Inequality focus for service restoration

by Seamus Ward

10 August 2020

Health systems in England have been told to focus on addressing inequalities as they put together their plans for restoring pre-Covid patient activity.

Guidance from NHS England and NHS Improvement, which follows up the planning letter sent on 31 July outlining expectations for the third phase of the NHS response to Covid-19, says urgent actions must be taken to address inequalities in healthcare access and provision. The extent of inequalities and their effect on health, particularly in black, Asian and minority ethnic (BAME) communities, had been highlighted by the Covid pandemic, it said. (The HFMA has produced a summary of the key points in the guidance.)layla.Mccay l

The guidance also emphasised the need to address inequalities suffered by people with mental ill-health. It said the mental health investment standard (MHIS) will remain national policy. Independent audits of implementation of the standard – which applied to previous financial years – will be repeated.

Every clinical commissioning group will be expected to have made progress in addressing historical underinvestment in mental health. Mental health providers should be organised at system level, with a lead provider) to produce plans to meet the activity requirements in 2020/21. To support system by default from April 2021, ICS and STP leads must sign off the plans. These should confirm mental health investment covers all priority areas.

An outline is given of the details to be included in integrated care system (ICS) and sustainability and transformation partnership (STP) plans. The guidance says that when systems come to sign off investment plans for 2020/21, they should do so with the confidence that they have triangulated activity, finance and workforce trajectories, and produced a plan that is feasible. An STP/ICS overview tab is included in the plan template, detailing activity and workforce, and whether these align with the expected financial position; whether the levels of activity accounts for seasonality and meets activity expectations; and whether provider and commissioner activity aligns.

The guidance says the priority is to maintain the momentum on the long-term plan. It confirms that mental health transformation funding for 2020/21 will be available – sites should proceed with delivery and the funding flow mechanisms will be confirmed soon.

‘As with the rest of the NHS, the phase three mental health planning process closes on 21 September, with an interim submission on 1 September, allowing us to allocate the additional funding required to meet the MHIS,’ it adds.

Addressing the process of restarting a wider range of services, the guidance stresses that the immediate focus is on protecting those at greatest risk of contracting Covid-19. Services should be restored inclusively, and targeted prevention programmes accelerated – laying the foundation for further actions to enhance prevention, and contribute to the cross-government and societal effort to address the wider determinants of health.

The guidance sets out eight immediate foundation actions:

  • Protect the most vulnerable: Systems should work with local authorities to protect those at greatest risk from Covid-19. Plans should be updated regularly, and staff protection remains a priority.
  • Restore NHS services inclusively: with the NHS required to return to near-normal levels of patient activity, the guidance emphasises the need to support access to diagnosis and treatment for disadvantaged patients. This will be monitored each month against a range of performance measures in patients from the 20% most deprived neighbourhoods and those from black and Asian communities, where data is available.
  • Develop digitally enabled care pathways to increase inclusion: maintaining and extending the uptake of digital tools and solutions during the Covid-19 pandemic, taking care not to affect health inequalities for others. New pathways should be assessed to ensure they have a positive impact on inequalities, starting with 111 First, total triage in general practice, digitally enabled mental health and virtual outpatients.
  • Accelerate preventative programmes aimed at those at greatest risk of poor health: these include immunisation (such as improving uptake of the flu vaccination); creation of priority lists in general practice for programmes such as obesity reduction; recognising the extra barriers following Covid-19, for example by increasing diabetes referrals in black and minority ethnic communities; and implementing continuity of maternity care for at least 35% of women by March 2021.
  • Support those suffering with mental ill-health: mental ill-health contributes to long-term inequalities and the impacts of Covid-19 could contribute to or exacerbate these problems. Systems must validate their plans to transform and expand mental health services over the next eight months, paying particular attention to equality in outcomes and experience of communities, including the BAME community.
  • Strengthen leadership and accountability: before October, each NHS organisation must name a board-level lead for tackling inequalities. Primary care networks should also nominate their clinical directors or an alternative champion of health equality. As outlined in the NHS people plan, organisations should reflect the communities they serve. Organisations must publish an action plan to show how they will, over the next five years, match the BAME composition of their workforce or local community, whichever is higher. At least 19% of NHS staff, including directors, should come from a BAME background by 2025.
  • Ensure complete and timely datasets: all NHS organisations should review the quality and accuracy of their data on patient ethnicity by 31 December. In general practice, recording of ethnicity in adults eligible for the flu vaccination should begin by 1 September.
  • Collaborate locally in planning and delivering action: the actions will be overseen by systems (ICSs and STPs), and system plans to restore critical NHS services should reflect the actions by 21 September.


The guidance says that areas of greatest deprivation have received addition funding as part of clinical commissioning group allocations – these resources should be used to target the most deprived areas. Systems will be asked to review how resources have been used to address health inequalities over the financial year by 31 March 2021.

The letter adds a focus on patient-initiated follow-ups, saying it benefits patients, clinicians and organisations (through, for example, reductions in costs and waiting times, and improved clinical productivity).

Layla McCay (pictured), director at the NHS Confederation, said the targets for restoring services in the third phase of the coronavirus response were ‘extremely stretching’, so practical guidance was welcome and provided NHS bodies with greater clarity.

‘It is essential that we focus our attention on the startling health inequalities throughout England which have been further exposed by the pandemic. We welcome the national emphasis to tackle this in the next phase of the response and the focus on protecting those most vulnerable to Covid-19 and restoring services inclusively. While no-one will argue against the aims, it is important that systems are supported to implement these actions, particularly increased monitoring.’