1. Introduction

1.1 What is the purpose of this statement on information on health inequalities?

This statement supports relevant NHS bodies (NHS bodies) to fulfil their legal duties and take an evidence-led improvement approach to tackling health inequalities, aligned with Core20PLUS5 for adults and children and young people.

It also provides guidance on how health inequalities information should be used to inform local action and how this should be reflected in annual reports.

It is provided by NHS England further to its duty under section 13SA of the National Health Service Act 2006 to publish a statement setting out a description of the powers available to NHS bodies to collect, analyse and publish information, and NHS England’s views about how those powers should be exercised in connection with such information.

This updated statement sets the expectation that NHS bodies should collect, analyse and publish data to:

• understand population health need by drawing on local analysis, demographic insight and population health outcomes data to identify the risk factors for health inequalities and Core20PLUS population groups
• disaggregate data (at a minimum by deprivation, ethnicity, age, and sex) and analyse performance data and local service insight to identify unwarranted variation in access and outcomes across population groups and geographies
• improve data quality, collection and analysis by identifying gaps in datasets (including where key demographic data is recorded as unknown or not stated) and identifying practical steps to make improvements
• use information on health inequalities to take action across commissioning and service delivery, and evaluate impact on reducing health inequalities
• publish information on health inequalities as part of annual reports, and embed health inequalities data into other data publications throughout the financial year, such as public board papers, through any relevant channels

To support annual reporting requirements, we have developed key lines of enquiry (KLOEs) (appendix 2) and a measurement framework (appendix 3), with a menu of measures aligned with national policy priorities.

1.2 What time period does this statement cover?

This statement was published in November 2025 and replaces the previous version of the statement, published in November 2023. It provides information on how powers should be exercised in connection with health inequalities information from this point onwards. NHS England will review, and if necessary update, descriptions of how powers relating to the collection, analysis and publishing of health inequalities information should be exercised. If there are any changes to health inequalities’ legal duties, this will be clearly communicated.

1.3 What are ‘relevant NHS bodies’ for the purposes of section 13SA of the NHS Act 2006 and this statement?

Relevant NHS bodies, described as NHS bodies throughout this statement, are integrated care boards (ICBs), NHS trusts and NHS foundation trusts (providers).

1.4 What is the legal status of this statement?

This statement does not create any new legal responsibilities in and of itself. The statement is designed to help NHS bodies understand their duties and powers and how they should be exercised. Further information on statutory responsibilities can be found in the joint reference document on health inequalities and equality legal duties.
Annual reporting guidance for ICBs and NHS trusts and NHS foundation trusts requires NHS bodies, in their annual reports, to review the extent to which it has exercised its functions consistently with NHS England’s views set out in this statement.
The Medium Term Planning Framework asks ICBs to demonstrate how they will reduce health inequalities in the exercise of their functions. NHS England’s regional teams will assess this as part of the statutory annual performance assessment of ICBs. They will check whether an ICB has met its legal duty to consider the need to reduce inequalities in access and outcomes, and whether an ICB’s actions align with NHS England’s statement on information on health inequalities.

1.5 How will this statement help NHS bodies address health inequalities?

Health inequalities are systemic, unfair and avoidable differences in health across the population, and between different groups within society. Healthcare inequalities relate to inequalities between groups in the population in the access they have to health services, and in their experiences of and outcomes from healthcare. Tackling inequalities in health outcomes, experience and access is one of the 4 core purposes of integrated care systems (ICSs).

Good quality, robust data and sound analysis enable NHS bodies to identify groups at risk of poor access, experience or outcomes and deliver evidence-based action to reduce health inequalities.

The duty to report information on health inequalities aims to encourage better quality data and increased transparency, supporting NHS bodies to shape and monitor improvement activity.

1.6 What approach has been taken to updating the statement?

Responding to the 10 Year Health Plan

To put the NHS on a sustainable footing for the future, there is an explicit focus in the 10 Year Health Plan on tackling persistent inequalities in health and halving the gap in healthy life expectancy between the richest and poorest regions in England. This statement reflects a shift to focusing on how healthcare access and outcomes contribute to population health across the life course.

The 10 Year Health Plan highlights inequalities faced by people from areas of high deprivation, ethnic minority communities, people who live in rural or coastal areas or deindustrialised inner cities, people who have experienced domestic abuse, and those who are experiencing homelessness. These populations are encompassed within the Core20PLUS5 approach. Core20PLUS5 should continue to be used to focus action on healthcare inequalities to deliver the 10 Year Health Plan and the government’s health mission.

A vision for a redesigned operating model was set out in The 10 Year Health Plan. The Model ICB Blueprint (Futures Collaboration Platform log in required) further clarified ICBs role as strategic commissioners, working to improve population health, reduce inequalities and improve access to more consistently high-quality care within their footprint.

Building from this, the Model Region Blueprint (Futures Collaboration Platform log in required) sets out the role of NHS England’s regional teams in leading the holistic oversight of performance for commissioners and providers. This includes overseeing the statutory annual assessment of ICBs and ensuring that commissioning and other statutory functions are driving a reduction in health inequalities.

Building on feedback to date

NHS England gathered feedback from key stakeholders and a user testing group with regional, system and provider representation. This helped shape and strengthen this statement.

