Health inequalities: How ICBs are tackling this

Victoria Vaughan: Could you start by introducing yourselves and sharing what your ICB focuses on?

Edward Kunonga: I’m a director of transformation and population health management in North of England Commissioning Support (NECS), which is one of the Commissioning Support Units, but seconded into North East and North Cumbria ICB as director of population health management. I’m also a public health consultant.

In our ICB, we have developed Healthier and Fairer, the umbrella programme for our approach to health inequalities. It is a partnership between the ICB and directors of public health, and we’re continuing the journey on prevention that started before ICBs.

Prevention is a big priority. We have a regional tobacco office called Fresh – one of the targets is a 5% prevalence by 2025 – and we also work on alcohol with a regional alcohol office called Balance. And we’re working on healthier weight too. We’re working very closely with our clinical colleagues on the obesity pathways and working beyond service-related interventions.

And we’ve got Best Start in Life, working with the local maternity systems and supporting multi-agency work on children’s health and wellbeing priorities.

The last priority is around the NHS’s role in social determinants of health. Our ICB has a budget of £6.5 billion, and the NHS estate is the biggest land owner in our region. So how do we utilise all of that significant resource beyond being a healthcare provider? We’re looking at ourselves as a massive anchor institution for our communities.

Jack Lewis: I’m a public health consultant and the lead for Humber and North Yorkshire ICB‘s population health and prevention programme.

A large part of our public health prevention programme and our role around health inequalities in the ICB is simply connecting the system to itself.

We want to reduce the healthy life expectancy gap between our richest and poorest areas. It’s acknowledging that there’s a long history of this work from Clinical Commissioning Groups and local authorities and, before them, different configurations of the health system. So how do we then take advantage of what an ICS can offer? That’s where some of our first round of intentions come from.

Part of our programme on inequalities is supporting the thinking around integration – what does that look like? And it’s supporting the wider research community within our system, supporting population health management, and thinking about how we get quality improvement.

 A large part of our role around health inequalities in the ICB is simply connecting the system to itself.
Jack Lewis

Liz Gaulton: I’m chief officer of population health and inequalities for Coventry and Warwickshire ICB. Previously, I was a director of public health in Coventry.

It’s been a year – not quite a year – since we started the work on health inequalities in the NHS setting locally. The ambition is to embed it in everything we do. So we’ve spent time corralling different perspectives around health inequalities, and it feels like the penny has dropped in the last month or so.

I had GPs saying things like, ‘Well, what can I do around air pollution?’ And I had non-exec directors saying, ‘It’s all about education skills, isn’t it?’ So there were all these different perspectives, and now we can be clearer on the ICB/ICS responsibilities – that feels like a bit of a breakthrough for me.

The other different interpretations and views come from the NHSE and our locality. So when we have our quarterly review with NHSE, they want to know what we have done on hypertension and maternity access, which is completely at odds with what our local councillors say on our ICB.

And the other thing that is quite complex is the fourth aim of the ICB/ICS, which is about supporting social and economic development. They get quite muddied in people’s thinking in terms of what’s health inequalities and what’s that broader social-economic development. So we’re doing some work with NHS Confederation with The Institute of Policy Research regarding that fourth aim.

VV: Could you talk about how Core20 fits in with your current strategies around health inequalities?

LG: The Core20PLUS5 as a framework has been really helpful, but the plus groups have been quite difficult locally. That element of the Core20PLUS5 framework has muddied the water quite a bit.

For example, North Warwickshire has very deprived areas and South Warwickshire is one of the most affluent areas in the country, and a bit annoyed with this whole agenda and being quite loud about having inequalities too – rural deprivation, older people and hidden homelessness.

JL: Like Liz, we’ve got a lot of variety. In Hull, 50% of the population’s in the 20% most deprived in the nation. In York, it’s 4% – so huge gaps.

We’re taking a system approach. So, for example, an asylum seeker or a homeless person in York has similar needs to those in Hull. And perhaps actually less access to services because in Hull, there are economies of scale that already exist to wrap around homeless and rough-sleeping populations. So how we create parity for individual service users and citizens, population groups, and patients in our systems is on our mind around Core20PLUS5.

Core20PLUS5 has done a fantastic job of capturing the zeitgeist of inequalities and converting that into policy. We’ve got a really good partnership around inequalities inside the acute trust, which are aircraft carriers of systems that require someone inside to be doing work.

Like Liz, we’ve got programmes around Core20. We leave our plus groups to Place to some extent, though we are doing some system-wide work around inclusive health services on them.

