Seven months on from the launch of Core20PLUS5, some primary care leaders have begun to see the results of the approach.
Health inequalities – and ways of tackling them – are nothing new. The subject was highlighted by the Marmot review Fair Society, Health Lives in 2010, and a decade later in 2020 an update found that the health gap had grown, and place mattered – with people living in deprived areas of the North East experiencing a life expectancy of five years’ less than those living in similarly deprived areas in London.
In the last few years Covid has exacerbated the issue, but also shone a light on it, with the recent Fuller stocktake report, Next Steps for Integrating Primary Care, outlining a new vision for primary care that reorientates the health and care system to a local population health approach.
Its recommendations include building multi-disciplinary neighbourhood teams and streamlining access in order to proactively tailor care to meet the needs of particular communities and individuals in their local population.
It backs a particular focus on the most deprived 20% of their population, as set out in the Core20PLUS5 approach to support the reduction of health inequalities at both national and system level.
Health inequalities had also been a feature of the Five Year Forward View but with no strategic funds committed to addressing it, until the Long Term Plan moved this issue on and invested in a senior role at NHSE – Dr Bola Owolabi, director of national healthcare inequalities improvement programme.
Describing the aim of Core20PLUS5 to support integrated care systems to narrow healthcare inequalities as a “long-term ambition [that] is still being implemented across the country”, Dr Owolabi says some seven months on from its launch, early indications are that “it is being positively received”, and is playing a vital part in NHSE’s post-pandemic work.
‘We are working closely with national NHS programme teams – including cancer, maternity, cardiovascular disease, respiratory disease and mental health – to ensure at-risk populations are carefully considered as part of our post-pandemic recovery,’ says Dr Owolabi, and ‘this includes those living in the most deprived areas, some of our ethnic minority communities and inclusion health groups’.
‘We have also funded local, community-based roles and initiatives to support the reduction of healthcare inequalities as part of our Core20PLUS Connectors programme, and are continuing work to further improve the national healthcare inequalities improvement dashboard, which collates key health inequality indicators to help ensure our actions are targeted to the communities or health groups who need us most.”
Results so far
The results of this work have not gone unnoticed by the NHS Confederation, which just a year ago expressed its and its members’ view that health inequalities was one of the priorities it wanted more support on.
‘Through the work of Dr Owolabi, we have seen a significant push in our members being supported to do work on health inequalities’, says Joan Saddler OBE, director of partnerships and equality at NHS Confederation, ‘and along with PCNs, CCGs, and their successor ICSs at the coalface, there is a framework along which we can know how to add value and get impact. This means PCNs as well as trusts and new ICSs will have a framework through Core20Plus5 where we can hang our NHS hat towards tackling health inequalities.’
Targeting the most deprived 20% of the population may not sound like it could make a big difference, but Saddler, who is also co-chair of the NHS equality and diversity council, says the 20% contribution that the NHS has some control over in terms of tackling health inequalities directly through its resources is ‘a meaningful proportion of resources including funds from the overall NHS budget. We have accurate, well-evidenced research as well as improvement support behind how our collective money can make an impact.’
Describing how the view of health inequality as an ‘inclusive approach’ within the Core20Plus5, Saddler says its three key elements give healthcare leaders a ‘framework to be able to work with communities’, adding: ‘These are about tackling deprived communities, tackling inclusive health priorities relevant to local places or systems and tackling five key clinical areas. These all require intelligent community engagement expertise which feels a very different hill to climb for the NHS, as it is not all about money and cutting costs, but about coproduction with communities and using our resources differently to attack and not sustain inequalities.’
Nonetheless, Saddler has two caveats. ‘We must have patients involved in co-producing these actions on health inequalities improvement’, she says. ‘It feels different from a planning point of view, but the test is if the plans come to fruition. Will we see the national stats coming back in line with what Marmot talked about when we stop ‘doing to’ and start co-producing ‘with’ patients?’