As a result, we have:

• added KLOEs (appendix 2) to support NHS bodies reflect on and assess how they have exercised their functions consistently with NHS England’s views set out in this statement
• taken a more holistic approach to reporting, encouraging NHS bodies to consider national and local priorities and draw on a range of information sources – a measurement framework (appendix 3) sets out a menu of measures that align with national priorities, including Core20PLUS5 for adults, Core20PLUS5 for children and young people, NHS Oversight Framework and the Medium Term Planning Framework
• broadened the focus on health inequalities, encouraging NHS bodies to take a more holistic and life-course approach in line with Core20PLUS5, clarifying the need to give consideration to locally determined PLUS groups, including but not limited to:
  • ethnic minorities
  • inclusion health groups
  • people experiencing digital exclusion
  • rural and coastal communities
  • LGBTQ+ communities
  • people with multiple long-term health conditions
  • disabled people (such as people with a learning disability and autistic people)
  • other groups that share protected characteristics as defined by the Equality Act 2010

Alignment with the national approach to oversight

NHS England oversees overall delivery, performance and improvement of both ICBs and providers. The NHS Oversight Framework 25/26 outlines a focused set of national priorities, in line with those set out in national planning guidance. Health inequalities are considered throughout the NHS Oversight Framework, including through metrics which reflect medium term ambitions linked to Core20PLUS5. Metrics within the NHS Oversight Framework inform NHS England’s national oversight response.
The statement’s measurement framework (appendix 3) highlights where areas of measurement link to NHS Oversight Framework 2025/26 metrics. These are reflected as core measures that link to national priorities.  
The NHS Oversight Framework will be updated to include a comprehensive set of metrics to account for new models of services provision, with 1 of the core principles being on driving system-minded behaviours, including addressing health inequalities.  

2. What powers are available to NHS bodies?

2.1 What does section 13SA of the NHS Act 2006 say?

Section 13SA of the NHS Act 2006 sets out that NHS England is required to produce a statement setting out:

(1) (a) A description of the powers available to relevant NHS bodies to collect, analyse and publish information relating to:

(i) inequalities between persons with respect to their ability to access health services;

(ii) inequalities between persons with respect to the outcomes achieved for them by the provision of health services (including the outcomes described in section 13E(3) of the NHS Act 2006- see below); and

(b) the views of NHS England about how those powers should be exercised in connection with such information.

The outcomes referenced in section 13E(3) are outcomes that show:

(a) the effectiveness of the services,

(b) the safety of the services, and

(c) the quality of the experience undergone by patients.

2.2 What powers are available to NHS bodies to collect, analyse and publish information about health inequalities?

NHS England’s description of the powers available to NHS bodies to collect, analyse and publish information is set out in appendix 1. The legal powers and responsibilities are set out in different areas of the NHS Act 2006 and reflect the respective roles of ICBs as commissioners of healthcare services, and NHS trusts and NHS foundation trusts as providers of healthcare services.

Many of the specific provisions described do not expressly reference the collection, analysis or publishing of information about inequalities. However, it is implicit that information will need to be processed to exercise the functions listed, and other general powers available to NHS bodies permit information to be used to discharge their responsibilities.

3. What are the views of NHS England about how these powers should be exercised?

3.1 Understanding health needs

NHS bodies should draw on data and information from a range of sources to develop a robust understanding of a local populations’ health, care and wellbeing needs across the life course. This should build on integrated needs assessments, joint strategic needs assessments (JSNAs) and neighbourhood health plans as a starting point. External data tools – such as Fingertips, the ICB Place Based Allocation Tool or the NHS Trust Catchment Populations dashboard – should support analysis and provide public health insight.

NHS bodies should draw on local analytical capability through ICS intelligence functions and population health management platforms. This includes the use of linked, longitudinal datasets that enable population segmentation and risk stratification to develop a deeper understanding of the extent and nature of health inequalities within populations. As a minimum NHS bodies should be able to understand the following areas.

The demographic profile of people living in the local area: including age, gender, race, ethnicity, education, occupation and economic activity – and the size and geographical distribution of more disadvantaged PLUS groups. This should account for how geographic characteristics impact health, for example, in rural, coastal or highly concentrated urban communities. This should also include a robust understanding of digital exclusion rates within the population, and how that can exacerbate challenges with access to healthcare, in line with NHS England’s digital inclusion framework.

The current and forecasted health needs of the population: including life expectancy, healthy life expectancy, birth and mortality rates, disease frequency and multimorbidity, and risk factors – particularly among people living in more deprived places, who have protected characteristics, or those from more disadvantaged social groups.

Wider social, environmental and economic factors that affect health and wellbeing: NHS bodies can influence the social determinants of health – such as employment, education, housing and the environment – in their role as anchor institutions. These factors also provide important context for understanding healthcare needs and inequalities in access, experience and outcomes.

To enrich this quantitative data and develop actionable insights, NHS bodies should also harness community engagement and user involvement functions to further inform the understanding of local populations and their needs, in line with public involvement duties.

NHS bodies should:

• use local qualitative intelligence (for example, surveys or consultations) to support or challenge information from quantitative sources (for example, national data sets, clinical audits or GP records)
• develop an understanding of the drivers of identified issues, based on the measurable inequality shown in quantitative data and qualitative community insight

Further guidance is in Care Quality Commission’s Framework for engaging with people and communities to address health inequalities.

3.2 Understanding healthcare access, experience and outcomes

NHS bodies should collect and analyse information to identify inequalities in access, experience and outcomes across local and national priority areas. The measurement framework (appendix 3) sets out a menu of core and supporting measures for the Core20PLUS5 (adults and children and young people) clinical areas of focus and operational priorities. Alongside national priorities, NHS bodies should also consider any priorities identified locally as part of an integrated care strategy or ICB strategy. Information and data on NHS services that have been commissioned to integrated health organisations (IHOs) or other providers, including voluntary, community and social enterprise (VCSE), independent or private sector organisations, should also be analysed.

NHS bodies should routinely disaggregate performance data or clinical audits to identify variation across population groups and within systems at provider, place and neighbourhood level to understand how health inequalities are changing over time. Disaggregated data should be embedded into core performance reporting, and be used as a means of understanding inequalities in access, experience and outcomes as a driver of operational and performance challenge.

