Leading questions: Lord Victor Adebowale, chair of the NHS Confederation

The NHS Confederation chair shares his thoughts on health inequalities in England with senior reporter Jess Hacker

Can you give an overview of the current state of health inequalities in England?

Health inequalities in England were already stark before the Covid-19 pandemic. The rising cost of living will have further impact on people’s mental and physical health.

The Covid-19 pandemic increased public awareness of this. The impact of the pandemic, both directly and indirectly, was greater for people from minority ethnic groups, children and older people, people on lower incomes, and disabled people.

The rising cost of living means rising rates of poverty. Around eight children in a class of 30 are being brought up in poverty. Poverty in communities means cold homes, meals being skipped and people taking the cheapest route to feeling full – often foods high in fat, salt and sugar. This has a negative effect on health. And ‘money worries’ isn’t just a glib turn of phrase – cost-of-living pressures are having a significant impact on the nation’s mental health too. One adult in four in the most deprived areas of England is experiencing moderate to severe depression.

The term ‘health inequalities’ has become more prominent in policy in recent years. Why is this? 

General practice clinicians have long seen how social determinants of health affect patients. Factors like where we were born, where we work and the air we breathe all contribute to our health. This is health inequalities in action: the unfair, avoidable and systematic differences in health between different groups.

It’s not just clinicians who understand this. The unequal impact of the Covid-19 pandemic showed the public, the press and policymakers across the political divide that it’s not just our individual choices that affect how healthy we are.

The NHS Long-Term Plan has reducing health inequalities at its core, and PCNs form a key part of this. Lots has happened since 2019, but the aim and direction of travel are laudable. We need to make sure we don’t lose momentum, we keep what has worked well (such as PCNs) and continue to translate policy into action.

What is expected of general practice in regard to health inequalities? 

General practice is expected – not mandated – to be a part of a PCN. A specific PCN service is tackling neighbourhood health inequalities, and excellent progress has been made, especially with annual physical health checks for those on the learning disability register.

Future contracts must give PCNs the ability to focus on what matters for their communities and what primary care does best – caring for patients in their communities. We need to go back to those core aims and learn from primary care about what works and what does not.

Are PCNs the best vehicle for addressing health inequalities in primary care?

We know that the only way to address health inequalities is by addressing capacity issues. The longer they continue, the worse health inequalities will become.

The rising demand and declining GP numbers mean that primary care needs to work to benefit from economies of scale and meet demand.

PCNs are one example of this, federations are another, as are primary care provider collaboratives and networks of networks. A merger of practices is also an example of this.

We cannot say a thing is the ‘best vehicle’ without knowing what the other options are, but PCNs were introduced with an objective of addressing health inequalities. Since 2019, when they started, they have contended with a lot of extraordinary events – the pandemic, the Covid vaccination programme, rumours
about their future when they had barely got started, but they have achieved a huge amount in this time. Their services are up and running, thousands of additional roles reimbursement scheme (ARRS) staff are in place and they led the vaccination programme, which did a great deal to reduce health inequalities. Their outreach initiatives, from buses to everyday conversations, were remarkable. They have a lot to commend them.

Is the NHS sufficiently focused on reducing inequalities?

When I speak to NHS leaders, I hear resoundingly that they are focused on and committed to reducing inequalities.

The NHS alone cannot ‘solve’ health inequalities – central policy change is needed too. NHS leaders were looking to the health disparities white paper to address the national, structural causes of health inequalities. This white paper was shelved last summer, and has now been folded into an upcoming major conditions strategy.

Policy must be translated into action and this requires capacity. At present, in primary care – and all across health and social care – demand is outstripping supply. It’s difficult for the NHS, both management and clinicians, to do what’s needed to reduce health inequalities when they’re understaffed and demoralised. In primary care, the annual funding increase in the GP contract is nowhere near inflation. And investment – and permissions – to improve estates have not been forthcoming. A fully funded workforce plan and investment that at least keeps pace with inflation, as well as vital capital investment, would help alleviate these pressures.

As well as this, GPs working in a challenged area should be paid a premium, and all training exam costs should be covered if they then work in the NHS for a minimum of three years. This would help retention and the recruitment of GPs and relieve a lot of pressures primary care currently faces.