19 – making recommendations for policy and practice. A full list of RHO evidence and practice interventions is at Annex 4
• continued to support the delivery of Core20PLUS5 programme through the provision of evidence and best practice examples

Policy change

• published its Manifesto for Race and Health, outlining seven priorities for the incoming government, and has led engagement with communities and political leaders to support racial equity and inclusion work
• directly fed into government and broader policy on the Major Conditions Strategy, stimulated and supported Dame Margaret Whitehead’s review of equity in medical devices, is contributing to the public inquiry into COVID-19, to various APPG reports and other strategic priorities
• continued to build upon domestic and international partnerships, with the UK Faculty of Public Health, the US Centers for Disease Control and Prevention (CDC) and the Commonwealth Fund – fostering a global approach to racial health equity
• provided strategic advice on race equity to many organisations including NHS trusts and ICSs, HSIB, CQC, the NIHR, the PSA, Diabetes UK, and are scoping collaborative work with Alzheimer’s Society, the Runnymede Trust, and Impact on Urban Health
• provided expert advice on race and racism through its position across a range of advisory and steering groups, including the NHS Assembly, National Genomics Board, NHS Advancing Mental Health Equalities Taskforce, and the Mayor for London’s Structural Racism and Health Equity Review
• supported the implementation of Martha’s Rule by providing strategic input on ethnic inequalities in raising worries and concerns, and continued to support Donna Ockenden in her maternity reviews

Practical solutions

• launched its landmark Learning Action Network (LAN) programme, in collaboration with the Institute for Healthcare Improvement. The LAN brings together 8 ICSs to develop anti-racism practice to tackle ethic inequalities in maternal and neonatal outcomes. This work is a precursor to the development of an improvement model and strategy for an anti-racism approach to tackling inequalities in healthcare more broadly
• supported the process by which key recommendations from RHO reports are taken forward by policymakers, e.g. initiating the distribution of mannequins with a variety of skin colours to acute NHS trusts across the country
• created resources, infographics, and guides for the health and care sector e.g. on tackling inequalities in learning disabilities, genomics, neonatal testing, access to psychological therapies, and on equitably tackling the elective care backlog
• engaged broadly with the public through traditional media, social media, and events, including the recent launch at the House of Commons of its research into neonatal assessment and practice

Planned actions for delivery in the next 3-6 months and beyond

NHSE Healthcare Inequalities

13. Over the next period, the Healthcare Inequalities Improvement Programme will:

• further engage on and develop our strategic approach to addressing healthcare inequalities
• provide further guidance for local organisations to support Core20PLUS5 The handbook will bring together best evidence and practice examples to support successful delivery of Core20PLUS5 interventions for underserved groups
• agree the evaluation framework for the evaluation of Core20PLUS5
• mobilise 3-4 digital inclusion accelerator sites
• embed health inequalities monitoring framework indicators and metrics into individual NHSE programme performance packs
• increase Core20PLUS Connectors to over 500 connectors (people) by December 24
• develop a community languages, translation and interpretation framework
• embed the frameworks for action on digital inclusion, inclusion health and statement on information on health inequalities
• complete the procurement exercise for hosting arrangements for the NHS RHO contract to secure a host organisation for the next 3-year period

Race and Health Observatory

14. Over the next period, the RHO will:

• launch its new strategy and work programme for the 2024-2027 period
• publish its anti-racism implementation and improvement model, designed to be adopted by organisations across the healthcare system
• publish evidence and practical resources on: the benefits and implications of transcutaneous bilirubin (TCB) monitoring for neonates; racial bias in healthcare education curricula; dementia screening, maternal mental health, trauma informed care, inequalities in Genomic Medicine Services, and on tackling healthcare inequalities for those with sickle cell disease
• progress its work programme on maternal and neonatal health including through its Learning and Action Network, with a focus on evaluation, scale and spread of replicable good practice
• support NHS England in establishing an evidence-based, national resource on prevention to tackle health inequalities and disparities amongst patients and communities, and a toolkit for meaningful community engagement
• further support the NHS with a focused programme of work looking at the challenges facing Black, Asian, and ethnic minority members of the healthcare workforce – including tackling health inequalities challenges in the workforce, and the ethnicity pay and progression gap across the NHS
• launch its online Action Resource Centre – providing data visualisation on ethnic health inequalities and open access to replicable good practice
• continue to build international partnerships with organisations and healthcare systems – sharing knowledge and solutions to common global challenges 

Annex 1: Updated set of indicators for monitoring progress on Core20PLUS5 clinical areas

National government ambition

Slope index of inequality in health life expectancy

Narrow the gap in healthy life expectancy between local areas where it is highest and lowest by 2030

This reflects mission seven of the Levelling up White Paper – to increase healthy life expectancy by five years by 2035 and narrow the gap.  

