Monday, April 08, 2013

NHS England Business Plan puts health inequalities to the fore

NHS England Business Plan Goal 8

NHS England (the new name for the NHS Commissioning Board) has published its three year business plan (2013-16) today.

The plan, "Putting Patients First", which you can download here, claims to put patients at the heart of the board's mission, and rests on an 11-point 'scorecard', which will be used to measure progress made.

As you will see, the promotion of equality and reduction of health inequalities figures clearly in the measures.

Priority 8, is an explicit commitment about promoting equality and inclusion.

Many of the other scorecard priorities (e.g. 1, 2 , 6, 7, 9 and 10) refer to areas in which the achievement of equal outcomes would need to be a significant factor if the goals are to be meaningfully achieved.

1 = Satisfied patients

2 = Motivated, positive NHS staff

6 = Ensuring that people have a positive experience of care

7 = Treating and caring for people in a safe environment and protecting them from avoidable harm

9 = NHS Constitution rights and pledges

10 = Ensuring the staff of NHS England understand their roles, are properly supported, and are well motivated

On the face of it, this will all be very welcome if outcomes measure up to promises.

Not all things, Not everyone

Anyone who works in this field will know that inequalities are difficult to address.

The larger the landscape, the more complex and embedded the issues.

If there was an easy way to address inequalities then everyone would have done it by now.

The best any organisation can hope to achieve in any one period of time is to pick your strategic goals on the basis of the evidence and focus on them.

Sadly, unless you have a lot of resources, that means you can't be all things to all people.

However, it is important to be clear about what priorities are being applied.

Tackling health inequalities

As I predicted recently, the emphasis in this plan appears to be much more about health inequalities (Steve Field's obvious area of interest) compared with other aspects of equality.

Now that, in itself, is not a bad thing.

Health inequalities predicated on peoples' characteristics (gender, race, disability, sexual orientation, gender identity, religion/belief or age) have tended to suffer in the past, with most of the emphasis in public health strategy being focussed on factors such as where people live and their economic status or class.

Thinking about health in a more nuanced kind of way is what PCT commissioners were supposed to be there to do. I.e. They were employed to design and manage a health service based on local needs.

If they weren't factoring those local needs then it somewhat begs the question why we needed 151 PCTs to essentially commission the same thing.

Garbage in, garbage out

My experience is that that is exactly one of the ways in which PCTs were too often failing in their responsibilities though.

And they failed often because their major partners in local planning, the Local Authorities, were pretty awful at this function too.

Take a look at any Joint Strategic Needs Assessment (JSNA) and the chances are that it will present a limited picture of the population, based on the information most readily to hand … age, sex and place. (The place where people live is then used rather crudely to infer racial demographics too).

Groups who don't all obligingly live in one electoral ward (such as disabled and LGBT people) tend not to figure in JSNAs, since nobody is sure how to count them.

So, if NHS England plans to use its immense muscle to influence how local health strategy is designed through CCGs to identify and tackle health inequalities then that is no bad thing.

However, it will need to recognise that it is dealing with essentially the same commissioning personnel as before … who failed to gather the data and analyse it under the previous management.

That previous management often showed us, through generally poor outcomes in goals 2 and 3 of our EPIT framework, that they were often clueless about where to begin.

It will be interesting to see their strategy to overcome that weakness.


There are therefore (in my opinion) limits to what NHS England can promise to do.

The staff in the equality and health inequalities team will need to realise that they cannot produce the outcomes themselves; they need to influence a system of 212 CCGs to produce the outcomes for them.

And to measure whether progress has in fact been achieved in three years, the first challenge will be to have some kind of baseline measure which you can then eventually compare with.

However, if the mechanisms to collect that baseline data don't already exist (as they generally don't) then that problem is, in itself, an essential precursor to address.

This is why I have then picked up on the precise wording of priority 8 above. Read it carefully.

The priority refers to "progress in reducing identified health inequalities on all indicators for which data are available".


This is a constraint that worries me, as I know from experience that the amount of actual peer reviewed evidence available for some very real health inequalities is practically non-existent.

And it is peer-reviewed evidence that clinicians tend to want to see.

There is plenty of the other kind. We call it "grey research".

This is the kind of largely qualitative, experiential, data that is collected by equality stakeholder organisations in order to make the case for policy interventions. It is often collected using methodologies (such as convenience and snowball sampling) which are easy to criticise and dismiss.

Such organisations carry out this kind of field research precisely because the other kind has not been prioritised or funded.

In 2009 an academic study carried out by the Department of Public Health and Epidemiology West Midlands Health Technology Assessment Group researched just how much peer reviewed research there was on LGBT health needs, for instance. They found very little, and their conclusions as to why this should be the case are very instructive.

With the possible exceptions of gender and race, a similar picture is likely to be found for other protected characteristics too.

This raises the concern, therefore, whether NHS England's health inequalities team will simply apply the definition of their performance indicator to exclude the protected characteristics where data isn't easily available (in the interests of scoring well in NHS England's performance culture) or whether, in pursuing a policy objective with grey research, they will hit a familiar wall with CCGs regarding such evidence as "just political propaganda, not REAL evidence".

I know where my bets would be.

The assessment, therefore: Great objective, but keep an eye on whether the implementation is as equitable as we all hope.

And the rest

As I pointed out in a previous article, inequality is not just restricted to health outcomes … important as they are.

I've also written before about the concerns for equality in the NHS workforce … underlined, particularly, by the failures admitted by NHS England Management in their own recruitment drive. Some very senior clinicians also voiced these kinds of concerns.

Furthermore, the experiential evidence from many protected groups of patients also points to the barriers experienced in actually trying to access services across the board … whether that is in GP surgeries, community services, in hospitals, ambulance or mental health services.

An example of these kinds of barriers is illustrated by the cases collated recently by trans community campaigners, which the GMC are considering investigating further.

Disability groups have also argued for years about the various kinds of barriers they encounter.

We also know that lack of cultural competence can get in the way of engaging with patient groups in some Black and Minority ethnic communities.

As I said at the outset, one management cannot tackle everything that is wrong across the board.

Inequalities have had generations to work their way into the fabric of a massive and complex system like the NHS, and it would be unfair to expect NHS England to fire off wildly at everything that moves.

For one thing, there are limits to the scope of NHS England's own influence. I addressed this in a previous article where I argued that fragmentation threatens the ability to pursue some inequalities.

However, if areas are not being addressed because decisions have been made to prioritise efforts in places where the data will look good then it is as well that patient and workforce communities become aware of that.

Where, then, will NHS England trim its cloth?

What isn't measured...

The clues are in the priorities and measures chosen by NHS England … the measures on which it will hold itself accountable.

What isn't measured doesn't get done.

Therefore, although the organisation has managers who are nominally working in other areas as well as those on the dashboard, stakeholders will need to scrutinise carefully whether the things that matter to them are subject to being counted in three years time.

You can be pretty sure that the focus will be on those things.

And my assessment is that the one which will suffer in particular will be the NHS workforce, as this is the area where the executive have already demonstrated they don't really grasp how to solve the problems. This is reflected in the paucity of hard specific scorecard measures to show that they ever will.



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