System design, governance & accountability

Tackling health inequalities: the role and impact of Integrated Care Systems

The aim of this study is to provide evidence to inform national policy makers as they design policies and mechanisms to support Integrated Care Systems in tackling health inequalities

April 2022 - December 2023

Background

Read our final report here | 2023

Inequalities in health outcomes and in access to and experience of health and care services have become increasingly recognised over many years (Marmot, Allen et al. 2020). The Coronavirus pandemic has exacerbated existing inequalities and heightened the urgency of efforts to address them (Munford, Khavandi et al., 2021). The current Health and Care Bill recognises this, placing a duty on newly constituted Integrated Care Systems to tackle health inequalities. However, this will not be straightforward. The most recent Care Quality Commission report on the state of the health and care system (Care Quality Commission 2021 p68-9) states:

‘We have found that most systems had some understanding that inequalities in health and social care existed in their areas before the pandemic, and how they had worsened or changed due to the pandemic. But tackling inequalities was often not a main priority for systems, or strategies to identify and tackle health inequalities across some systems were not yet well established…. Overall, across all our provider collaboration reviews, we highlight the strong need for leaders in local systems to work hard to understand the inequalities that exist in their areas, and to develop strategies to specifically address them.’

The report highlights specific issues with a lack of appropriate data on ethnicity, gender, etc., as well as services for those with learning difficulties.

Clearly, if ICSs are to successfully address their new ‘duty’, coherent plans and a strong understanding of the dimensions and drivers of local health and care inequalities will be required. Furthermore, serious action on inequalities may require difficult decisions to be made, including with regards to resource allocation, setting priorities and meeting performance targets. Some of the factors influencing their ability to do this will be external, such as performance targets and incentives, whilst others will be internal, including relationships between partners and the development of shared understandings about the nature of inequalities. It will also require a thorough understanding of the roles and responsibilities of different actors within the ICSs, the “accidental” inequality consequences of decisions that are made and points at which decisions can be made “proactively” to address inequalities.

Previous research has shown that commissioning and service planning authorities may not find tackling health inequalities easy. For example, a study of the approaches taken by Clinical Commissioning Groups to health inequalities showed that those involved often did not have a shared understanding of the nature of health inequalities (Warwick-Giles, Coleman et al. 2016), and that how far inequalities were seen as important depended crucially on the relationship between Clinical Commissioning Groups and their local Public Health Teams (Warwick-Giles, Coleman et al. 2016). Analysis of links between budgets, use of services and indicators of population needs demonstrates that there are very large differences between Clinical Commissioning Groups in how they allocate resources internally that are not known, discussed or investigated (Sutton, Anselmi et al. 2021). Indeed the recent Lancet-LSE commission on the future of the NHS set as a priority the monitoring of inequalities in health and care. It is recommended to “Develop and monitor metrics that indicate the quality of integration at the local level” and metrics to benchmark the progress of local organisations in tackling health and care inequalities (Anderson, Pitchforth et al. 2021), beyond the one already in use to measure inequality in ambulatory care sensitive emergency admissions by small area deprivation within CCGs (Cookson, Asaria et al. 2018). Considerable emphasis has been placed on data-driven approaches to tackling inequalities, with ‘population health management’ seen as an important approach for ICSs to adopt (NHS England 2019). However, this depends upon accurate data, something which the Care Quality Commission finds to be currently lacking (Care Quality Commission 2021), and it does not obviate the need for difficult decisions about priorities, nor does it necessarily help ICSs in deciding which responsibilities, resources and decisions should be taken at which levels within the system.

Understanding how ICSs are conceptualising inequalities, how they are making decisions about their priorities, what information they are collecting, collating and using, and how tensions are being resolved, will be important in ensuring that national policy supports them as they develop. At the same time, research is required to investigate whether ICS are showing signs of making early progress in factors that can be changed in the short-term, such as redistributing resources and reducing inequalities in access. This will shed light on which approaches appear to work and on whether we should expect to see reduction in inequalities in outcomes over the longer-term. This could also establish the base for a set of indicators comparable across systems and over time to routinely monitor progress in health and care inequality. Furthermore, this research will shed light on more general issues of ICS development, including decision making, the roles of different partners, internal and external accountabilities and approaches to internal resource allocation.

  • Aims

    The aim of this research is provide evidence to inform national policy makers as they design policies and mechanisms to support Integrated Care Systems in tackling health inequalities.

