Andrew Fenton reflects on a re-energised NHS focus on health inequalities, a place-based approach, and the vital role of ICS partnerships.
The slow re-emergence of an NHS focus on health improvement and inequalities
It's taken a long time, but population health, health improvement and reducing health inequalities are now firmly back on the agenda for the NHS. Looking back to 'Liberating the NHS' (the explosive 2010 White Paper that led to large-scale NHS re-organisation in 2013) 'population health' is only mentioned three times, and 'health inequalities' also just three. Whilst 'health improvement' bags 10 mentions, that related mostly to the move of Public Health to Local Government.
But by the Long Term Plan (Jan 2019) and now the Integration and Innovation White Paper (Feb 2021), population health, population health management, and health inequalities all have prominence in the strategy for how the NHS in England plays a vital role to get upstream on long-standing problems in the nation's health.
New but not new
Of course, if you've been working in Public Health these long years, perhaps moving from the NHS into Local Government in 2013, the renewed NHS interest in health improvement and inequalities may be looked on with scepticism. Everyone knows that only about 20% of health outcomes are influenced by healthcare services, with the dominant factors relating to housing, employment, the environment, and the experience of early years.
Smoking, physical inactivity, poor diet, and alcohol may be the most direct cause of much ill-health, but in Michael Marmot's phrase, the focus needs to be on 'the causes of the causes'. So whilst there is a renewed focus and energy in the NHS on health improvement and inequalities, largely emerging out of the highly unequal experience of the COVID-19 pandemic, we need to put this in a long-term context and understand what could be different this time, and what role NHS organisations and ICS Partnerships can play.
Improvement, inequalities and the role of ICSs
One aspect of what's new this time (at least in a post-2010 context) is that the now England-wide Integrated Care Systems (42) have population health improvement and the reduction in health inequalities core to their purpose:
- Improving outcomes in population health and healthcare
- Tackling inequalities in outcomes, experience and access
- Enhancing productivity and value for money; and
- Helping the NHS to support broader social and economic development.
What is particularly welcome is the much stronger focus now on the role of the NHS in reducing health inequalities, with attention to disparities in both healthcare access and health outcomes.
The impact of the Covid pandemic has been so starkly unequal across society, reflecting the historic and well-evidenced pattern of disparities linked to social deprivation and across ethnic minorities, that there is now a greater sense of urgency for the role the NHS can play with a wide range of partners. COVID-19 deaths have followed an all-too-familiar pattern with mortality rates twice as high in the most deprived 10% of areas compared with the least deprived areas.
But whilst ICS's will have formal (and expected to be statutory) responsibilities for health improvement and reducing health inequalities, much of the real action and potential for impact happens at either the higher national level or at 'place' level - typically aligned to Local Authority boundaries or in some cases historic patient flow. Nationally, so much rides on social and economic policy, and a 'health in all policies' approach.
The role of the new Office for Health Promotion and the expected cross-Ministry board are key elements of the reformed public health system being created. Also of importance is the development of the new Health Inequalities Improvement Team at NHSE, under the leadership of Dr Bola Owolabi, which will play a key role in expectations on and support for ICSs in their role on inequalities.
Place, community, neighbourhood
Most of the heavy lifting involved in integrating care and improving population health will happen more locally in the places where people live, work and access services. Place-based partnerships within ICSs will therefore play a key role in driving forward change.
It's at the geographic levels below ICSs that much of the leg-work on partnership building and links with communities takes place, with the emphasis on population need across a geography rather than organisational interests, and through to community and neighbourhood level. With the welcome recognition of the key role of population health management, one risk to avoid is to over medicalise the support and action on health improvement, and to ensure a localised joint focus on the wider determinants of health.
Two recent reports help bring the issue of place-based collaboration into focus. From the King's Fund, Developing place-based partnerships: The foundation of effective integrated care systems. This is a valuable report based on research with a number of ICSs and identifies key functions and principles for partnerships that bring together primary care, local government, community and voluntary organisations, and secondary care providers. Core to the report is the emphasis on local action that develops community and asset-based approaches to health improvement, with partnerships coordinating the focus on -
- Developing an in-depth understanding of local needs
- Connecting with communities
- Collectively focusing on the wider determinants of health
- Mobilising local communities and building community leadership
- Harnessing the local economic influence of health and care organisations
The Kings Fund report makes some good observations about the role of Primary Care Networks in place-based partnerships. Given the central role of PCNs in population health management (focused on providing upstream support and care interventions for patients based on their need and risk), it’s important that primary care teams are also closely engaged and influence wider action on health improvement and inequalities. But in the current context of intense demand and extensive concern about capacity in primary care, that engagement and input will be difficult to realise. It will be a challenge for General Practice to engage in transformational conversations when they are in survival mode.
And from the Health Creation Alliance (formally the NHS Alliance) with the RCGP, Primary Care Networks and place-based working: addressing health inequalities in a COVID-19 world provides more targeted attention on the role of PCNs, with some challenging ideas -
PCNs need to see themselves as part of a wider health and wellbeing system that reaches way beyond the NHS. The system needs a good vision for health in a place and partners need to find ways of working seamlessly to achieve it, building each other’s capacity to contribute along the way.
At a practical level, this can mean closer primary care involvement in partnership initiatives with local government and community groups (for example on substance abuse, physical activity, isolation, early years) and building a closer connection with population health management and the focus of additional roles such as Social Prescribing Link Workers and Health & Wellbeing Coaches.
The new PCN DES Additional Service specification on Tackling Neighbourhood Inequalities is expected this year, and it will be an important step in how primary care is supported and if there is any form of additional financial incentive.
Looking ahead, as ICSs develop further and form the arrangements for becoming statutory organisations, a big challenge will be how well they can support and enable place-based and local partnerships for action on health improvement and inequalities.
For more insights, watch this panel session from NHS Confed featuring a panel of leaders from health and care discussing this topic:
- Fiona Edwards, ICS Lead - Frimley Health and Care
- Dr Rupa Joshi, PCN Co-Clinical Director and GP - Wokingham North PCN and Woodley Centre Surgery
- James Williams, Director of Public Health - Medway Council