The Integrator: An opportunity to tackle widening health inequalities

It seems hard to remember after the torrid two months the UK has been through that March 2020 was the month final five-year system plans were due to be submitted to NHS England and Improvement. These plans were meant to set out how each area will implement the NHS long-term plan and establish how sustainable and transformation partnerships were to become integrated care systems by April 2021.

Matt Hancock said the NHS is to restart non-covid services in the next six weeks. But a much deeper rethink of what the NHS does is required if these local systems are to be fit for a post-covid world.

The issue of health inequalities has risen up the agenda as the covid death toll has hit the poorest areas of the UK harder, as well as BAME citizens.

Prior to covid, I was told that some of the draft STP submissions had well developed plans for tackling health inequalities while others had some way to go.

During a webinar hosted by NHS Confederation this week, it was heartening to hear one hospital consultant say health inequalities were now at the “core” of its reset plans. He said: “If we get that wrong we will widen inequality when we come out of the pandemic.”

However, this isn’t an issue that the health service can tackle alone. During a Commons women and equalities committee hearing this week, Professor Sir Michael Marmot, long-standing guru on health inequalities, said: “The pandemic has exposed and amplified underlying inequalities in society and the lockdown will have the effect of increasing these inequalities.”

As one charity leader told me, “It is entirely possible the NHS might do a lot of positive things to get a better understanding of inequality but the NHS won’t be able to shift it, as it is fighting against a recession.”

Greater direction from the government and NHS England may well be needed to improve how inequalities are managed as well as an increase in resources to local authorities to help tackle the issues behind deprivation such as housing and education.

It is unsurprising therefore that in a recent paper on the development of ICSs, NHS Confederation called for the NHS to ask for a “system and partnership by default” approach to ICSs to replace the “system by default” mantra that was championed in March. It argued this change is vital if local authority involvement in system plans is to no longer be seen as optional.

The involvement of local authorities in STP plans is more important than ever if the NHS is to stop another care home catastrophe which in part resulted from an “us” and “them” approach from the health sector. It might also help mitigate rising concern about councils enacting care easements, in which people will no longer receive the care they need but only the care that prevents their human rights from being breached.

The charity Independent Age has warned these easements, temporarily allowed under the Coronavirus Act 2020, could see the most vulnerable in society being left without any care and health problems soaring as a result.

NHS Confed’s paper also called for “reset strategies… to understand and expand on the role that the NHS and wider systems can play as anchor institutions themselves in supporting the rebuilding and prosperity of their place”/ The NHS will have to double down on its intention to hire and promote fairly if its role as an employer is to have an impact on social inequalities during an anticipated recession.

Within all this there is also some unpicking to be done around the move to online and digital consultations. At the same NHS Confed webinar one GP warned that the wholesale move to online consultations could “widen the gap between the haves and have nots” as it is dependent on access to smartphone, 4G and/or Wi-Fi. This will be further embedded if becomes routine for GP surgeries to ask patients to buy expensive home monitoring kit such as oxygen meters and blood pressure monitors.

A rethink of ICS plans also needs a rethink about timelines. The deadline for STPs to become ICS is a mere 11 months away and the NHS will spend all that time also managing the coronavirus fall out.

NHS Confederation’s view is clear that the deadline should be stuck to, or otherwise momentum will be lost. It calls on NHS England to be clearer on what is expected of STPs and to also loosen the requirements so that some of the ICS work can be done after the April deadline.

It said: “Systems could still become ICSs in name with an understanding that there are still areas of development to address.” While there is a benefit to this approach, the speed could well result in a lost opportunity to rethink how health inequalities could be better tackled.