Equity is at the core of the NHS’ founding principles
So why, 74 years after its creation, do people experience inequitable health outcomes?
Hailed as “the first health system in any Western society to offer free medical care to the entire population”,[1] the NHS was designed, from inception, to be a universal service, free at the point of use, with access based on clinical need rather than an ability to pay. The NHS constitution states that it has “a wider social duty to promote equity through the services it provides and to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population.”[2]
Despite this fundamental commitment to equity, people in the different regions of England experience large variations in health outcomes.
Variations in health outcomes today
Age-adjusted mortality rates from COVID-19 are two to three times higher among black ethnic groups compared with white ethnic groups.[3]
The life expectancy of people with a learning disability is 23 to 27 years less than the rest of the population.[4]
The difference in healthy life expectancy between the most and least healthy places in England is 26.2 years.
The life expectancy of men in the 10% most deprived areas of England was almost a decade less than those in the least deprived areas in 2017-19.[5]
Women in the 10% least deprived areas in England can expect to live almost eight years longer than those in the most deprived areas.
Even before the pandemic, life expectancy was falling in one in five communities for women and one in nine for men, mostly in urban areas of northern England.[6]
Discrepancies in health outcomes are driven by more than just healthcare. The social determinants of health (SDoH) are “the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.”[7] Healthy People 2020, a US federal government initiative, organises the SDoH into five themes:
- economic stability;
- education;
- health and healthcare;
- neighbourhood and the built environment; and
- social and community context.[8]
The Marmot Review, which assessed strategies to address health inequities in England in 2008, summed up the outcomes of these themes succinctly: “People with a higher socio-economic position in society have a greater array of life chances and more opportunities to lead a flourishing life. They also have better health. The two are linked.”[9]
In fact, access to healthcare is estimated to influence up to 20% of total health outcomes[10], which is often taken to mean that the NHS has limited scope to significantly improve these inequities. But the NHS doesn’t just provide healthcare. It is also one of the world’s biggest employers, employing roughly one in 20 people in the UK. It also has huge economic power, with an annual budget of £136 billion in 2021/22[11] and a real estate portfolio estimated at more than £30 billion[12]. In other words, its impact reaches across all five SDoH themes. And even if it didn’t, the 20% of outcomes influenced by access to healthcare represents a significant opportunity to maximise its impact on health equity.
This poses the question: Is the NHS maximising its impact on health equity? And, if not, what more could it do?
Defining health equity
Throughout this paper we use the World Health Organization’s definition:
“Health equity is defined as the absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically or geographically.”[13]
Our work on health inequities
Over the last year we have conversed with experts and leaders, some of whom work within the NHS, researching how health inequities manifest in England and how they could be influenced by the NHS. These interviews also included individuals from across the public sector, charities and PwC’s international colleagues. To complement this, we polled approximately 2,000 members of the public to understand broader perspectives on what role the NHS should play in reducing health inequities, asking their views of it as a provider, employer and buyer. Our respondents are from diverse backgrounds, varying by region, age, ethnicity, employment, income and education. Our primary research polling is UK wide, for the NHS statistics, we have focused on NHS England as UK-wide data sets are not available. Many of our recommendations can be applied to the UK.
Since launching our summary report in June 2022, we have continued to receive input from across the NHS and wider communities. We are pleased to now outline our findings and recommendations in greater detail.
Our findings
Our findings show that a huge amount of work is already underway in many areas, with a notable gear change evident over the last 18 months. This follows commitments to prevent and address healthcare inequalities in the NHS Long Term Plan, and five strategic priorities being included in the NHS Operational Planning Guidance 2021/22.[14] Describing the extraordinary work happening every day across the NHS would be a monumental task, so we have focused our attention on a handful of areas where we believe tangible action could be taken. As such, we have identified nine key findings and ten recommendations, which are supplemented with case studies of good practice that could be replicated more broadly.
Each button reveals the findings and recommendations under each theme.
The NHS as a provider
1. The formula used to distribute funding includes adjustments aimed at improving health equity
But there are still some contrasts when comparing funding and outcomes. In addition, the move towards larger commissioning footprints risks significant variations being obscured at the local level.
Although there is a negative correlation between funding and life expectancy/ healthy life expectancy (i.e. places with relatively poorer outcomes tend to receive higher funding per capita, owing in part to the health inequities adjustment in the funding formula), the relationship is not strong. There are several examples of places with relatively poor levels of funding and poor outcomes and vice versa, as shown in the table here.
| NHS Leicester City CCG | Percentile | NHS East Sussex CCG | Percentile | |
|---|---|---|---|---|
| 2019-20 funding allocation per capita (£) | 1572 | 95% | 1880 | 27% |
| Average female life expectancy at birth | 82 | 73% | 84 | 22% |
| Average male life expectancy at birth | 77.3 | 92% | 80.2 | 27% |
| Healthy life expectancy women | 59 | 83% | 63 | 51% |
| Healthy life expectancy men | 59 | 86% | 65 | 25% |
| Incomplete pathways per hundred people | 20.18 | 52% | 21.54 | 68% |
| 52+ week waiters per hundred people | 2.87 | 99% | 0.37 | 11% |
| Population per GP | 1870 | 74% | 1911 | 77% |
| COVID-19 deaths per capita | 158 | 56% | 138 | 43% |
Making comparisons like this has become more difficult as the number of CCGs in the country has decreased in recent years because of larger footprints obscuring differential investment and outcomes between areas.It will become increasingly difficult following the creation of Integrated Care Boards (ICBs) earlier this year. Although larger footprints have many advantages, averages across large geographies risk obscuring significant variations within them. As a result, historical disparities in services and funding could become entrenched.