The Core20PLUS5 has been useful as a hook because, in the NHS, it gets done whenever something is a target or given the profile.
Edward Kunonga

VV: The Core20 says that it’s down to ICBs to identify who these groups are. So does the ICB identify them or the ICS? And who are they? Or you’re leaving them to Place – is that correct, Jack? 

JL: We do leave it to Place. We’re not going to exclude certain plus groups because they don’t fit into the five that happen to pop up first.

LG: Yes, we left it to Place. We’ve got four places – one for Coventry and three separate ones for Warwickshire, north, south and Rugby. Everyone agreed quite quickly on newly arrived transient communities because it was a moment when we had a lot coming. Coventry also agreed to people on long-term sick benefits and long-term sickness with back pain.

Warwickshire is still debating. So, yes, it’s a little bit contentious, I would say.

EK: The Core20PLUS5 has been useful as a hook because, in the NHS, it gets done whenever something is a target or given the profile. But we are very clear that, even if we deliver the Core20PLUS5, it would not achieve the population health gains we are interested in. However, given the national forecast, we’re using that as a narrative that helps people to understand the Core20PLUS5.

For us, the Core20 population is a third of our population. And if you are in Middlesborough, it’s more than half of your population. So, we are mindful of the size of the challenge and the limited resources. To do the Core20, it needs to be embedded in everything that we do, it can’t just be a little project over there, and then the rest of the stuff gets done separately.

For example, we have a programme called Waiting Well, where we support patients waiting for surgery with targeted interventions. So we are using the Core20 as our prioritisation to prevent exacerbating health inequalities.

VV: Julia, you’ve just joined, if you could just introduce yourself and then just jump in on where you are on Core20 in terms of your health inequalities?

Julia Robson: I’m the inequalities programme lead for Beds, Luton, Milton Keynes ICB.

In terms of our plus groups, we commissioned a literature review to understand which population groups we really wanted to focus on.  It’s called the Denny literature review, and we’ve got a steering group attached to that. We’re going to meet to decide what the next steps are going to be.

The groups include LGBTQ+, homeless, migrants, Bangladeshi women in the Bedfordshire borough and learning disabilities. We’ve been working with Health Watch and VCSE to do some engagement with those groups, and we’ve just had a lot of those reports back.

We’re probably going to attach a lot of our inequalities funding to some of the quick wins – recommendations that have been put forward. Some are at Place, and some are system-wide.

We have taken a quality improvement approach against the whole of the inequalities program. Through the 22/23 funding, we recruited an improvement advisor. We’re focusing on working with the population groups to design ideas and test them together, so we can understand where improvements have been made. So, next financial year, we’ll probably be at that point where we’re testing some of the ideas.

VV: Another thing I wanted to move onto, which Liz touched on, is the idea of shifting funding to be more equal and more affluent areas feeling that they’ll lose out. How is your ICB approaching that?

EK: It’s a very topical issue within our ICB. We have a resource allocation working group to see how we can use data and insights to change how we allocate resources. That group has our finance directors from the different parts of the system, public health and population health management.

We have used the cake analogy to help people understand. So, if we’ve got a population of 3.2 million and we’ve got a £6.5 billion cake, how do we slice it to make sure that we are giving sufficient coverage to our population in an equitable way? You need to think about physical health versus mental health, primary care versus secondary care, and adult versus children and young people.

That led to some people saying the national allocation formula is not right. It’s not giving us a big enough cake for the healthcare needs of our population. So, we are looking at how we make our case in terms of the national resource allocation formula so that we receive an appropriately sized cake. But that’s not going to happen overnight, so in the meantime, how do we slice the cake that we have?

We have not cracked it yet, but it is right at the centre of the ICBs intentions to make sure that we allocate resources in an equitable way. The challenge is that there will be people who perceive themselves as losers and those who are perceived winners. Unless you move away from that, there will always be resistance in terms of shifting that resource. But our ICB is clear that one of the priorities is moving away from historical CCG expenditure to a different way of allocating resources.

LG: It’s shifting the money so that it’s aligned to need, but historically that’s just not been done. Historically, the allocation has been built a lot around age, and more affluent areas tend to have more older people.

If you think about the health inequalities money that’s come in, it’s 0.2% of our budget. So we can spend a lot of time arguing and fighting about whether a plus group’s included and should get a little bit of the 0.2%, or we can actually focus on shifting the dial so that primary care, for example, is equitably funded across the patch, because it absolutely isn’t.