Where possible, data should be used to create a baseline and establish improvement plans to focus on improving performance and outcomes, or addressing root causes of unwarranted variation, using a range of metrics to monitor progress towards a broader outcome goal. This may include building on Model Health System to benchmark performance across the system and compare it to ‘statistical neighbours’ (other organisations or places with similar characteristics) or national trends.

NHS bodies should interrogate quantitative and qualitative insights to identify barriers for patients and service users accessing care or not attending appointments, such as digital exclusion, lack of transport, or language and translation barriers. Supplementing performance data with supporting health inequalities insights enables NHS bodies to understand the drivers of poor access, and to identify solutions.

For example, by looking at rates of ‘did not attend’ and ‘was not brought’ within elective services broken down by deprivation, ethnicity, age and sex, an organisation can start to identify barriers to attendance for these groups and how this may influence waiting times or outcomes. Similarly, differential rates of smoking, hypertension or obesity within Core20PLUS populations can be used to understand inequalities in waiting times for surgery driven by lower rates of surgery readiness, and be used to develop strategies to improve health so that people can receive timely treatment.

3.3 Improving data quality, collection and analysis

Good quality data – meaning data which are complete, accurate, up-to-date, and consistently recorded across systems – is essential for carrying out effective service planning, quality improvement, and monitoring the equity of services.

Datasets do not always represent the whole population equally. NHS bodies should actively consider how to improve data collection and mitigate for incomplete datasets to ensure population health management techniques based on incomplete data does not exacerbate inequalities. To strengthen data quality, NHS bodies should consider how they can draw information from multiple sources and across system partners. Consider the following areas.

Disaggregation: at a minimum, data analysis of performance, quality and patient outcomes should be disaggregated by age, sex, ethnicity and deprivation – as identified by the national Index of Multiple Deprivation (IMD). This allows NHS bodies to surface disparities in care faced by population groups who face known health inequalities. Where possible, consideration should be given to where data can be disaggregated by protected characteristics – such as disability status, sexual orientation and gender identity – or broader socioeconomic measures, such as employment or housing status. Disaggregation can reveal hidden patterns of inequality which can be used to guide resource allocation and service design.

Triangulation: this uses multiple indicators and types of information (for example, patient feedback and community engagement) to gain insight into complex areas that cannot necessarily be measured using single metrics in isolation, or where existing data does not capture the needs of groups that may experience health inequalities. Seemingly non-related elements can, when taken together, reflect an underlying pattern of inequality that otherwise may not have been picked up. It can also support the exploration of intersectionality, such as how deprivation and ethnicity intersect, and how these factors may compound disadvantage. Insights from a range of system partners should be drawn on to support triangulation. For example, ICBs may work closely with primary care and local medical committees as part of National Child Mortality Database deep dives and LeDeR reviews to understand the drivers of premature mortality for people with learning disability and where improvements in the provision of care could be made.

Ethnicity recording: this remains a challenge across NHS datasets, with the most significant data gaps and inaccuracies often found among communities already experiencing the greatest disadvantage. Some communities – such as Gypsy, Roma and Traveller communities and the Jewish population – are not well reflected in current healthcare data yet are known to experience profound inequalities in their access, experience and outcomes. Action to improve the quality and completeness of ethnicity data should be prioritised to enable high-quality analysis, with a particular emphasis on reducing incomplete fields and residual codes (not known/not stated). Completeness of ethnicity recording should be routinely monitored in line with national guidance. The Ethnicity Recording Improvement Plan is a resource for ICBs and providers to implement best-practice recording and analysis of ethnicity data. As outlined in section 4, NHS bodies must report on the completeness of ethnicity coding within their annual report. The measurement framework (appendix 3) includes a domain on ethnicity recording with core and supporting measures.

Housing status recording: this can enable a better understanding of how social risk factors such as insecure housing or homelessness affects health outcomes and health inequalities. Precarious housing status can be a common experience among people in inclusion health groups, who are often invisible in health care data. Housing status can act as a helpful proxy for understanding the experiences of those experiencing the most profound health inequalities. The Emergency Care Data Set (ECDS) and the Mental Health Service Data Set (MHDS) have adopted housing status SNOMED codes. NHS bodies should consider how recording of housing status can support the upstream identification of health inequalities, in line with NICE Guideline 214, and as recommended in the Elective Care Reform Plan. This will also support emergency departments, urgent treatment centres and in-patient services to meet their legal duty to refer service users they consider may be homeless or threatened with homelessness to a local housing authority. The Supporting people experiencing homelessness and rough sleeping toolkit provides guidance to emergency departments on how to meet this duty.

Employment status recording: as key determinant of health, occupation status should be routinely recorded to identify patterns of health and socioeconomic inequality, including the risk of economic inactivity due to ill health. Data on employment status can highlight where poor health and deprivation contribute to disease burden, lower healthy life expectancy and higher economic inactivity among working-age adults. It should be used to inform the strategic commissioning of work and health pathways and to understand how unequal access to services affects outcomes. This supports the government’s Get Britain Working White Paper, which commits to scaling the contribution of the NHS and wider health system to improve employment outcomes.

Disability status recording: Disabled people often face barriers to accessing healthcare, experience poorer health outcomes, and are disproportionately affected by social and economic exclusion. Up to 10 million people have hidden disabilities such as a mental health condition or learning disability. Capturing disability data enables the NHS to identify patterns of unmet need, tailor services more effectively, and address disparities in access, experience, and outcomes, including through making reasonable adjustments. It supports strategic planning and commissioning of inclusive services, aligns with the NHS’s legal duties under the Equality Act 2010, and contributes to a more equitable health system.

