Date published: 27 July, 2023
Date last updated: 27 July, 2023
Board meetings

Annual report on NHS England’s work on healthcare inequalities and the NHS Race and Health Observatory

Agenda item: 6 (Public session)
Report by: Prof Bola Owolabi, Director, National Healthcare Inequalities Improvement Programme; Dr Habib Naqvi MBE, Chief Executive, NHS Race and Health Observatory
Paper type: For discussion
27 July 2023

Organisation objective

  • NHS Long Term Plan

Executive summary

NHS England and integrated care boards (ICBs) have both statutory obligations and strategic imperatives to contribute to the reduction in health inequalities among the population. This paper outlines the progress and impact of NHS England’s Healthcare Inequalities Improvement Programme in supporting the NHS nationally and locally to achieve this, including the work commissioned from and delivered by the NHS Race and Health Observatory.

Action required

The Board is asked to note the progress made by NHS England (NHSE) and the contribution of the NHS Race and Health Observatory (RHO) in 2022/23 and plans for 2023/24 and beyond.

Background

1.The NHS has various general and specific legal duties related to equalities and health inequalities, in particular under the Equality Act 2010 and the NHS Act 2006 (as amended by the Health and Care Act 2022). NHS England is also accountable to the Government for delivery against policy priorities, principally through the NHS Mandate from the Secretary of State for Health and Social Care. The 2022 Levelling Up White Paper also sets out specific focus areas within the NHS’s purview to contribute to Mission 7: By 2030, the gap in Healthy Life Expectancy (HLE) between local areas where it is highest and lowest will have narrowed, and by 2035 HLE will rise by five years.

2. The NHS Long Term Plan also made a clear commitment to tackling health inequalities. The Healthcare Inequalities Improvement Programme (HIIP) was established to take forward this commitment, principally by supporting wider NHSE policy and programme teams, as well as local commissioners and providers, to tackle health inequalities through use of insight and high impact interventions. We are continuing to drive an ambitious programme of work across the NHS, having set five clear priorities (NHS England, 2021/22 priorities and operational planning guidance: Implementation guidance) and a focus for delivery through the Core20PLUS5 approach.

3. NHS England has agreed the Core20PLUS5 (Annex 5) approach for adults to focus action on reducing inequalities on issues within the NHS’s direct influence which are major contributors to inequalities in life expectancy through major conditions (cancer, CVD, respiratory disease, smoking) or Long Term Plan priorities where stark inequalities are evident (maternity, severe mental illness). A graphic summarising the approach is at Annex 5. Core20PLUS5 remains a feature of NHS priorities and operational planning guidance for 2023/24 and is part of the NHS mandate for 2023/24.

4. With the COVID-19 pandemic further highlighting longstanding health inequalities experienced by people from ethnic minority backgrounds, NHS England established the RHO by commission in April 2021 to support mobilisation of evidence on racial inequality in healthcare and encourage practical change to policy and practice across the health system. The Observatory’s mission is ‘Ensuring racial equity within our health and care systems through effective leadership, evidence and partnerships’. Its work focuses on patients, communities, and the healthcare workforce. The RHO is accountable to NHS England via its core contract, managed by the HIIP.

Delivery and impact of work to date

Mainstreaming health inequalities improvement

5. We continue to ensure there is appropriate focus on tackling health inequalities across a range of national NHS reports and guidance. This includes:

  • Providing health inequalities insight and evidence to support the delivery of the key NHS recovery and service improvement priorities, including the urgent and emergency care, primary care access and elective recovery plans, and ongoing programmes including cancer, mental health and maternity.
  • Ensuring that a range of NHS national guidance and policies drive practical actions on inequalities at every level of the system. For example, the 23/24 Joint Forward Plan guidance includes a focus on the health inequalities requirements for ICBs.
  • Working to ensure that the NHS Long Term Plan commitment to tackling health inequalities is maintained.

6. The HIIP also lends its expertise to cross-government programmes of work – such as Levelling Up, the UKHSA approach to health equity[3] and the DHSC Major Conditions Strategy – to continue to amplify the Core20PLUS5 approach.

7. The RHO further leverages its research and evidence base and policy analysis to form collaborations across the health and care sector. Most recently this has included a formal partnership statement with the National Institute for Healthcare Research, and a collaboration with the Care Quality Commission to provide evidence for their upcoming State of Care Report.

Progress on five priority areas for tackling inequalities

8. In operational planning guidance we have set five strategic priorities for system action on health inequalities recurrent since 2021/222 that we anticipate will be in place for at least a five-year period (Annex 1). The priorities are intended to:

  • Drive improvements to operational delivery including inclusive restoration of services particularly elective care, and acceleration of preventative programmes, starting from those areas covered in Core20PLUS5.
  • Promote action on the enablers of progress on inequalities with improved data, digital inclusion, and strengthened leadership and accountability.