There’s an inverse care law here in that those CCGs that were more affluent had more money and time to invest in staff who could do development and innovation. So that then generated more money and more innovation. And those in the more deprived areas have just been absolutely slogging it for a long time. So, yes, that needs to shift, and it isn’t going to shift in the next year. It’s going to take time.

It’s shifting the money so that it’s aligned to need, but historically that’s just not been done.
Liz Gaulton

VV:  How do you shift that?

LG: Well, I think it has to be an ICB board conversation. My concern is that government policy gives us enough time to do that and that the ICBs continue long enough for us to embed it because it is a 5 to 10-year journey, I would say.

Ultimately, either we take money off one part of the system and give it to another, or it happens very, very slowly with growth money. And that will take a long time.

JL:  I think some shift happens naturally when you start to harmonise policies across areas.

We’re starting to have conversations around our providers having a pooled waiting list and theatre capacity. When you start to move patients around the system to manage that, it naturally starts to create some equality in terms of resources and workflows.

JR: I wish I had this magic answer, but I don’t, and I also struggle with it. Even the inequalities funding from last year – we couldn’t come up with an answer to this, and we ended up giving it out evenly to each of our places because we just needed to get on with spending some of the money.

The approach we’re taking, especially with the funding, is more of a population health approach. So, we’re following people through life, especially when looking at learning disabilities. It’s looking at the lifestyle behaviours, early interventions, and prevention – that will also be our approach for the funding next year.

We will also focus on one big system-wide project, such as childhood obesity. That will hopefully start taking place next year as well.

VV: Some programmes that you’ve mentioned – such as alcohol and smoking –  were running before, but I’m interested in what ICBs and ICSs will do that wasn’t done before. What can they do that can really shift the dial?

LG: To me, the difference that the ICB can make is that the NHS, for the first time, focuses on need rather than demand. Thinking about population health and the circumstances people live in, and why that makes them either high users of NHS or late users of the NHS or using the wrong parts of the system.

And the other thing would be about the prevention and the upstream work. So, they’re both things that I think that NHS thought it had responsibility before, but it never got to the top of their to-do list, so it feels like it should now.

EK: I think for a long time, the NHS has focused on providing a universal service – we open our doors and we see whoever comes in. And to some extent, that detracts from thinking about who’s not walking in through those doors, or who’s getting in through which pathway and how we can reach out to them.

We have been reminding our ICB executive that the NHS has suddenly woken up to health inequalities, but that does not mean they are the first ones to the game. And, actually, they need to have humility and respect for the other parts of the system who have been in this game for a very long time.

There are things that the ICB should lead, especially decision-making on healthcare resources. Then there are things that the NHS or the ICB should collaborate on – this is where the healthcare pathway comes into contact with other pathways, whether that’s housing or employment. How do we make sure that the patients who have got the greater need are prioritised by the other systems? Winter warmth programmes, as an example – can we link our respiratory pathway with what’s happening on tackling fuel poverty so that those patients with the greatest vulnerability end up at the top of the list for support for winter warmth schemes?

I’m hoping that one day we won’t call our population ‘seldom heard communities’ and that everyone feels listened to.
Julia Robson

VV: Finally, a look to the future on what you hope to have achieved in your ICB area in the next 5 or 10 years?  And the barriers that need to be overcomed to get there? 

EK:  I just hope the NHS does not get inequalities fatigue. The vision for tackling these healthcare inequalities needs to be long-term with an acknowledgement of milestones. Otherwise, if they think it will be done by the next planning round, then we might find people getting tired of it.

JL: I’d hope that in a year or two, there’s a centralised and cohesive voice across our fairly diverse system that is paying attention to the right metrics about health inequalities. What are some qualitative components of how people feel about their lives in our area, and have we moved the dial on them? I’m hoping that in five years, we can say yes or no and here’s why and here’s what’s missing.

LG: For me, it would be about decision-makers across the integrated care system thinking about need not demand. And for front-line clinicians to be mindful of need, not demand. To do that successfully, we really need to get the data architecture right around population health management so that a practice manager, for example, has at their fingertips an understanding of the needs of their population.

And also, within five years, the NHS, in all its forms, understands its importance to the wider system as an employer. I think we take it for granted without realising the impact of that.

JR: I’m hoping that one day we won’t call our population ‘seldom heard communities’ and that everyone feels listened to. And hopefully, we can start moving away from them feeling that we’re not to be trusted, and we can begin having equal relationships.

This Healthcare Leader roundtable took place in March.