Health Inequalities through the lens of Levelling Up

Shivani Sen

Research and Policy Analyst at Curia

The Levelling Up Commission’s First Inquiry Sessions of 2023

On March 24^th, the Levelling Up Commission held its first two virtual inquiry sessions of the year. Both sessions were hosted by Director of the NHS Transformation Unit, Janet Budd, with part one focussing on the relationship between preventative care and health inequalities and part two looking at integrated care systems (ICSs) and how they level up deprived areas.

In both parts, Budd was joined by a range of experts in their respective fields. For part one, these were

• Jeffrey Matsu, Chief Economist at CIPFA
• Christina Gray, Director of Communities and Health at Bristol City Council
• Abdul Razaq, Director of Public Health at Blackburn and Darwen Council

In part two, the panellists were

• Geoff Little, Place-Based Lead for Bury Council’s Health and Care
• Richard Stubbs, Vice Chair of Yorkshire and Humber Academic Health Science
• Sarah Reed, Senior Fellow at Nuffield Trust

The Role of Prevention in Health Inequalities

One of the key topics covered in session one focused on the role of prevention when it comes to narrowing health inequalities. There was a general acceptance amongst all panellists that preventative measures are the best way forward to tackle health inequalities at the earliest possible stage. Christina Gray said,

“You have to do the leg work of researching the inequality you are talking about at which level of the system and then decide on what the intervention is. Afterwards, you’ve then got to monitor the intervention to find whether it is working and whether there have been any unintended consequences.”

Meanwhile, Abdul Razaq provided an example of how preventative measures are already working in parts of the UK. He said,

“There are some good examples in the North East of England where ICSs have invested in tobacco control. NHS and local authority money has been combined to try and make history to reach the target of only 5 per cent of the population being smokers by 2030.”

Health Inequalities at a Local Level

Another topic of interest in session one was about looking at health inequalities locally rather than nationally. For all three panellists, there is an urgent need to take a more granular look at health inequalities.

Research has suggested that taking a regional overview of inequalities helps to target resources at an appropriate local level, improving outcomes amongst disadvantaged communities.

Christina Gray said,

“The levelling up agenda has been focused on a national scale, which means the Government has been looking at levelling up entire regions rather than taking a more granular approach. However, if we look at rural authorities – which on a wider scale look like they have few inequalities – on a granular level, then we find clusters of extreme poverty.”

Jeffrey Matsu backed this point up and added,

“It’s about making sure that we have that level of granular understanding of what’s happening in neighbourhood services such as schools and criminal justice systems. How are these services being delivered at a local level? Because they cascade over time and have detrimental health impacts.”

He continued,

“To improve outcomes at a local level, we need to improve incentives to invest in prevention. If organisations don’t have the incentive to help each other, then it’s going to be difficult to reach our targets.”

ICSs and Health Inequalities

Part two kicked off with a discussion around ICSs and their role in tackling health inequalities. Can these new care systems help to reduce inequalities in certain neighbourhoods?

As far as Geoff Little is concerned, so far, they have to a certain point but he would still like to see improvement. In terms of what he would suggest, Little said,

“My first suggestion would be to push for further delegation of power. Not only within the NHS but also across Whitehall to ICSs and that delegation shouldn’t just be to ICSs but also from ICSs to local authority level partnerships and neighbourhoods.”

“We need double and triple delegation to promote two-way accountability – one way to NHS England and Parliament and the other way to local democracy.”

“My second suggestion would be around the neighbourhood level, where we need to improve structures and relationships with carers, friends, families, neighbours, etc. We need to work directly with those experiencing inequality to help change our systems for the better. Once we are doing that, each ICS will be able to develop its own programme for real substantial change.”

For Sarah Reed, the culture within the NHS, from the top down, needs to change in order for ICSs to be able to work effectively against health inequalities. Reed said,

“The reality is that there’s a top-down culture in this country, which means the NHS is most accountable upwards rather than outwards. While we live in this culture, it will hinder a long-term approach to tackling health inequalities, which is what is needed. Ultimately, a huge culture change is needed.”

Altering the Metrics That ICS

To steer ICSs in the right direction moving forward, key data and metrics are going to be vital. But what outcomes should they be assessed against directly to ensure health inequalities targets are met? Little said,

“This is about wider public serves, not just NHS metrics. We need less detailed NHS targets and more balanced ‘scorecards’. These scorecards will help us to look at things like how levels of activity in deprived neighbourhoods compare to the national average and whether levels of school exclusions are going up or down.”

Richard Stubbs added,

“Trends over time are important, perhaps more important than absolute measures. In terms of metrics, we often focus on what’s been invented locally rather than what’s been adopted. We should start championing areas that have ‘stolen with pride’ from neighbouring communities for vital interventions”

Final Thought

It is positive to see changes within healthcare that call for a more human led approach across systems. Shifting away from a siloed approach where life outcomes were determined, measured, and address based solely on metrics developed within healthcare, it is a step towards better integration when leading experts call for a cohesive outlook, bringing in education, criminal justice mental health, quality of relationships etc. If we are to employ this approach across health policies in the UK, it is necessary that the vision of levelling up becomes more detailed and focused, looking at geographical clusters and communities where people might experience high inequality within larger populations that might not be reflected as unequal. A more devolved approach should replace the largely broad, surface level and national approach to levelling up health that has previously existed. Ultimately, as the session highlights,  cultural shift is essential, where the way we understand health and the clustering of populations across which we measure it become fundamentally narrower, acknowledging the deeper sociological interrelations that perpetuate inequalities.