For example, prior to the merger of CCGs in North West London, the Royal Borough of Kensington and Chelsea had some of the highest life expectancy statistics in the country, combined with funding per capita in the top 20% nationally. The funding for the post-merger North-West London CCG is in the bottom 20% and its outcomes are around the mean. This shifts the onus for allocating funding to overcome inequitable outcomes to ICB commissioning decisions rather than being driven systematically through the national funding formula.
2. There is more public support for equal access than there is for equity of outcomes
In our poll, 87% of UK adults believe that people should have equivalent access to NHS services regardless of where they live, while 56% think resources should be allocated according to where the need is greatest.
3. The NHS does not consistently measure and report equity measures across key performance metrics
For instance A&E, cancer and elective wait times are not consistently broken down and reported along ethnic, social and economic lines.
4. Adopting new methods for delivering services has the potential to reduce or exacerbate inequity
For example, virtual consultations make access to services much easier for people with mobility or travel restrictions, but risk excluding those with language or technology barriers. This mustn’t be used as an excuse to avoid virtual consultations becoming routine, but appropriate adaptations and alternatives need to be in place to ensure potential negative impacts are minimised.
The NHS as an employer
5. The NHS compares well to other large employers in terms of workforce diversity
As shown in the chart on this page, the ethnic diversity of the NHS workforce broadly reflects the working age population nationally.
6. But minority groups are poorly represented at more senior grades
The NHS Workforce Race Equality Standard Leadership Strategy shows that, despite improvements in consecutive years, Black, Asian and minority ethnic representation at bands 8a upwards is 11.2% despite making up 18.9% of the total workforce. Even though NHS gender analysis suggests a roughly even split of men and women in senior roles, women, who make up 77% of the workforce, are much more likely to be in less well-paid roles.[15] Equivalent measurements related to representation from different social backgrounds are not routinely reported.
7. Workforce wellbeing is being supported, but more could be done
Significant efforts have been made to increase support for staff wellbeing, particularly in relation to impact of the COVID-19 pandemic. But retention continues to be a challenge, and benefits and support for staff with some conditions and life events, such as bereavement, are inconsistent and often lag other leading employers.
The NHS as a buyer
8. Legislation has shifted procurement focus to the social determinants of health
The Social Value Act of 2012 shifted the procurement mantra from ‘low cost’ to ‘value for money’, and now there is an increasing move towards measuring social value in procurement decisions. But this is early in its development, and links between local health and social equity objectives are not made consistently.
9. There is scope to increase the use of the NHS’ buying power to put greater focus on local socio-economic determinants through the supply chain
A more focused and purposeful definition of value, linked to local health outcomes such as the SDoH (e.g. employment and air quality), would help the NHS make better use of the Social Value Act requirements in a way that specifically targets health equity.
Our recommendations
Click on the buttons to see the findings and recommendations under each theme.
The NHS as a provider
1. Increase the size of the health inequities adjustment in the ICB funding allocation formula to direct greater funding towards places with lower overall outcomes.
2. Use more consistent messaging to improve public understanding of the discrepancies in outcomes between different population groups. Reporting these metrics should be treated with the same significance as the 18-week and four-hour wait metrics, among other commonly reported measures.
3. Ensure that all key performance measures are systematically analysed and reported in a way that indicates equitable service use – by age, gender, location, economic deprivation, employment, education and race.
4. Each integrated care system (ICS) and provider should establish a comprehensive strategy for improving health inequities that includes measurable targets. This should be supported by programme boards/ working groups within providers taking practical steps to improve performance.
5. Boost the profile of health Equality Impact Assessments (EIAs) associated with changes in working practices and use them to inform mitigating actions rather than justifying inaction.
The NHS as an employer
6. Develop a national NHS Social Mobility Strategy, with actions based on evidence of good practice from top-ranked employers in both public and private sectors.
7. Scale up initiatives already in place in some parts of the country to create greater connections with local communities, such as driving increased numbers of apprenticeship schemes and partnering with schools in disadvantaged areas to further diversify recruitment.
8. Increase the pace and scope of action on workforce wellbeing, such as offering transport, greater potential for flexible working, and targeted support for employees with disabilities, medical conditions and life events (e.g. childbirth, adoption and bereavements).
The NHS as a buyer
9. Link supply chain and buying strategies to local health needs – for example, by including impacts on local population health issues (e.g. air quality or employment) as a scored element in procurement exercises.