3.4 Using information on health inequalities

NHS bodies should use information on health inequalities to develop actionable insights to inform strategies and plans for commissioning, resource allocation and service improvement. As outlined in the Medium Term Planning Framework, ICBs will develop 5-year integrated strategic commissioning plans – also known as population health improvement plans – focused on improving population health and addressing health inequalities. Trusts and foundation trusts will develop 5-year integrated delivery plans, focused on delivering national and local priorities, and improving quality and operational performance.

Where available, service and pathway redesign should draw on national modern service frameworks and guidance, alongside local intelligence, to ensure best practice and evidence is considered from a range of sources.

Clear governance and accountability mechanisms should be in place for monitoring progress towards equitable access and outcomes, with a focus on assurance that activities are delivering the expected changes and have the necessary operational and financial support. Healthcare inequalities should form a core part of NHS bodies’ analysis of performance against national standards and local ambitions, and should be included routinely in board reporting. Executive leads for health inequalities play a key leadership role in overseeing and ensuring that information is embedded into board reporting. The Insightful board guidance provides guidance on what boards should be looking at, and how to drive better outcomes, better productivity, and better decisions.

ICBs – as strategic commissioners – are expected to improve population health, reduce health inequalities and improve equitable access to consistently high-quality healthcare. The Strategic commissioning framework sets out that, in line with Core20PLUS5, ICBs should ensure they understand how different population groups access services and experience care and how their outcomes vary, and consequently how any gaps will be narrowed through the ICB strategy and population health improvement plan. ICBs commissioning will be guided by population segmentation and risk stratification, to ensure commissioning models take a person-centric approach to address the drivers of risk and have a sharp focus on equity in access, experience and outcomes. To drive efficiency, ICBs should identify how inequalities drive cost variation, and how resource allocation can be targeted to where it will have the greatest impact.

Strong relationships with local government partners, including working with local health and wellbeing boards, will be required to build a shared understanding of their population, develop neighbourhood health approaches and, where appropriate, jointly commission services. This should be underpinned by engagement and co-production with patients and the public.

Trusts and foundation trusts should ensure that information on health inequalities is used as part of trust-wide improvement approaches. This includes engaging with those who are seldom heard, such as people from inclusion health groups and people who have a learning disability or require support to communicate.

The independent Review of patient safety across the health and care landscape has recognised equity as a core dimension of quality. To drive quality, frontline teams should be empowered with access to data, to inform coherent and actionable improvement plans, supported by routine monitoring of progress towards closing gaps in access, experience or outcomes between groups. Trusts should work with local partners and collate a range of data sources to build a picture of inequalities in access, experience and outcomes and understand the drivers behind these.

3.5 Publishing information on health inequalities

NHS bodies must, at a minimum, publish information on health inequalities alongside or within annual reports. In line with the expectations set out in this statement, this should demonstrate an understanding of:

• population level health inequalities
• inequalities in access, experience and outcomes from healthcare services
• how this information has informed action and evaluation of improvement interventions

Guidance on what to include in the annual report is provided in section 4.

ICBs should at a minimum publish information at an ICB level. However consideration should be given to publishing information that shows inequalities at sub-ICB level, including at place or neighbourhood level or by mapping geographical variation at ward level to demonstrate small-area inequalities which may be masked when viewing data at larger geographical levels. This is particularly relevant where ICBs have been clustered or restructured to form larger organisations.

Note: it is expected that an annual report for 2025/26 will need to be produced for each of the 42 current ICBs, but that for those being dissolved and replaced by new ICBs on 1 April 2026, this duty will fall to their successor ICBs.

ICBs may also wish to publish information at an individual NHS trust level, subject to discussion with the relevant trusts.

NHS trusts and foundation trusts should publish information at a trust level. Even where the information is also included in the relevant ICB(s)’ annual report, a trust must still set out within its annual reports how it has complied with legal duties in relation to health inequalities.

NHS bodies should routinely publish information throughout the financial year – not solely in annual reports – to increase transparency and accountability for addressing health inequalities. Where NHS bodies publish information about the performance of their services or progress towards strategic plans, this should include information about how health inequalities have been impacted.

Information on health inequalities should be embedded in routine reporting within the organisation. At a minimum, it is good practice for boards to review health inequalities trends at quarterly intervals. This could be presented as part of board reports or board performance dashboards, to support evidence-based discussions about service planning, quality improvement and resource allocation. This should include performance data disaggregated by demographics and information about quality of care and access to services, including qualitative metrics, such as patient reported outcomes measures (PROMS) and patient reported experience measures (PREMS).  

In relation to data protection, it should be possible to report on health inequalities using existing anonymised data sources – for instance derived from Hospital Episode Statistics (HES) and Secondary Uses Service (SUS) data – without any additional processing of confidential patient information. If additional confidential patient information is required for health inequalities analysis and reporting, then NHS bodies will need to make sure they meet the requirements of the common law duty of confidentiality and data protection law.

4. What should NHS bodies include in and alongside their annual reports?

NHS bodies must include in their annual reports a review of the extent to which they have exercised their functions consistently with NHS England’s views in this statement. NHS England’s views on how these powers should be exercised are outlined in section 3.

NHS bodies should use the KLOEs (appendix 2) to reflect how they have met NHS England’s views in the annual report and use the measurement framework (appendix 3) to evidence this.

The KLOEs encourage NHS bodies to reflect on how they have taken a whole-scale approach to embedding health inequalities improvement across planning, delivery, monitoring and governance, in line with national strategic priorities. NHS bodies can choose to structure their annual reports around key analyses which highlight the most prominent inequalities across national and local priorities, or use the KLOEs to form the basis of a narrative supported by published data.

