
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.
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:
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?
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]
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 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.
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.
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.
For instance A&E, cancer and elective wait times are not consistently broken down and reported along ethnic, social and economic lines.
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.
Click on the buttons to see the findings and recommendations under each theme.
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.
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:
[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.