Conclusion and recommendations

This research took place between September and November 2023 when ICBs were still relatively new, having to make running cost allowance savings and working within a health and care system under immense pressure. It focused primarily on how the ringfenced health inequalities allocation was spent in this first year. This was a moment in time and represents a starting point for further action in future years. Year one was particularly turbulent, not least as the first Joint Forward Plan was only produced for the subsequent year. For those initiatives that were commissioned in year one and in year two, it is far too early to test whether they had an impact on population health inequalities. However, it has provided useful insights into the approaches that ICBs are taking to addressing health inequalities. 

Although some health inequalities leads indicated that a ringfenced health inequalities budget would be helpful, it is clear from our research that the ringfence put in place in the first year of health inequalities funding was not the crucial enabler for a significant number of ICBs (and there are cumulative drawbacks of centrally ringfencing funds to ICSs). Other factors such as pressure to achieve financial balance coming from NHS England oversight can take precedence over even ringfenced funds. 

In addition, when there was a visionary leadership commitment to tackling inequalities within the ICB, this funding was more likely to be used for its original purpose, and commitments made for future years. This strong leadership seems to be a more important driver than ringfencing. As such, the ongoing commitment to recurrent funding to address health inequalities in the baseline (not ringfenced) is helpful. A number of ICB health inequalities leads indicated that they had been able to use this to commit to programmes that were longer than one financial year.

This research found that leadership, governance and relationships were enablers for success in health inequalities. The biggest barrier that systems reported overcoming was balancing long-term strategic priorities with short-term operational must-dos.

The health inequalities leads we spoke to were determined to develop meaningful programmes of action to address health inequalities in ICSs. Addressing health inequalities coherently is challenging both because of its complexity and because this is an area that successive governments have been reluctant to address explicitly.

Recommendations

For government

Tackling health inequalities is a long-standing complex challenge that is in significant part affected by government socio-economic policies: 80 per cent of what affects our health outcomes comes from outside of the health system. This means that local health and care systems are working to determine what they can reasonably do to reduce health inequalities within a wider context, where there has not been a cross-government health inequalities strategy since 2010. 

To support the work of local health and care systems in tackling health inequalities, central government should: 

• lead the development of a cross-government strategy to reduce health inequalities. We are calling for this alongside the 250 other members of the Inequalities in Health Alliance, convened by the Royal College of Physicians.
  
  
• lead a cross-government national mission for health improvement, led by the Prime Minister, and set up a sub-cabinet committee responsible for this mission. The government should introduce new criteria in the Treasury’s green book assessing the impact of spending decisions on the health of the nation. This will ensure that the physical and mental health implications of all government policy are undertaken as part of the broader impact assessment process.
  
  
• have a view to the longer-term vision of integrated care when setting national targets to the health service, and therefore ensure that national priorities and targets are aligned with all four core purposes of integrated care systems.

For national regulators

This research has shown how central oversight can destabilise the work of systems when it is not aligned with all four core purposes of integrated care systems. National regulators, including the Care Quality Commission (CQC) and NHS England, can play a key role in this, by:

• ensuring that oversight of integrated care systems incentivises systems to focus on reducing health inequalities, as one of their four core purposes. This would realise the Hewitt review recommendation that the CQC considers, as part of its assessment of ICSs, ‘how far the system is making progress in shifting resources towards prevention, population health and tackling health inequalities’.
  
  
• supporting the sharing of good practice by emphasising areas of progress towards tackling health inequalities in assessment reports and publications, including the CQC’s annual State of Care report.

For NHS England

Embed health inequalities in all activities, by: 

• ensuring that executive team requests of systems are compatible with the long-term strategic vision for systems of improving population health and tackling inequalities
  
  
• ensuring that central initiatives, such as NHS IMPACT, align with the statutory purposes of ICSs, including tackling inequalities
  
  
• continuing the work of NHS England’s National Healthcare Inequalities Improvement Programme and embedding the inequalities approach across all NHS England activity. 

For integrated care systems

• Use our toolkit: This report was created as a response to ICS leaders requesting the opportunity to learn from each other’s approaches to tackling inequalities. To support them to embed the learning from this report we have developed a toolkit: How to embed action on health inequalities into integrated care systems. is available on the NHS Confederation website and draws upon the research and interviews. It outlines a quality improvement approach to embedding addressing inequalities into system working and has been coproduced with 36 ICSs.
  
  
• Access peer support: There is a significant amount of good practice emerging within ICBs. Going forward it will be important to continue to provide spaces where systems and partners have an opportunity to share concerns and successes and for these to be used to drive further development. The NHS Confederation convenes a number of peer-support forums, which include:
  
  
  • NHS Confederation’s ICS Health Inequalities Reference Group (bi-monthly meetings of a closed group of ICS chief executives, chairs, NEDs and system health inequalities leads).
    
    
  • NHS Confederation’s EDI Reference Group (quarterly meetings of a closed group of chief executives and chairs of NHS Trusts, systems and national bodies).
    
    
  • The NHS Confederation, Local Government Association and Association of Directors of Public Health’s Public Health and Integrated Care Systems Forum, bringing together national and local public health functions.

These networks, with their specific focus on inequalities and EDI, also connect with a wider range of networks that include those for ICB NEDs, ICB chairs, place leaders, ICP chairs and system improvement leads.