It is also NHS England’s view that NHS bodies must exercise their functions to publish health inequalities information within or alongside annual reports – this includes both quantitative and qualitative information. NHS bodies should publish information that reflects a balance of national and local priorities. The measurement framework (appendix 3) is intended to support this expectation by outlining a menu of core measures that align to national priorities and supporting measures that encourage a deeper understanding of areas of inequalities and how this affects population health outcomes.

However, annual reports must go beyond qualitative statements of ambition and  descriptions of activity, and demonstrate an evidence-based response to service-level and population-level inequalities. This includes clear reflection on:

• how this data has informed action
• the degree to which expected progress towards local health inequalities ambitions has been made

Any assurance given on progress towards addressing inequalities in access and outcomes should be accompanied by clear evidence and narrative about how this progress is being monitored, and what trends show within the data being used to do so.

NHS bodies must publish information on how health inequalities have been identified and addressed within national operational priorities and Core20PLUS5 clinical priorities (appendix 3). Within this, emphasis should be given to measures most relevant to both local populations and relevant bodies’ services.

NHS bodies must also report on the completeness of ethnicity data within their annual report. The measurement framework (appendix 3) includes a menu of measures to guide selection and analysis of data, but these are not a mandatory or exhaustive list.

Annual reports should move beyond reporting on nationally set core metrics. Reporting on the core measures for a chosen clinical domain should be considered the minimum expectation. This should be supplemented with supporting measures and local analysis which explores the drivers of these inequalities.

The following examples illustrate the approach different NHS bodies may take.

If data has been used during the year to address health inequalities, but is not included in appendix 3, it can still be used within the annual report to demonstrate compliance with legal duties on health inequalities. NHS bodies can draw on local data, national data sets, routine reporting or existing information collected as part of service planning, commissioning, delivery and monitoring – provided that this leads to a robust, evidence-based account of how the NHS body has identified and sought to address inequalities in access and outcomes across different population groups, including how these have changed over time.

This aims to minimise burden and maximise links between annual reporting and use of data throughout the year. Sources of health inequalities information could include equality and health inequalities impact assessments (EHIAs) for a service, information collected as part of compliance with the Public Sector Equality Duty (PSED), Patient and carer race equality framework (PCREF) or actions taken as a result of LeDeR reviews.

Presentation of data should adhere to the following principles:

• transparent and accessible – a member of the public should be able to read the report and understand action being taken locally to identify and address inequalities in access to health care services and health outcomes
• clearly presented data with graphic overviews, statistical summaries and commentary
• rates or percentages consistently adopted to show relative significance and to allow for comparison, for example with national averages or with ‘statistical neighbours’
• disaggregated data used to identify differences in health need, access to services, activity and outcomes across different population groups
• statistical tools used to account for random variation (for example, using 95% confidence intervals) and age and sex standardisation used to allow for comparisons between population groups
• disclosure controls and small number suppression to protect patient confidentiality
• key themes or trends which may identify what drives inequalities are explored
• successes, innovation or examples of improvement are highlighted, alongside reflections on challenges or gaps, and how these will be addressed  

What good looks like

A high-quality annual report shows how robust health inequalities data is used across services and in the organisation’s oversight, accountability and quality mechanisms. Data should reflect the approach taken throughout the reporting year. The report should explain how the organisation collects, analyses and uses data in line with this guidance, demonstrating that the consideration of health inequalities is embedded in a data-driven way throughout the year.

5. Further information

5.1 Questions and feedback

Please send questions, information on the type of support you would find useful or feedback to: england.healthinequalities@nhs.net

5.2 Additional resources

National healthcare inequalities improvement frameworks

• NHS England – A national framework for NHS – action on inclusion health
• NHS England – Inclusive digital healthcare: a framework for NHS action on digital inclusion
• NHS England – Improvement framework: community language translation and interpreting services
• NHS England – Patient safety healthcare inequalities reduction framework
• NHS England – Ethnicity recording improvement plan

To access data tools and resources that can support health inequalities analysis, please visit the Healthcare Inequalities Improvement Programme’s Futures page (Futures Collaboration Platform log in required).

Appendix 1: Powers available to NHS bodies to collect, analyse and publish information about health inequalities

ICBs

ICBs have the following duties or powers that should enable and inform collection, analysis and publication of information on inequalities.

1. The core general duty to arrange healthcare services to meet reasonable requirements for the people for whom it is responsible (section 3 of the NHS Act 2006) and the associated commissioning power (section 3A of the NHS Act 2006). It is NHS England’s view that the arrangement of healthcare services includes understanding the needs of the population the ICB is responsible for, any barriers to access and the effectiveness of services. In commissioning services, ICBs must act consistently with the NHS Mandate (sections 3(4) and 3A(4) of the NHS Act 2006). The Strategic commissioning framework outlines NHS England’s expectations for how ICBs should develop their commissioning approach.
2. The power to do anything which is calculated to facilitate, or is conducive or incidental to, the discharge of any of its functions (section 2 of the NHS Act 2006) – this duty, in conjunction with the core commissioning duty described above and the functions listed below, is likely to provide the key statutory foundation for processing information. This power can include collecting, analysing and publishing information insofar as it is done in compliance with other legal requirements, including the matters set out below.
3. The duty to exercise functions (among other things) efficiently and effectively (section 14Z23).
4. The duty (jointly with NHS trusts and NHS foundation trusts) to produce a forward plan annually (section 14Z52), including in particular addressing the needs of children and young people and those who are the victims of abuse. NHS England has published guidance on developing a forward plan.
5. The responsibility (jointly with upper tier local authorities) to produce joint strategic needs assessments, and health and wellbeing strategies, and to have regard to them, under section 116 and section 116A of the Local Government and Public Involvement in Health Act 2007.
6. The duty, as a member of an integrated care partnership, to produce, publish and keep under review an integrated care strategy, under section 116ZA of the Local Government and Public Involvement in Health Act 2007. The Secretary of State published statutory guidance on the creation and content of the strategy, including matters relating to health inequalities.
7. The duty of an ICB to have regard to reducing inequalities in the exercise of functions (in section 14Z35 of the NHS Act 2006), including by reference to access and outcomes.
8. Public involvement duties and promotion of patient involvement (sections 14Z36 and 14Z45 respectively). NHS England has published statutory guidance on working in partnership with people and communities.
9. The duty, in the exercise of its functions, to facilitate or promote research into matters relevant to the health service, and the use in the health service of evidence obtained from research (section 14Z40).
10. Duties to have regard to the wider effects of decisions, including in inequalities issues (section 14Z43 of the NHS Act 2006).
11. General duties under the public sector equality duty in section 149 of the Equality Act 2010, and the specific duties to create and report equalities information further to the Equality Act 2010 (Specific Duties and Public Authorities) Regulations 2017. NHS England published guidance: A reference document for NHS commissioners and providers to support NHS bodies meet their legal duties for both health inequalities and equalities.