9. During the year, we have:

  • Developed a set of inclusive recovery case studies to provide guidance to Trusts, illustrating practical actions that can be taken across the care pathway, and showcasing these through the NHS Horizons ‘data driven inclusive recovery’ event in April 2023.
  • As part of our response to findings of the Kerslake Commission on Homelessness and Rough Sleeping, we have engaged extensively on core principles for an inclusion health framework.
  • The plan for digital health and social care set out the intention to publish a framework for NHS action on digital inclusion to ensure that patients with low levels of digital access and literacy are not left behind by advances in care. A draft framework was developed over the year, involving an evidence review and codesign and engagement with key stakeholders.
  • We have also developed an approach to assess progress made on the Core20PLUS5 approach. This has included development of measurement framework with indicators for monitoring progress to be included on the Health Inequalities Improvement Dashboard and other data tools.
  • NHSE has developed a programme of work on sickle cell disease (SCD) management to accelerate action and interventions that improve experiences and outcomes for people with SCD. We have dedicated funding to deliver up to six hyperacute unit (HAU) pilots in high SCD prevalence metropolitan areas; digital care plans and a digital platform for SCD patients; and a communications campaign to promote existing prescription cost reduction schemes. Working with NHS Blood and Transplant, we have also established a programme to identify the blood group genotype of SCD patients, to ensure that blood transfusions are better matched and therefore present a lower risk of side effects. These actions, developed with a stakeholder group including patient representatives, are in addition to a campaign launched last year to improve awareness of sickle cell symptoms among healthcare staff, particularly in ED settings, to improve timeliness and experience of care for those experiencing a sickle cell crisis.

 The NHS Race and Health Observatory

10. During 2022/23, the RHO has made progress against all five of its impact domains, and has:

  • Published and overseen work across the domains of maternity and neonatal health, mental health, sickle cell disease, genomics, the workforce, and COVID-19, making recommendations for policy and practice. A full list of commissioned research can be seen at Annex 2.
  • Directly fed into government and broader policy on the Major Conditions Strategy, Dame Margaret Whitehead’s review of bias in medical devices, the public inquiry into COVID-19 and other strategic priorities.
  • Created resources, infographics, and guides for the health and care sector and continued to develop its upcoming Action Resource Centre (Annex 3).
  • 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.
  • Continued to build upon overseas partnerships with the Centers for Disease Control and Prevention (CDC) and the Commonwealth Fund to foster a global approach to racial health equity.
  • Provided strategic advice on race equity to many organisations including HSIB, the PSA and Diabetes UK, with collaborative work also in the scoping phase with Alzheimer’s Society, the Runnymede Trust, and Impact on Urban Health.
  • Provided expert advice on race and racism through its position on advisory and steering groups, a list of which can be found at (Annex 4).

11. The RHO has many routes to impact, and is increasingly focusing its attention on implementation, assuring there is a pipeline from evidence generation to practical change on the ground. This involves two programmes of work:

  • An action research project exploring anti-racism improvement developed in collaboration with the Institute for Healthcare Improvement. This will involve work with ICSs to test whether existing improvement models can be modified to tackle structural and institutional inequalities. In its initial phase, this project will focus on maternity and neonatal health.
  • Development of an implementation model and strategy for an anti-racism approach to tackling inequalities in healthcare. This programme will create a futureproof pipeline from research to impact across all RHO programmes.

Delivery of the Core20PLUS5 approach

12. The Core20PLUS5 approach has been refined over the last year and is now supported by an infrastructure of accelerator sites and networks of people:

  • Our Core20PLUS Connectors programme supports community-based approaches to addressing inequalities through co-production and co-design. We invested £1m in 2022/23, involving 24 sites over three waves, over 300 Connectors and 48 Healthwatch or voluntary sector partners.
  • Our Core20PLUSAmbassadors programme is an opportunity for people working in healthcare organisations to develop their skills, knowledge and ability to drive targeted action on healthcare inequalities. We recruited over 100 Ambassadors in wave one of the programme.
  • In collaboration with the Institute for Healthcare Improvement and the Health Foundation, we launched seven Core20PLUS Accelerator sites, one per region. They will use improvement methodologies and test innovative approaches to address inequalities in locally identified groups.
  • We launched a Core20PLUS Collaborative, a forum bringing together strategic partners and experts working to reduce healthcare inequalities.

13. In addition, we launched the Core20PLUS5 approach for children and young people (Annex 6) in November 2022, providing a framework with specific areas of clinical focus to tackle inequalities in this population. A graphic summarising the approach is at Annex 6.