10. Place a requirement on the suppliers of products and services to take action related to health equity, such as making progress against diversity targets, ethical procurement and investing in employee wellbeing.
Big actions for the NHS nationally
These findings and recommendations apply across various layers of the NHS. At a national level they include a handful of key actions that can be taken in the short term to make a significant impact across the whole service:
- Increase the size of the health inequities adjustment in the ICB funding allocation formula to direct greater funding towards places with lower overall outcomes.
- Systematise data collection to the most granular community level possible – to allow accurate and evidence-driven action.
- Require every ICS, place and trust to establish and resource a programme to use this data to inform tangible action at a local level.[16]
- Establish standard measurements that will be reported regularly and used to hold ICSs to account for delivering progress. The lag between input and impact means that this will need to be a mix of input measures (e.g. variation in wait times between ethnic, social and economic groups, uptake of apprenticeships or the proportion of goods and services sourced locally) and output measures (e.g. comparing the healthy life expectancy metric with the national average or between different groups within the ICS).
- Develop a national NHS Social Mobility Strategy, with measurements and reporting akin to the Workforce Race EqualityStandard (WRES).
Conclusion
Broader economic and policy issues will continue to act as headwinds to the NHS’ efforts to improve health equity. These include competing internal priorities, such as urgent and emergency care performance, the elective backlog, workforce shortages and financial pressures. For the NHS to successfully achieve this objective, action on health equity can’t compete with other priorities, but instead must be a foundational principle upon which the response to these other challenges are built.
Some themes are consistent across our examination of the NHS as a provider, employer and buyer. Two stand out:
Maximising the value of data.
The NHS collects and uses a huge amount of data but its analysis is inconsistent from an equity point of view. Improving this consistency would help better inform the public and point towards challenges and opportunities.
Using the opportunity afforded by ICSs and ICBs.
The development of ICSs and creation of ICBs represents an opportunity to cement the role of the NHS as a local anchor institution and accelerate its own action on health inequities, as well as influencing its partners more effectively.
We hear first-hand from our clients that health equity should be a higher priority in the NHS, an opinion that has been expedited by the pandemic. Public sentiment also resonates with this.
According to two thirds (68%) of UK adults, the pandemic has made health equity worse and 63% say the pandemic has had a negative impact on their access to health and/or social care services.
While there has been a recent doubling down on the issue, with the NHS showing great intent, increased focus and tangible action, this is inconsistent across the country.
The pandemic has shown that healthcare needs to be accessible and equitable to all, as the virus (and any future variants) affects everyone in society it did not affect everyone in the same way. The COVID-19 vaccination programme proved that enormous change can be achieved when resources, funding and leadership are focused on a clear, shared issue. Among the programme’s many impressive features, it used data to inform a strategy to maximise its effectiveness and target resources where the biggest opportunities lie. If health equity could be treated with the same urgency and inventiveness, amazing things could be achieved.
[1] Delamothe, Tony, ‘Founding Principles’, (2008)
[2] Department of Health and Social Care, ‘The NHS Constitution for England’, (updated 2021)
[3] Office for National Statistics, ‘Coronavirus (COVID-19) related deaths by ethnic group, England and Wales: 2 March 2020 to 15 May 2020’, (2020)
[4] The 2018 Learning Disabilities Mortality Review found the median age at death was 60 for men and 59 for women, for those (aged 4 and over) who died April 2017 to December 2018. This is significantly less than the median age of death of 83 for men and 86 for women in the general population.
[5] Men in the least deprived 10% of areas in England could expect to live to 83.5 years, almost a decade longer than men in the 10% most deprived areas (74.1 years). See Office for National Statistics, ‘Health state life expectancies by national deprivation deciles, England: 2017 to 2019’, (2021)
[6] Head, Emily, ‘Life expectancy declining in many English communities even before pandemic’, (2021)
[7] World Health Organization, ‘Social determinants of health’
[8] https://wayback.archive-it.org/5774/20220413183449/https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/interventions-resources
[9] Marmot, Michael, Goldblatt, Peter, Allen, Jessica, et al, ‘Fair Society, Healthy Lives (The Marmot Review)’, (2010)
[10] Hood, Carlyn M., Gennuso Keith P., Swain Geoffrey R,, and Catlin Bridget B., ‘County health rankings: Relationships between determinant factors and health outcomes’, (2016)
[11] The King’s Fund, ‘The NHS budget and how it has changed’, (2022)
[12] NHS Property Services
[13] World Health Organization
[14] See https://www.england.nhs.uk/about/equality/equality-hub/national-healthcare-inequalitiesimprovement-programme/our-approach-to-reducing-healthcare-inequalities/strategic-drivers/ for more detail
[15] NHS Employers, ‘Gender in the NHS infographic’, (2019)
[16] This was reflected as one of the five strategic priorities for reducing health inequalities in the operational planning guidance of 2021/2022: "Priority 3: Ensuring datasets are complete and timely". See https://www.england.nhs.uk/about/equality/equality-hub/national-healthcareinequalities-improvement-programme/ourapproach-to-reducing-healthcare-inequalities/strategic-drivers/ for more details.
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