Tackling health inequalities is cast into legislation as one of the core functions of an integrated care system (ICS). ICSs have also been identified as key organisations responsible for ensuring post-pandemic efforts to recover elective care are conducted in an inclusive way.
In summer 2020 after the first wave of Covid, NHS England asked systems to recover services in a way that also tackled health inequalities – there are some groups who wait longer for treatment than others for reasons that are not directly related to their clinical condition. NHS England asked systems to disaggregate waiting lists for elective care by deprivation and ethnicity (as evidence suggests health inequalities widened in these areas during the pandemic) and prioritise service delivery taking this into account.
The King’s Fund recently undertook research looking at what progress ICS and trusts had made with tackling their waiting list backlogs in an inclusive way and we have just published our findings. This policy does exactly what we think is needed to make progress on tackling health inequalities – it embeds work to tackle inequalities into business-as-usual core NHS work, rather than it being an add on, conducted on the side. We wanted to find out whether the approach was working.
Our findings will not be surprising to people working in ICSs – progress tackling inequalities on waiting lists has been slow. There were some pockets of innovation and progress which showed real promise, but the trusts and ICSs we looked at had not embedded an inclusive approach into their elective recovery efforts.
The potential for ICSs to play a key role was striking, but the ICBs we looked at were still working out what this might look like.
The argument we heard over and over again was that it was not possible to tackle inequalities on waiting lists until long waits were addressed. But is this an either or?
Unfortunately, there is no simple answer to that question – the answer is ‘it depends’. It depends what inequalities exist on your waiting list, why they are there and what is needed to address them. The key first step is for systems to find out what they are dealing with by looking at the data.
There are ways that partners can work together across a system to address inequalities – we heard about ICBs that were using targeted mutual aid to direct patients to providers with shorter waits, support packages to help patients reach their appointments and make the most out of them (support with travel, longer appointments when required, interpreters etc.), or system wide pre-habilitation programs that work with patients while they wait to ensure they are as healthy as possible and primed to make the most of treatment once they reach the top of the list.
Systems can also work to mitigate the risk that some initiatives developed to tackle the backlog inadvertently exacerbate inequalities. For example, we heard about the need to look across a system at the use of independent sector providers to support recovery. They play an important role treating large numbers of low-risk patients for high throughput procedures like cataracts and hip replacements. But this can mean patients who are higher risk because of factors like comorbidities are left with longer waits at a local NHS hospital because they are not eligible for the faster alternatives.
It comes back to looking at the data and understanding whether and how the experience of waiting is different for different groups in your local population. Then working with those groups who are losing out to understand what would work to improve their experience. The ICB can play a critical role bringing together data and people from organisations across sectors to discuss its implications.
Another argument we heard from many people working in trust and systems was that it can be difficult to know where to start with this work. Here are a few questions that we came up with that can be useful to think about as a starting point:
- Is tackling health inequalities a priority within your elective recovery strategy?
- What can the board do to signal the importance of this work?
- What are the main barriers to change in your trust/organisation?
- Who can you work with across the integrated care partnership on this?
- What data do you need to see to understand inequalities on your waiting lists and be assured about progress in addressing them?
In the long-term tackling inequalities on waiting lists leads to healthier communities and a more equitable health system. These are reasons that many people I speak to who work in healthcare turn up for work and people who are progressing this work have spoken to me about the way this gives them deep satisfaction and makes them feel like they are making a difference. A key message from The King’s Fund’s research is that tackling inequalities on waiting lists is important and doable. What does this mean for you and your ICS?