NHS trusts

NHS trusts have the following duties or powers that should enable and inform the collection, analysis and publication of information on inequalities:

12. Duties to provide goods and services as part of the health service (section 25 of the NHS Act 2006).
13. Duties to exercise functions efficiently, effectively and economically (section 26 of the NHS Act 2006).
14. Duty to have regard to likely wider impacts of decisions, including on wellbeing (section 26A of the NHS Act 2006).
15. Powers to do anything which appears to it to be necessary or expedient for the purposes of or in connection with its functions (schedule 4, paragraph 14 of the NHS Act 2006).
16. Public involvement duties (section 242 NHS Act 2006).
17. Powers to undertake research (schedule 4, paragraph 16 of the NHS Act 2006).
18. General duties under the public sector equality duty in section 149 of the Equality Act 2010, and the specific duties to create and report equalities information further to the Equality Act 2010 (Specific Duties and Public Authorities) Regulations 2017.

NHS foundation trusts

NHS foundation trusts have the following duties or powers that should enable and inform the collection, analysis and publication of information on inequalities:

19. Duties to provide goods and services as part of the health service (section 43 of the NHS Act 2006).
20. Powers to do anything which appears to it to be necessary or expedient for the purposes of or in connection with its functions (section 47 of the NHS Act 2006).
21. Duty to have regard to likely wider impacts of decisions, including on wellbeing (section 63A).
22. Public involvement duties (section 242 of the NHS Act 2006).
23. General duties under the public sector equality duty in section 149 of the Equality Act 2010, and the specific duties to create and report equalities information further to the Equality Act 2010 (Specific Duties and Public Authorities) Regulations 2017.

Appendix 2: Key lines of enquiry (KLOES) to inform how inequalities information should be used

As set out in section 3.4, information on health inequalities should be used by NHS bodies to inform service improvement and guide targeted action.

As set out in section 4, NHS bodies are required, in their annual reports, to review the extent to which it has exercised its functions consistently with NHS England’s views set out in this statement. NHS bodies should use the KLOES below as prompts to articulate how, throughout the reporting year, they have:

• identified population health need
• addressed data quality issues
• analysed inequalities in healthcare access, outcomes and experience
• used information to inform targeted action and service improvement

Understanding population health needs

• What steps have been taken to understand health needs and inequalities experienced by local ‘Core20’ and ‘PLUS’ population groups, for example, ethnic minority communities, people with a learning disability, autistic people, groups that share protected characteristics, inclusion health groups and coastal or rural communities, across a range of clinical domains?
• How is intersectionality between these groups explored, for example, inequalities that may exist for people with a learning disability from different ethnic backgrounds, or children and young people from deprived areas.
• What steps have been taken to understand the prevalence and distribution across your geography of risk factors for healthcare inequalities, for example, digital exclusion, geographical access barriers such as transport, health literacy, language barriers? How has this insight informed targeted planning, commissioning and delivery of services?

Improving data quality, collection and analysis

• What actions have been taken to identify and improve the completeness and accuracy of coding and recording practices, including for ethnicity, other protected characteristics and socioeconomic factors such as housing status?
• How is data processed and, where relevant, linked to identify population groups who are underrepresented in the NHS data sets and to understand pathways across services and patterns of access and demand among groups experiencing inequalities?
• Where gaps in data quality affect the ability to carry out healthcare inequalities analysis, how is assurance undertaken on steps to address these?

Understanding healthcare access, experience and outcomes

• To what extent have health inequalities across a range of population groups and clinical domains been identified as a driver of trends in performance, productivity and resource utilisation?
• How is routine performance data – including elective and urgent and emergency care data – analysed and broken down by deprivation, ethnicity, age and sex, to better understand areas of inequality, and how have other triangulated sources of insight supported an understanding of the drivers of these including barriers to access or inequalities in patient experience?
• How is analysis being undertaken to identify those who frequently attend A&E, and understand the health inequalities they face, to inform proactive targeted support?
• How has local data been analysed to better understand areas of inequality in access to primary care, and how have other triangulated sources of insight supported an understanding of the drivers of these?
• How has qualitative information, such as patient reported outcomes measures (PROMs) and patient reported experience measures (PREMs) been collected and analysed to address healthcare inequalities?   

Using information to take action on health inequalities

• How has information on health inequalities informed strategic commissioning decisions, pathway redesign or long-term strategies?
• How has information on health inequalities informed quality improvement approaches in service delivery, including in neighbourhood health models?
• To what extent have inequalities in population health outcomes been used to inform decision making? Where trends exist, what ambitions have been set to target improvements?

