Addressing health inequalities through engagement with people and communities

A self-assessment and improvement framework for integrated care systems

Foreword - The King's Fund

Health inequalities exist as a result of systematic variations in factors across a population, with many being avoidable, unfair and systematic differences between different groups of people. Action on health inequalities needs a coherent approach nationally, regionally and locally. The latest data shows that men living in the most deprived areas of England die almost 10 years earlier than those living in the least deprived areas, and women almost 8 years earlier. Much of this is a result of more severe and earlier experience of multiple long-term conditions where people living with more than one long-term condition too often experience fragmented care. On average, the most deprived fifth of the population develop multiple long-term conditions 10 years earlier than those in the least deprived fifth. This contributes to those from most disadvantaged backgrounds experiencing 20 fewer years spent in good health than those in the least disadvantaged.

This pattern of inequalities is a product of many things, which can be summarised into differential exposure to 4 key factors or ‘pillars’ of population health:

• First, and most important, are the wider or social determinants of health; put simply whether we have good employment, live in good quality housing, and have access to a clean and high-quality environment.
• Second are health behaviours – whether we smoke tobacco, our relationship with alcohol and whether we eat well and are physically active. These can cluster in certain population groups, leading to health inequalities.
• Third, is having access to good, timely and appropriate services, especially health and care services. CQC’s State of Care report looks at the trends, shares examples of good and outstanding care, and highlights where care needs to improve.
• Fourth, and combining the other factors, are the communities we live in. Good support and positive relationships can help protect our health, whereas loneliness and lack of support can do the opposite.

It is in this context that integrated care systems (ICSs) have been created. Together with their partners, they have a key role in tackling health inequalities.

Under the Health and Care Act 2022, integrated care boards, which sit within each ICS, are required to focus on reducing inequalities between people’s ability to access health services, and between the outcomes for patients through providing health services. Tackling health inequalities is set out as one of the 4 core principles of ICSs alongside improving population health, enhancing value for money and making a wider social and economic contribution to society.

Tackling health inequalities and their causes are at the centre of ICS strategies and joint forward plans, but system leaders need support to do this. Health and care systems can support this through:

• designing and delivering care by working with people and communities – not just for them – with emphasis on listening to and acting on the insight from communities with the poorest access to services, experiences of care, and health outcomes
• understanding their wider role in local economies, helping to support people into employment and through procurement that supports local firms
• supporting people to change their health behaviours
• using the findings of research across the factors that drive health inequalities.

The introduction of NHS England’s core20plus5 approach to health inequalities, and it’s extension to children and young people has been an important development. This recognises the complexity of health inequalities and the role of the NHS. To support NHS staff and community members to contribute to the goals of core20plus5, NHS England provides tools and a wide range of support, including core20plus5 NHS ambassadors and community connectors.

With funding from the Regulators’ Pioneer Fund, CQC’s partnership with National Voices and the Point of Care Foundation has developed a framework to support a whole-system approach to embedding meaningful engagement and reducing health inequalities. The framework ensures that engagement strategies are customised to meet the unique needs of each community. It helps ICSs identify marginalised groups and assess their current engagement strategies. Where gaps are identified, the framework encourages collaboration with external networks that have stronger ties to these communities, all aimed at tackling health inequalities. It is not just about listening but also using the framework to explore how well an ICS is listening to, understanding and responding to the need of people and communities to reduce health inequalities.

This aligns with The King’s Fund’s own work on Understanding integration: how to listen and learn from people and communities, where we made clear how critical it is that health and care systems hear from all parts of the communities they serve.

The framework responds to this and recognises that the needs, strengths and experiences of communities are very different between, and within, different ICSs. But it is based on the principles of what we know is likely to be most effective including: the integration of qualitative and quantitative data and insight; the design of services with communities; and ensuring that there is an ongoing relationship with communities that is not purely transactional but is based on long-term listening, understanding and visible change and improvement in health inequalities in response.

The Health and Care Act 2022 gives CQC new regulatory powers to assess integrated care systems and aims to understand how they are working to tackle health inequalities and improve outcomes for people. This means looking at how services are working together within an integrated system, as well as how systems are performing overall. While the inequalities framework does not form part of CQC’s assessment methodology, ICSs will be able to use it to enable them to demonstrate and assure outcomes in reducing health inequalities.

Success in applying the framework, as with any serious approach to health inequalities, will therefore require committed leadership, consistency over time, and genuine partnership and trust in communities themselves. The framework itself cannot ‘solve’ health inequalities, this requires a much broader range of action from government, civil society and communities themselves. But it can make a difference and is designed so that difference is made visible. This visibility is critical, as communities with the greatest health needs have the right to know how our health and care systems are responding to their needs and how this can shape services, as well as people’s access to and experience of care, and inequalities in health outcomes. This is what the legal duties on reducing health inequalities mean in practice, and this framework will help ICSs deliver on those duties.

Dan Wellings and David Buck, Senior Fellows, The King’s Fund