NHS Five Year Plan: Implementation and Progress

1. The NHS Five Year Forward View and beyond:
Addressing health inequalities
David Buck (@davidjbuck)
Senior Fellow, Public health and health inequalities, The King’s Fund
26th May 2016
NHS Five Year Plan: Implementation and Progress, 26th May 2016,
Royal National Hotel, London WC1H 0DG

2. Progress under the coalition?

3. The Coalition’s record on inequalities in health
Positives Negatives
Legislation in Health and Social Care Act 2012, a new duty on
system to have due regard to inequalities in health
Legislation hasn’t bitten, despite warm words in NHS mandate,
Dept of Health has not held the system to account for
reductions in inequalities in health outcomes
NHS England beginning to use its operational independence –
putting more weight on deprivation in NHS resource allocation
and more focus on representativeness of its own workforce
Historic opportunity missed, NHS England as a monopoly
purchaser of primary care could have been transformative in
focussing primary care on inequalities reduction
Some of the structures are in place, if used. For instance PHE,
local authority role (with funding), Health and Wellbeing
Boards, new legislation
Setting up PHE assumed to “sort inequalities in health” in and
of itself, health premium incentive risible (regardless of views
on desirability), MECC not a national priority
HWBs “get Marmot” (but yet to move to significant action as
opposed to strategic decisions)
Result, a clutch of disconnected, under-powered sub-
strategies, not helped by fragmentation of system leader role
Wider government role inequalities creation, and solution, has
been largely ignored – cross-government sub-committee on
public health (where HIAs could have happened) abolished
“The coalition’s own brief assessment of its record is buried in the
Department of Health’s annual accounts, stating ‘good progress’ has
been made to ‘embed action on inequalities across the system’.
There is some truth in this, including legislative change and the
Workforce Race Equality Standard. But across the term, the lack of a
coherent strategy and translating that into accountability means the
initial rhetoric has not been lived up to.”

4. Where are we now?

5. There are multiple routes to supporting the
NHS’ role in tackling inequalities
The health inequalities duty.. and
integration
NHS CB and each clinical commissioning group must
exercise their functions with a view to securing that
health services are provided in an integrated way
where they consider that this would -
(a) [improve quality];
(b) reduce inequalities between persons with respect
to their ability to access those services; or
(c) reduce inequalities between persons with respect to
the outcomes achieved for them by the provision of
those services.”

6. Measurement, and better multiple ways to
assess progress is key
Mock-up national dashboard

7. Concerns – national and local persistence
London has areas of persistent significantly low
and significantly high life expectancy over
time.
If in travel to work area of central London
– 46x more likely to have persistently high
life expectancy, all other things equal
– 4x as likely to have low life expectancy,
same basis
Little change in life expectancy and disability-
free life expectancy gap by levels of income
deprivation over time.

8. The FYFV and beyond:
“Putting the NHS in its place”?

9. Optimism - getting it right would be good for
the NHS budget
Socioeconomic inequality costs NHS
inpatient services in England £4.8
billion a year, if extrapolated to the
whole NHS budget, £20bn per year.
Over a lifetime, men (women) living
in the most deprived
neighbourhoods cost the NHS 16%
(22%) more than men living in the
most affluent neighbourhoods,
despite having shorter life
expectancies.
Miqdad Asaria, from the Centre for
Health Economics said: “At a time
when the NHS budget is under a
great deal of pressure this study
shows that socioeconomic
inequalities in society are exacting
a huge bill on the health service.

10. NHS has multiple roles to play in inequality
reduction
Access of course AND…
Wider determinants
of health
Integrated
health and
wider services Our health
behaviours
?

11. The NHS’ economic power = a massive wider
determinant of health, in place

12. Heath and fairness commissions…
“Fairness commissions” in 23
places, to June 2015.
Focus on poverty, inequality and
the effects in “place” and those who
are affected and those who can
make a difference.
NHS represented in some, in
various ways, to various extents
but needs to be a corporate citizen.
Liverpool’s Health Commission –
part of the Fairness Commission –
goes far beyond models of
integrated care and sees the NHS
as a key player in a city-wide
strategy to address the
consequences and causes of
poverty.

13. Sustainability and Transformation Plans
(STPs), devolution and HWBs?
 Yes… place-based
 But... “two maps” and where are HWBs?
 Yes… real opportunities for inequalities
 But... superfast timetables

14. Wider
determinants of
health
[+Health in All
policies]
Integrated
health, care
& public
health
services
[+PH
contribution]
Our health
behaviours
The NHS maximising its
potential as a massive
economic and social
power in all communities
(e.g. paying the living
wage, using the Social
Value Act, playing a
greater part in civic live)
Policies with a stronger focus
on the links between lifestyles,
their clustering, and the
influence of socio-economics
(e.g. MUP, social norms,
lifestyle impacts in HIAs of
OGD HIAs of wider
determinants)
Greater weight on health and care services role in supporting
lifestyle change (e.g. MECC, 5YFV commitments) and PH role in
diverting from, contribution to and widening definition of, integrated
care
Moving to population
health systems:
A system with a stronger
joint narrative, incentives,
information and leadership
for population health with a
focus on inequality
reduction
Towards a place-based, inequalities focussed
population health system?

15. Conclusions

16. Conclusion
Inequalities in health are many and varied, but they can be changed for
the better.
We are doing better than ever at measuring and monitoring them, without
that it is harder to act.
The NHS has multiple roles to play…
– Access to care  reducing inequality in outcomes from that care
– Prevention  for all, not just low-hanging fruit
– Wider determinants  massive potential, including use of SVA
– Joining the dots between the above  not thinking in the usual silos
– Being a better place-based partner than it is now  a social actor
Place-based population health systems are the future, the NHS has a key
role in these, we have to ensure that they have inequalities reduction at
their heart.

17. Some of our recent thinking, more to come