The Levelling Up agenda is an opportunity to consider how inequality manifests itself across the health and care system and take steps to address it.
Infrastructure, such as outdated buildings and equipment are a particular issue. Although the largest share of the issues is in London, sites outside the capital (where backlog maintenance is high due to cost) also have serious problems, like many hospitals in East Anglia. Current plans to ensure universal coverage of electronic patient records [EPRs] also highlight the desire to level up digital capability across the NHS.
The way funding is allocated to local areas has also created inequalities. Our previous work on rural healthcare suggests that some of the unavoidable additional costs of delivering services in remote areas – such as being unable to benefit from economies of scale – may not be fully reflected in the way allocations are calculated.
Workforce issues – one of the biggest challenges facing the NHS - vary across the country. For example, the rate of patients per GP varies by area, with GPs in London and the South East responsible for a much higher number of patients compared to other areas. This is concerning given the well established pattern of the ‘inverse care law’, where those most in need of healthcare are least likely to receive it. Initiatives to address regional variation in staffing levels (known as recruitment and retention premia) do exist, but evidence on their effectiveness is limited.
At the same time, levelling up relates to improving the health and wellbeing of the local population, although a promised ‘health disparities’ White Paper is yet to emerge. Tackling the social determinants of health (such as the impact of housing or poverty) is important, and healthcare services have a key role to play in this.
The objectives of the recently created Integrated Care Systems [ICSs] include improving outcomes in population health, tackling inequalities and helping the NHS support broader social and economic development. Importantly, this requires having a thorough understanding of their population and what services are required to meet their needs. Our recent review of the Mayor of London’s Health Inequalities Test recommended a greater focus within healthcare services on the structural drivers of inequalities (particularly relating to economic deprivation).
The Health Foundation has suggested that to level up general practice, more action is required to take account of the impact of deprivation on their services. At a policy level, NHS England’s Core20PLUS5 approach sets out a way to inform action to reduce inequalities by focusing on the most deprived 20 per cent of the population, groups such as those experiencing social exclusion and five priority clinical areas of focus which include early cancer diagnosis and maternity care.
With the recent political and financial turbulence leaving the status of the Levelling Up agenda unclear, the issues we’ve highlighted are longstanding. Despite attempts to address them, more action is required to tackle the persisting inequality which exists across the NHS. Addressing this issue is vital for the Levelling Up agenda to have a significant impact.
Key Points:
• Inequality exists across healthcare services in different ways. This includes longstanding variation around funding, infrastructure and staffing, as well as access to healthcare for different populations.
• Addressing inequalities is a key objective of the recently created Integrated Care Systems – this should include recognising the structural drivers of inequality (such as economic deprivation).
• Despite ongoing uncertainty over the government’s levelling up plans, NHS organisations will have a key role to play. This requires a clear understanding of existing variation and inequality across healthcare services.
This article originally appeared in The Leaders Council’s special report on ‘The Levelling Up agenda’, published on November 30, 2022. Read the full special report here.
Photo by Francisco Venâncio on Unsplash