Publishing information on health inequalities

• How is health inequalities data incorporated into performance reporting at board level, and what has been the impact of this on reducing health inequalities?
• How have action plans to reduce inequalities in access and quality of care been developed and monitored across services and pathways?

Appendix 3: Measurement framework for collecting, analysing and publishing information on health inequalities

The measures set out here are guidelines (and not prescriptive) based on broad national evidence about health inequalities and its drivers. NHS bodies may use national data sources, or draw on data from local analysis, routine reporting or existing information collected as part of service planning, commissioning, delivery and monitoring to demonstrate how they are identifying and addressing health inequalities.

Relevant data sources have been outlined. Where data is being drawn from unpublished management information, organisations can publish their own figures from locally collected and validated data. Organisations must not publish national, regional or local comparisons from unpublished national management information.

The measurement framework includes:

• core measures: areas of analysis linked to key national priorities around improving access, experience and outcomes, which should therefore be prioritised for analysis and publication of data
• supporting measures: areas of analysis which support a further understanding of wider inequalities including population health, which should be used to support a contextual analysis of the drivers of key inequalities and priorities

NHS bodies should demonstrate how data has been analysed in line with the Core20PLUS5 approach. Where ‘inequalities’ are referenced, consideration should be given both to ‘Core20’ (the proportion of the population from the 20% most deprived nationally as identified by IMD), and locally identified ‘PLUS’ groups (including ethnic minorities, inclusion health groups, people experiencing digital exclusion, rural and coastal communities, LGBTQ+ communities, people with multiple long-term health conditions, people with a learning disability and autistic people, or other groups with protected characteristics). Insight can be drawn from disaggregated data and other forms of evidence to account for gaps in data quality for some groups (for example, those experiencing homelessness).

Operational priorities

Elective care and community services

Core measures

• inequalities in percentage of people waiting 18 weeks or less for elective treatment*
• inequalities in percentage of people waiting over 52 weeks for elective treatment**
• inequalities in annual change in size of waiting list**
• inequalities in percentage of people waiting over 18 weeks, over 52 weeks, over 104 weeks for community services*

*Links to the Medium Term Planning Framework 26/27-28/29 and the NHS Oversight Framework 25/26
**Links to NHS Oversight Framework 25/26

Supporting measures

• inequalities in rates of did not attends/was not brought across elective services
• inequalities in rates of did not attends/was not brought across community health services
• inequalities in access to core community health services
• inequalities in access to community health services for people who are frail

Potential data sources: Hospital Episode Statistics data, Waiting List Minimum Data Set

Urgent and emergency care

Core measures

• inequalities in mean time in emergency department
• inequalities in the proportion of ambulance patients in cardiac arrest that receive a post-ROSC care bundle
• inequalities in the proportion of ambulance patients with a ST-elevation myocardial infarction (STEMI) that receive the appropriate care bundle

Supporting measures

• inequalities in rates of ambulance calls across different patient groups

Potential data sources: Emergency Care Data Set

Core20PLUS5 (adults)

Maternity

Core measures

• inequalities in gestational age at booking*
• completeness of ethnicity data in the Maternity Service Date Set (MSDS)*

*Links to Maternity and Neonatal Equities and Equalities Dashboard

Supporting measures

• inequalities in women who have a post-partum haemorrhage*

Potential data sources: Maternity Services Data Set, Maternity and Neonatal Equities and Equalities Dashboard

Mental health

Core measures

• inequalities in people achieving access and outcomes for NHS Talking Therapies*
• inequalities in rates of restrictive interventions in inpatient services**
• inequalities in use of the mental health act including use of community treatment orders (CTOs)**
• rates of eligible patients with severe mental illness (SMI) receiving an annual physical health check and action plan**

*Links to Medium Term Planning Framework 26/27-28/29, NHS Oversight Framework 25/26 and the Patient and Carer Race Equality Framework (PCREF)
**Links to NHS Oversight Framework 25/26 and/or the PCREF

Supporting measures

• inequalities in access to mental health services, including NHS Talking Therapies and other adult community mental health services ​
• inequalities in rates of premature mortality for people with severe mental illness
• inequalities in rates of diagnosed mental health conditions
• inequalities in the social determinants of health that impact on the prevalence of, acuity and recovery from mental health conditions​
• inequalities surfaced in patient reported outcome and experience measures recorded in local and national tools

Potential data sources: Mental Health Services Data Set, Public Health Outcomes Framework, Fingertips

Respiratory disease

Core measures

• inequalities in non-elective bed days occupied by asthma, chronic obstructive pulmonary disease (COPD) and community-acquired pneumonia (CAP)
• inequalities in pulmonary rehab completion rates

Supporting measures

• inequalities in access to diagnostic procedures for respiratory disease
• inequalities in under 75 premature mortality rate from chronic lower respiratory disease

Potential data sources: Hospital Episode Statistics data, Public Health Outcomes Framework, Fingertips, Quality and Outcomes Framework (QOF) data, National Respiratory Audit Programme

Smoking cessation

Core measures

• inequalities in inpatients making a supported quit attempt with an in-house tobacco dependence treatment service*
• inequalities in inpatients who successfully quit smoking as measured at 28 days after commencing a supported quit attempt
• inequalities in percentage of pregnant women identified as smokers at antenatal booking who are identified as non-smokers at 36 weeks gestation*

*Links to NHS Oversight Framework 25/26

Supporting measures

• inequalities in smoking prevalence in adults (18+)
• inequalities in smoking at time of delivery (SATOD) status*

**Links to Maternity and Neonatal Equities and Equalities Dashboard

Potential data sources: Hospital Episode Statistics data, Public Health Outcomes Framework, Fingertips Smoking Profile, Quality and Outcomes Framework data (QOF), Tobacco Dependence Patient Level Dataset, Model Health System, Stop Smoking Service Data Explorer, Maternity and Neonatal Equities and Equalities Dashboard

