Levelling up: down to business

by Sanjay Agrawal

16 September 2021


Addressing health inequalities is not only the right thing to do but may help to deliver value within the NHS and across society in general. And NHS finance practitioners need to be involved.

Covid-19 has shone an uncomfortable light on health and equalities. The silver lining is that this has led to a long overdue and welcome national focus on this area by government and the NHS. And this week there have been calls for this to be reinforced with a formal cross-government strategy.

There are lots of questions. How do we define health inequalities? What is the role of the NHS? What data should we look at? Who do we need to get involved and where should we start?

We don't have all the answers to these questions and our response will evolve as we understand more. The finance function needs to be at the forefront of this discussion due to its unique qualities and skills. NHS planning guidance has made health inequality board-level leads a requirement for integrated care systems and provider trusts. These lead officers and their teams will need to grapple with these questions.

The NHS is free at the point of care and there is an assumption that there is universal access. Access however requires a ‘push’ from the consumer (patient) and a ‘pull’ from the provider (the NHS).

There are lots of issues that affect the ‘push’ from patients. These can include: language barriers; confidence to navigate services; literacy to understand information; money to use transport; geographical isolation; social networks in place for transport and emotional support; and working arrangements to make visits possible. Some people will be on zero contract hours or shift work, or they might be looking after children, partners or elderly relatives. Others may have sensory deficits – in sight or hearing for example – making it difficult to navigate NHS 111/GP/ hospital telephone systems.

Then there are cultural issues, for example with myths about treatments inhibiting people from seeking help. And in some cases, the ‘hub and spoke’ arrangement of NHS services will simply disadvantage those that have to travel furthest, people without their own means of transport or the elderly.

There are also a number of issues that mean we have an imperfect ‘pull’ by NHS organisations and those referring patients for treatment. For example, people who are more insistent or who complain more may get more referrals than those who don’t make a fuss. Individuals may be subject to unconscious bias – potentially treating smokers, drinkers, obese people differently from other groups.

Referrers may not pick up on patients with confidence or literacy issues and assume ‘they don’t want’ care and may not take the time to scratch beneath the surface.

All these factors can lead to unequal access and uptake of services, exacerbating health inequalities on top of other social determinants such as housing, heating and educational attainment. There are increasing amounts of data that demonstrate unwarranted variation in referral rates, treatment interventions and discharge rates across a whole host of protected characteristics and deprivation deciles in every part of the NHS.

There is real potential to improve the ‘pull’ from providers to help break this cycle, but this will involve a lot of thought and dedicated time. That is what many trusts are grappling with currently and finance teams need to be involved with the discussions

It may be that ‘case finding’ will cost more through the increased use of services. However, as well as obviously being the right thing to do for patients, we need to look at the overall value being delivered. First getting to people earlier may well prevent more costly interventions downstream. But also, NHS bodies are anchor institutions and can deliver value more widely by helping to level up society.

I have been considering how health inequalities link to the social determinants of health.

I may not directly be able to have an impact on issues such as education attainment, housing, heating and employment – although this is changing as NHS bodies take forward population health management work in partnership with local authorities and others.

However, I can address some of the health elements of inequalities. For example, I can examine why some patients (often more affluent) are offered treatment interventions, while others are not. This might involve being offered surgery rather than physiotherapy or pain management for hip and knee disorders. Or why are some ethnic groups much more likely to be discharged after the first outpatient appointment than other groups? Why is it that waiting lists seem to vary by deprivation group and what can I do about it? 

There are some quick wins. We know that certain conditions such as tobacco addiction, alcohol misuse and obesity can lead to significant health-related problems and these conditions are often more prevalent in the most deprived in our society. The NHS long-term plan has specific funding to address these conditions. In fact, every provider trust in England as well as general practice should be thinking about how to implement treatment for these conditions with the funding that is currently sitting with lead clinical commissioning groups and integrated care systems.

The NHS finance function has a big role to play in the levelling up national agenda. Some of this will be data-related – with finance staff using their linked-data analysis and presentational skills to illuminate the issues and inform strategies. It can help us to understand both the cost and the value of delivering a more equal service. Very specifically, finance professionals will need to support the development of business cases for schemes that improve access. And they can use their experience to help the NHS to work better with other stakeholders through pooled budgets.

There are challenges ahead. But having recognised that people face different risks of getting ill and unequal access to services, there is a real opportunity to enhance the fairness of our national service.


Professor Agrawal is national specialty adviser for tobacco dependency for NHS England and NHS Improvement and an HFMA trustee