    The objectives are:

    • to characterise approaches to tackling health inequalities in developing Integrated Care Systems and identify what information ICS use to guide their inequalities work
    • to understand the factors underpinning and affecting those approaches, including national policies (including targets and standards), internal ICS organisation and governance, and relationships with Local Authorities
    • to investigate what progress ICS make in short-term indicators of addressing inequalities, including budgets and access and establish a set of indicators for routine monitoring in the longer term
    • to identify approaches that show promise in terms of reducing inequalities and summarise the prospects for reductions in inequalities in outcomes in terms of timescales and magnitude

    Research questions to be addressed include:

    Understanding health inequalities:

    • How are health inequalities conceptualised by ICS leaders?
    • Are these conceptualisations shared across system partners and between spatial levels within systems?
    • What has shaped the development of these conceptualisations?

    System responsibilities and governance

    • How is the duty to tackle health inequalities embedded within the System governance structure?
    • Does the duty to address inequalities influence core business or is it treated as an extraneous activity?
    • What consequences for inequalities are there of decisions that are not consciously focused on addressing inequalities?
    • What mechanisms are being chosen to tackle inequalities?

    Investigating proximal levers

    • What opportunities are there to affect proximal levers to reduce inequalities, such as budget and resource allocation?
    • Does the new duty to reduce inequalities lead to redistribution of resources?
    • Are there changes in short-term indicators, such as inequalities in access to services?

    Learning and longer-term prospects

    • What approaches appear to be successful in starting to tackle inequalities?
    • What should we expect to see from the new duty to address inequalities in terms of reduction of inequalities in outcomes and over what timescale?
    • How can inequality within systems be monitored?

  • We propose a mixed methods study which brings together a national survey of ICS leads, in depth qualitative case studies in 3 ICSs, and quantitative examination of outcomes. The relatively short duration of this project means that we will focus the quantitative work on proximal levers, such as budgets and resource allocation and inequalities in access, rather than outcomes. The quantitative work will also explore how the approaches being adopted by ICSs across the country can best be monitored and measured, including investigating what data is currently available, what new data might need to be collected and the extent to which the outcomes claimed and intended by ICSs might be measurable and attributable to the changes made.

    Work package 1 Initial national survey of ICS leads.

    We will design a short online survey for ICS leads. The survey will explore:

    • Their current understanding of inequality and the important health inequalities in their areas
    • Their top three priorities in tackling these inequalities
    • The mechanisms they are adopting
    • Their approaches to monitoring outcomes
    • The top three challenges they face in delivering their plans

    Work Package 2 Qualitative case studies of 3 ICSs

    Based upon the findings of the survey, we will choose three ICSs adopting differing approaches to health inequalities. We will undertake semi-structured interviews with:

    • ICS board members
    • Place-level leaders
    • Members of the Partnership Board

    We will seek to develop an in depth understanding of how ICSs are conceptualising health inequalities, the extent to which these conceptualisations are shared and the factors shaping them. We will explore governance and decision making mechanisms in order to understand how approaches to tackling health inequalities are developed and overseen. We will also consider approaches to data collection and monitoring, and explore how potential impacts on inequalities feature in decision-making processes.

    Work Package 3 Quantitative measurement and analysis of inequalities within ICSs

    Based upon the findings of the survey and on existing work (Cookson, Asaria et al. 2018) we will identify a set of outcomes for which individual level data are available through NHS Digital (e.g. Hospital Episode Statistics, Community Care Data Set, MHMDS, IAPT, PROMs, GPPS). Outcomes will cover use of resources, access, care processes and proxies for health.

    Based on the understanding of inequality and the objectives we will consider a set of inequality metrics (e.g. absolute versus relative and focusing on the whole population or on specific groups) and develop appropriate indicators for inequality within ICSs.

    We will measure inequality not only within ICSs, but also other organisations that compose it, based on the understanding of roles and responsibilities. For example we will measure inequalities within providers and within GP practices, when appropriate. This will help in identifying the level at which to act.

    We will investigate associations between inequalities in resource use, access, care processes and health through multivariate regressions.

    Limitations

    ICSs will be in the very early stages of their development during this project, and therefore it is unlikely that improvement in quantitative metrics will be detectable.

  • Dissemination Plan:

    An interim report will be prepared which will describe the findings from the online survey and will propose initial metrics for monitoring progress in tackling inequalities. We will work closely with DHSC and NHSE/I and will provide informal feedback from ongoing research as required. A final report will summarise the findings from the case studies and the quantitative analysis. Academic papers will also be prepared, and we will liaise with the NHSE Confederation to explore the potential for holding a workshop for ICS leaders to support them in developing plans to tackle inequalities.