Saddler’s second point focuses on the workforce. ‘The transformation we are looking for in the LTP cannot be done without tackling inequalities in the workforce as well as within the patient population’, she says. ‘The NHS is one of the biggest employers across the world so tackling inequalities in that workforce is a huge part of this.’
In West Yorkshire work is already well under way to raise awareness and build capacity and capability in the system to tackle health inequalities.
Across Bradford district and Craven there are significant health inequalities in communities and the gap in how long people will live is stark. Starting in the least deprived area, Wharfedale, life expectancy is 87 years for women and 84 years for men. Moving into central Bradford, this dramatically reduces. In the most deprived area, Manningham, people’s life expectancy here is around 10 years less than Wharfedale.
Dr Sohail Abbas, director of the reducing inequalities alliance at Bradford District and Craven place based partnership, says, ‘I believe that by working together we should be able to improve population health and reduce inequalities in our partnership.’
‘I am particularly proud of our reducing inequalities in communities (RIC) programme where people and projects work together to reduce the health gap in central Bradford by identifying groups of people at risk of ill health and then focusing on what can be done to prevent it or help them to manage it,” adds Dr Abbas, who is also chair of the health inequalities network at West Yorkshire Health and Care Partnership.
The RIC programme is made up of a range of projects led by organisations and partners who understand the health inequalities their communities face and who are committed to tackling these, which Dr Abbas says ties in well with the Core20PLUS5 approach.
‘Inequality has always been a public health issue that goes in peaks and troughs”, he says, ‘but the pandemic really exposed the cracks and devastating gaps of people losing their lives due to inequalities. It has been the catalyst that put health inequalities from the margins to the centre, and along with Core20PLUS 5 has brought health inequality squarely to the table so we can identify those people and put resource where needed – and indeed it has been resourced so we can’t ask for much more than that.’
Northamptonshire has used the Core20PLUS5 approach to drill down and understand health inequalities in greater detail than at a county level.
‘This is particularly important for us since as a county we often appear to be ‘average’ in our health outcomes,’ says Dr Joanne Watt, GP Chair of NHS Northamptonshire CCG.
‘But when we start to look at PCN or ward level the different health and life experiences become really obvious even in areas that are just a few miles apart.”
The CCG has used the Core20PLUS5 approach to produce data packs for a range of health and wellbeing measures at LSOA (lower super output area) level, which include aspects that affect housing, employment, leisure and issues such as air quality, as well as the more traditional data regarding people with learning disabilities and serious mental illness. It has also identified the top causes of the gap in life expectancy within the county as circulatory disease, cancer and respiratory disease.
As a result, each of the 16 PCNs in Northamptonshire is developing a plan based on their own population data aimed at supporting the reduction of health inequalities for their population and demonstrating the efficacy of their plans. There are also key collaborative workstreams within the ICS that include an elective care workstream and a frailty programme which will look at preventative and planned elements of these conditions as well as trying to avoid emergency admissions due to frailty where appropriate.
In future, Dr Watt says this will help commissioners and clinicians understand which interventions are effective in reducing health inequalities and share that learning with other similar areas elsewhere in the country. However, she stresses: “It is important to recognise that every area is different and working with local populations will often give us effective co-produced plans for interventions.”
The goal for health inequalities, according to Saddler, is that “it remains as important as bed space, targets, financial planning and balancing the books”, yet she warns: “We know the NHS is good at having plans, but the proof of the pudding is in the eating. My prediction is things will get harder first because to implement the plan you need time.”
The key, she says, is money and time. “Those health navigator roles, voluntary vaccination helpers, that approach we learnt from the setting up of the vaccination centres and past community and voluntary sector approaches, over last forty years, this all has to be the way forward as it proves we can co-produce and escalate ways of working through community hubs.
‘The most hopeful thing we can do is continue this drive and give Core20PLUS5 the time and money it needs or else it will fail – particularly in working with communities – so we need to invest in community organisations and support volunteers. After all, one of the quickest ways to take people out of health inequality is to give them sustainable jobs.”