14. Working with the cancer programme, we continued to support the delivery of targeted lung health checks to people aged 55-74 who have ever smoked in areas with high lung cancer mortality rates and high levels of deprivation with 43 live sites by the end of 2022/23. 1,898 lung cancers have been diagnosed (as of end February 2023); 76% at stage 1 or 2.

15. We have worked with the Accelerated Access Collaborative and AHSN Network to design and deliver the Innovation for Healthcare Inequalities Programme (InHIP). InHIP aims to enable accelerated access to innovations for people experiencing healthcare inequalities across the clinical areas of Core20PLUS5, through pathway redesign and innovation transformation. The programme allocated almost £3.8million in 2022/23 to fund 39 projects across England.

Collaboration with other Arm’s Length Bodies (ALBs) and partners

16. The HIIP and RHO collaborate closely on many areas of work, including work to improve the quality of ethnicity coding in the NHS, improvements in digital care plans for patients with sickle cell disease, and a jointly commissioned study into healthcare access for ethnic minorities with learning disabilities. We also meet regularly to align strategic actions and identify specific opportunities for collaboration. In addition, the RHO provides expert advice as part of the panel for the NHSE-funded Small Business Research Innovation programme.

17. NHSE and the NHS RHO, supported by the NHS Innovation Accelerator, are seeking innovations to address healthcare inequalities, with expressions of interest now open (July 2023). The call is intended to encourage innovations that can help debias the scoring and stratification systems in three clinical settings: maternity, elective care recovery and sickle cell disease.

18. The HIIP has also worked with other ALBs and partners to drive strategic action on inequalities. For example, NIHR has established a programme of research looking at underserved populations and communities. Our collaboration with NHS Resolution has also supported the better articulation of the intersection between patient safety and health inequalities (Action on patient safety can reduce health inequalities | The BMJ). Working with the Healthcare Finance Managers Association (HFMA), we have developed a health inequalities module and briefings for finance leaders, with three further modules to follow.

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

19. Over the next period, the HIIP will:

  • Continue to mobilise the Core20PLUS5 approach through the initiatives described above. Shortlisting for wave four of the Core20PLUS Connectors programme is complete, building on our ambition to ensure a Connectors site in every ICB area. We will also be preparing a Core20PLUS5 handbook, to inform practical action across the system, and will be considering modifications to the Core20PLUS5 framework, responding to feedback from the system.
  • Continue to develop the Making Every Contact Count (MECC) approach to further embed Core20PLUS, thus supporting early intervention and preventative activity across the health system.
  • Deliver key frameworks and strategies in support of our strategic priorities, including a new framework for NHS action on digital inclusion, and a healthcare inequalities strategy consolidating our priorities in a single place.
  • Build system capability in improvement methodologies to address health inequalities, collaborating with NHS Providers and The Health Foundation Q Community, to deliver a quality improvement programme.
  • Conduct a scoping exercise to better coordinate and understand work underway on community language, translation and interpretation., following Healthcare Safety Investigation Branch (HSIB) safety recommendations to NHSE.
  • Ensure fulfilment of our NHSE health inequalities legal duties, through publication of a legal statement, and continuing to ensure that NHS priorities and operational planning guidance and guidance for ICBs on Joint Forward Plans give good focus to the work needed to reduce health inequalities.
  • Progress our data monitoring approach, with a set of approved indicators to provide a monitoring framework, to increase transparency and inform ongoing oversight and support action on inequalities across the NHS.

20. Over the next period, the RHO will:

  • Publish research on the IAPT programme; Gypsy, Roma, and Traveller mental health; communication with ethnic minority women; effective communication with Jewish communities; and an analysis of the financial and economic cost of discrimination.
  • Finalise work on its online action resource programme, provide data visualisation on ethnic health inequalities and open access to case studies and research.
  • Further its partnership with the CDC in the USA to draw on lessons from overseas and to maximise the impact of its own research.
  • Further support the NHS with a focused and wide-ranging programme of work looking at the challenges facing Black, Asian, and ethnic minority members of the health and care workforce.

Annex 1: Five strategic priorities for reducing healthcare inequalities 

  • Priority 1: Restore NHS services inclusively including elective recovery, urgent and emergency care and primary care.
  • Priority 2: Mitigate against digital exclusion
  • Priority 3: Ensure datasets are complete and timely, particularly with regard to ethnicity coding.
  • Priority 4: Accelerate preventative programmes that proactively engage those at greatest risk of poor health outcomes, particularly by driving forward the Core20PLUS5 approach.
  • Priority 5: Strengthen leadership and accountability for action on healthcare inequalities.

Annex 2 – NHS Race and Health Observatory research and evidence commissioned or published in 2022/23

  • 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?

Publication reference:  Public Board paper (BM/23/25(Pu)

Date published: 27 July, 2023
Date last updated: 27 July, 2023