We know the NHS is awash with frameworks and toolkits, some of them well used, others less so. But as part of a project undertaken in partnership between the Care Quality Commission (CQC), National Voices and The Point of Care Foundation, we have recently published a self-assessment and improvement framework for Integrated Care Systems (ICSs).
The framework’s role in tackling health inequalities
What sets this framework apart is that it addresses a clear, pressing need among ICSs. It has been designed to help encourage a whole system approach to embedding meaningful engagement with people and communities, to help ICSs take action on health inequalities in their local areas.
Tackling health inequalities in outcomes, experiences and access is one of the four key aims of ICSs set out in the 2022 reforms, and is also a clear priority from the Government, featuring in their manifesto, as part of the recent Elective Recovery Plan and in the NHS Planning Guidance for 2025/2026. Creating a more equitable NHS is also at the very heart of the 10 Year Plan. We are heartened to see the urgent need to tackle health inequalities running through all the workstream groups, and policy overall.
At CQC, we understand that tackling health inequalities is not just about identifying gaps, it is about creating practical ways for systems to listen and act. ICSs need to ensure that the voices of people who use services, particularly those who experience the greatest health inequalities are not just heard but can influence how services are designed and delivered. That is why we commissioned this framework: to offer ICSs a structured, supportive way to assess and improve their approach to engagement and tackling health inequalities.
It is important to acknowledge that different ICSs are at different stages of this work, and that these changes cannot happen overnight. In some places, and with certain communities there are massive gaps in system knowledge, connections, networks and levels of trust. This is where the framework is particularly helpful.
The framework we have produced provides the structure for ICSs to understand where they are in terms of working with communities to address inequalities, and to understand where and how they can improve, and is designed to be accessible to ICSs at different levels and stages of their engagement journeys.
The value of meaningful co-production
The need to address inequalities in access, experiences and care is in the lifeblood of what we do at National Voices. To achieve this, it is fundamental to work with communities experiencing the greatest inequalities and poorest outcomes, helping us to understand what isn’t working and creating the opportunity to design solutions together.
CQC, National Voices and The Point of Care Foundation understood the need for this framework to be co-produced to work effectively. The Expert Advisory Group (EAG) for this project, co-led by Robyn and Jacob, brought together everyone who needed to be involved; ICSs, the VCSE sector, wider system stakeholders and most crucially, people with lived experience.
From the outset, the EAG helped us to agree the structure of the framework and the areas it needed to cover. We heard from the EAG, the need for ICSs to make more use of insights that have already been gathered from communities, and the importance of feeding back to those communities on how their contributions have led to change. The wide range of stakeholders encapsulated in the EAG enabled a real diversity of views; and all these voices were influential its development .
Lived experience voices were embedded from the very beginning, right from the early conceptual conversations, through each draft, the testing phase and final versions. Co-production can often be treated like a tick-box exercise, with individuals brought in at the later stages without the much-needed context to enable them to have meaningful input or impact. This where this project’s approach to co-production differed, enabling everyone in the room to benefit. This approach is worth the time it takes; we ensured Lived Experience Partners were fully briefed throughout, and agendas for meetings weren’t too dense which allowed everyone the opportunity for meaningful engagement.
We were also grateful to work in partnership with four ICSs, Black Country ICS, Gloucestershire ICS, Hampshire and Isle of Wight ICS and Nottingham and Nottinghamshire ICS. These particular ICSs were chosen for their diverse demographics, geography, and levels of experience in addressing health inequalities.
The enthusiasm and commitment demonstrated by the ICSs strengthened the framework, which has helped to make it applicable both at every level of an ICS and for ICSs at varying stages of their journeys involving people and communities. They were grateful for the open and flexible approach of the project, and we were able to work with them to adjust and tweak it as we went. Other national frameworks rarely undertake this level of working with local systems, and once developed, in these cases, the testing is often quite rigid.
Some of the ICSs also used the framework in partnership with local people and communities experiencing health inequalities, thus continuing the co-production process.
This approach is critical for co-production to succeed, an open mind and open eyes are what allowed us to work together to achieve the best end result. Meaningful co-production takes work, but work that is worthwhile.
Ensuring meaningful engagement requires both strong leadership and co-production, leadership that prioritises listening and acts on the insights of people and communities. Chris Day, Director of Engagement at CQC, emphasised at the launch event that how well-led an organisation is, fundamentally depends on how well it understands and responds to the voices of those it serves. Leadership at all levels within ICSs will play an active role in embedding this framework into everyday decision-making, ensuring that tackling health inequalities is not just an ambition, but a tangible, sustained practice.
Next steps
Through extensive co-production, CQC, National Voices and the Point of Care Foundation are confident we have created a framework that anyone can pick up and use.
In its development, we have also demonstrated that it is possible to fully co-produce something this size; but time must be allocated for building relationships and creating an open space for transparency and sharing information.
We are keen to continue our work on this, so it can be used out in the real world to drive improvement by ICSs. If you would be interested in a conversation or support please get in touch with either CQC or National Voices.
Robyn Chappell, Lived Experience Manager at National Voices; Jacob Lant, Chief Executive at National Voices and Tracey Halladay, Delivery Manager at CQC for the ICS Health Inequalities Improvement framework.
