King's Fund guest editorial: health inequalities

“The NHS is broken” – these were the stark words Wes Streeting chose to use in his first statement as Secretary of State for Health and Social Care.¹

Whether or not you agree with that, if you consider the deteriorating state of our nation’s health – as Lord Darzi did in his recent rapid analysis of the NHS² – it’s clear any ‘fix’ needs to go well beyond the health service. Health inequalities are deep and widening.³ It is impossible to ignore that some groups are disproportionately affected by the burden of ill health.

It is, therefore, heartening that tackling health inequalities – this issue’s focus – is a key commitment in the new government’s health policy. This includes an ambitious pledge to halve the gap in healthy life expectancy between the richest and poorest regions in England.⁴ Work has started to turn this goal into policy (and then practice), with the establishment of a ‘Health Mission’ board that will work across government and the initiation of work in the Department for Health and Social Care to develop a new 10-year health plan. Due to be published next Spring, it has been dubbed a once-in-a-generation opportunity to influence the future direction of the NHS.

In this issue

The fantastic set of articles in this issue provide clear and compelling examples of the challenge that the Government must address with these plans and some of the strategies needed to make progress.

Rob Danby from Anthony Nolan highlights the inequalities that exist in bone marrow donation and in patients’ access to and outcomes from haematopoietic cell transplant therapy, highlighting the way Anthony Nolan is prioritising work to tackle this.

Dr Veline L’Esperance and Professor Habib Naqvi from the NHS Race & Health Observatory summarise an important review that shows the urgent need to address ethnic inequalities in precision and genomic medicine – services that have the potential to revolutionise the diagnosis and treatment of disease. 

Anu Gunuvardhan and Meena Upadhyaya discuss the disparities in care that ethnic minority women face in the Welsh healthcare system.

Dr Samar Betmouni sets out the equality of access considerations that result from the rise of digital pathology.

Katrina Brown’s article on the inequalities in cancer care is stark reading. People in the poorest parts of England die almost a third more often from cancer than those in the richest areas – but Cancer Research UK has a mission to change this.

Finally, Ellie Gilham and Diane Ashiru-Oredope explain that the extent to which vulnerable and marginalised communities are disproportionately affected by anti-microbial resistance (AMR) is only just being realised and emphasise that this must be a focus for future work on AMR.

Driving progress in health inequalities

Supporting the health and care system in its work to tackle health inequalities and support people with the worst health outcomes – including issues like these – is a priority for The King’s Fund. Health inequalities cannot be tackled by the NHS alone; however, the NHS clearly has a role to play.

But we have found that, over the past decade, the NHS has made little progress, despite commitments from many to change things and pockets of innovation.⁵ At this moment of change, we have identified 7 priorities the new 10-year health plan should focus on to drive more progress.

1. The root causes of health inequalities, such as poor housing, low incomes and insecure employment, lie outside the NHS. We are calling for a cross-government strategy to tackle health inequalities that any new NHS plan must feed into. The NHS cannot do this alone.
2. Many of the big killers, like cardiovascular disease, disproportionately affect people from the most deprived parts of the country and ethnic minority groups.⁶ That’s why the NHS must reorientate itself to focus on prevention to tackle health inequality and be held to account.
3. The recent inquiry report on the Grenfell Tower fire and our own analysis of the healthcare response⁷ vividly show what happens when public services do not listen to communities. The NHS needs to radically change its relationship with people and communities from ‘power over’ to ‘power with’. The first place to test this is in the development of the 10-year health plan.
4. Racism and discrimination affect NHS staff in the workplace, the design of services and the health of the people who use those services. The NHS cannot address health inequalities without tackling systemic racism and direct and indirect discrimination; part of this is acknowledging the issue and cultivating a culture of compassion to support change.
5. Work to tackle inequality is often an add-on, but it must become part of everyone’s business-as-usual. National bodies and local health systems have an important role to play in building skills and enabling staff to identify and act on health inequalities and capture learning.
6. It is important that decisions are taken close to local communities by people who understand their needs and the inequalities that exist in health and access to health services. That’s why local ‘place-based partnerships’ – where local authorities, NHS organisations and the Voluntary, Community and Social Enterprise (VCSE) work together to plan and deliver services – must be empowered to take more decisions about how NHS money is spent, where possible delegating power further to local neighbourhoods.
7. The NHS must get better at working with local VCSE organisations that support many people who experience the worst health outcomes. This includes changing the way the NHS works with them to commission services.

Throughout this issue, you will see that many of these ideas are echoed in the articles. That these articles come mainly from voluntary sector organisations underlines the importance of partnership across sectors in making change happen.  The concerns outlined are stark but the energy to address them is also palpable.

References available on our website.

Ruth Robertson

Senior Fellow, The King’s Fund

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