Vaccines

Core measures

• inequalities in uptake of COVID and flu vaccines

Cancer

Core measures

• inequalities in percentage of cancers diagnosed at stage 1 and 2*

*Links to NHS Oversight Framework 25/26

Supporting measures

• inequalities in rates of 5-year survival following a cancer diagnosis
• inequalities in cancer screening coverage – including bowel cancer, breast cancer, cervical screening

Potential data sources: Hospital Episode Statistics data, Public Health Outcomes Framework, National Disease Registration Service, Screening datasets

Cardiovascular disease

Core measures

• inequalities in emergency admissions for stroke*
• inequalities in emergency admissions for myocardial infarction*
• inequalities in percentage of hypertension patients treated to target*
• inequalities in percentage of patients who are manged to target for cholesterol
• inequalities in percentage of patients who are manged to target for atrial fibrillation

*Links to NHS Oversight Framework 25/26

Supporting measures

• inequalities in percentage of adults classified as overweight or obese
• inequalities identified in hypertension case finding
• inequalities identified in detecting patients with risk of stroke
• inequalities in proportion of patients discharged from hospital who access stroke rehabilitation
• inequalities in the proportion of patients discharged from hospital following a heart attack that access rehabilitation
• inequalities in case fatality for stroke
• inequalities in case fatality for myocardial infarction
• inequalities in premature mortality from cardiovascular disease

Potential data sources: Hospital Episode Statistics data, Quality and Outcomes Framework (QOF) data, Public Health Outcomes Framework, CVDPREVENT, Sentinel Stroke National Audit Programme, National Audit of Cardiac Rehabilitation

Learning disability and autism

Core measures

• number of people in a mental health inpatient setting who have a learning disability or are autistic*
• percentage of patients aged 14+ on GP learning disability registers who have had an annual health check**
• percentage of people with suspected autism waiting more than 13 weeks for contact**

*Links to the Medium Term Planning Framework 26/27-28/29 and the NHS Oversight Framework 25/26

**Links to NHS Oversight Framework 25/26

Supporting measures

• percentage of people who have had a learning disability annual health check who have an accompanying health action plan
• length of stay for people with a learning disability and autistic people in a mental health inpatient setting
• number of adults with a learning disability or who are autistic in a mental health setting.
• inequalities identified in Learning Disability Improvement Standards
• inequalities identified in learning from lives and death reviews (LeDeR) faced by people with a learning disability and autistic people

Potential data sources: Mental Health Services Data Set, Assuring Transformation, Learning Disability Health Check Scheme, LeDeR reviews, Autism Waiting Times Statistics, Health and Care of People with Learning Disabilities, Learning Disability Improvement Standards

Core20PLUS5 (Children and young people)

Urgent, emergency and community care

Core measures

• inequalities in children and young people (CYP) emergency department attendances
• inequalities in accessing specialist paediatric and multidisciplinary support for CYP in community settings

Supporting measures

• inequalities in percentages of CYP attending ED departments without admissions
• inequalities in percentages of attendances broken down by acuity reported at triage
• inequalities in percentages

Potential data sources: Emergency Care Data Set

Asthma

Core measures

• inequalities in CYP asthma, including emergency department admissions and dispensing of reliever only inhalers

Supporting measures

• inequalities in prevalence of childhood asthma (under 18)

Potential data sources: Emergency Care Data Set, ePACT2

Diabetes

Core measures

• inequalities in percentage of CYP with type 1 and 2 diabetes receiving all the recommended NICE care processes*

*Links to NHS Oversight Framework 25/26

Supporting measures

• inequalities in percentage of CYP using diabetes technology, including continuous glucose monitoring, insulin pump, and hybrid closed loop

Potential data sources: National Diabetes Audit, National Paediatric Diabetes Audit

SEND, learning disability, autism and epilepsy

Core measures

• inequalities in access to epilepsy specialist nurses in the first year of care for those with a learning disability or autism

Supporting measures

• inequalities identified in National Child Mortality Database (NCMD) deep dives experienced by autistic children and young people, and those with a learning disability
• number of under 18s with a learning disability or who are autistic in a mental health inpatient setting

Potential data sources: Epilepsy12 audit, National Child Mortality Database

Oral health

Core measures

• inequalities in elective admissions of hospital-based tooth extractions due to dental caries

Supporting measures

• inequalities in percentage of children and young people with visibly obvious dental decay

Potential data sources: Public Health Outcomes Framework, OFSTED, Oral health survey of 5 year old school children

Mental health

Core measures

• inequalities in access rates to CYP mental health services for 0–17-year-olds*

*Links to NHS Oversight Framework and/or the Patient and Carer Race Equality Framework (PCREF)

Supporting measures

• inequalities in rates of diagnosed mental health conditions
• inequalities in the wider social determinants of health that impact on the prevalence of, acuity and recovery from mental health conditions
• inequalities identified in patient pathways, such as late entry/presentation to mental health services, differences in routes into services (for example, police vs. primary care) and rates of unattended contacts
• inequalities in the use of restrictive forms of care (such as the Mental Health Act detentions and restrictive interventions)
• patient reported outcome and experience measures recorded in local and national tools

Potential data sources: Mental Health Services Data Set

Data quality

Ethnicity recording

Core measures

• percentage of records with blank or null codes for ethnicity
• percentage of records with residual ethnic codes, including:
  • not stated
  • not known
• percentage of patient records with a valid, non-residual ethnicity code in data sets

Potential data sources: Admitted Patient Care, Emergency Care Data Set, Mental Health Services Data Set, Community Services Data Set, Maternity Services Data Set, Data quality maturity index

Publication reference: PRN02112