NHS Focus: CORE20PLUS5 for adults 

1. Maternity

a) midwifery continuity of carer

By: ethnicity, deprivation

Level: national and local

b) Slope index of inequality (SII) in preterm births

No increase in the SII

c) Ratio of rate of preterm births for Black and Asian women compared to White women 

No increase in the ratio 

By: deprivation

Level: national and local

2. Mental health and learning disabilities 

a) Number of annual health checks delivered to people with Severe Mental Illness (SMI)

390,000 people living with an SMI receive an annual physical health check by 2023/24

By: ethnicity, deprivation

Level: national and local

b) NHS Talking Therapies recovery rate

50% for all ethnic groups – narrow the gap between ethnic minority groups and white British groups

By: ethnicity

Level: national and local

c) Number of annual health checks delivered to people on learning disability register (new)

3. Respiratory disease

a) Flu vaccination update 

By cohort, narrow the gap in uptake by deprivation decile and ethnic group (when everyone has had an offer)

By: ethnicity, deprivation

Level: national and local

b) COVID-19 vaccination uptake

By cohort, narrow the gap in uptake by deprivation decile and ethnic group (when everyone has had an offer)

By: ethnicity, deprivation

Level: national and local

4. Cancer

a) Number of targeted lung health checks delivered in line with targets 

By: age, gender, deprivation, ethnicity (variable)

Level: national, local (lung health checks local data to be developed from April 2025)

b) Early-stage cancer diagnosis (new)

Increase early diagnosis rates across all populations, and by at least as much in most deprived areas as in least deprived areas

By: deprivation

c) Inequalities in take up of cancer screening – breast; cervical; colorectal (age standardised) (new)

Decrease in New Slop Index of Inequality

By: sex, deprivation, ethnicity (variable)

Level: national, system 

5. CVD

a) Stroke admissions per 100k population (age standardised)

Narrow the gap by deprivation decile and ethnic group

By: ethnicity, deprivation

Level: national and local

Percentage of patients aged 18 and over, with GP recorded hypertension, in whom the last blood pressure reading is below the age-appropriate treatment threshold

By: ethnicity, deprivation

Level: national and local (new)

6. Smoking cessation

a) Coverage of tobacco dependence treatment (%)

100% coverage in maternity and inpatient services 

By: no breakdown

Level: national (all inpatient settings – acute and mental health, and for pregnant women and partners)

b) Smoking quit rate

Achievement of individual ICB trajectories 

By: deprivation 

Level: national and local

Annex 2: Updated set of indicators for monitoring progress regarding inclusive recovery

NHS Focus: Inclusive recovery

1. Electives: size of waiting list

a) Size of waiting list

Equal pace of reduction in waiting list across groups

By: age, gender, ethnicity, deprivation

Level: national, regional, system

2. Elective: duration of waiting

a) people waiting 52 weeks or more

Eliminated by March 2025 for all groups at an equal pace.

By: age, gender, ethnicity, deprivation

Level: national, regional, system

b) People waiting 65 weeks or more

Eliminated by March 2024 for all groups at an equal pace. 

By: age, gender, ethnicity, deprivation

Level: national, regional, system

excluding cases where people choose to continue to wait.

3. Electives: activity levels

a) Activity levels by point of delivery 

Achieving growth targets per system, with an equal pace across groups

By: age, gender, ethnicity, deprivation 

Level: national, regional, system

Electives: inequalities in waiting times

A national measure to track disproportionality of long waits in the most deprives 20% of the population (in development) (new)

Level: national 

UEC and primary care

Conversion rate for Type 1 ED attendances: age-sex-acuity standardised (new)

By: deprivation

Level: national, regional, system 

Annex 3:  Health Inequalities subset of indicators for performance monitoring

Annex 4: NHS Race and Health Observatory research and practical interventions published to date

• tackling ethnic inequities in genomics and precision medicine
• review of neonatal testing and practice in Black and Asian newborns
• promoting effective and respectful communication with ethnic minority and pregnant people
• trauma-informed care in Black, Asian and ethnic minority communities
• review of NHS communication with (and for) the Jewish community
• review into factors contributing to ethnic health inequalities for those with learning disabilities from minority ethnic communities
• sickle Cell bundle cluster randomised trial project
• increasing representation of ethnic minority women in breast cancer clinical trials
• mapping of existing policy interventions to tackle ethnic health inequalities in maternal and neonatal health
• review of NHS managed national patient and public apps
• elective backlog and ethnicity: Is there variation in lost activity time to treatment and rates between ethnic groups?
• policy review of the Improving Access to Psychological Therapies (IAPT) programme
• identifying best practice in mental health care for Gypsy, Roma and Traveller communities
• Gypsy, Roma, Traveller mental health lived experience videos
• long term impact of COVID on NHS Health workers across UK from diverse ethnic backgrounds

Publication reference:  Public Board paper (BM/24/31(Pu))