The NHS Confederation is the independent membership body for the full range of organisations that make up today's NHS. Our membership includes over 95% of NHS organisations—acute trusts, ambulance trusts, mental health trusts, primary care trusts, foundation trusts and special and strategic health authorities. Independent sector members who provide NHS services are also part of the NHS Confederation. We also represent NHS organisations on workforce issues through NHS Employers.

  The NHS Confederation welcomes the opportunity to give evidence to the Health Select Committee on health inequalities. Health inequalities is one of the starkest health challenges facing Britain today and, working with other departments, must be the Department of Health's top priority. This evidence sets out our views, based on feedback from a cross section of our member forums and networks.

  The NHS Confederation is currently undertaking a major programme of work on health inequalities, which starts from the premise that, while reducing the gap in health inequalities is a huge multi-agency issue, health has a lot it can do to improve the current situation.

EXECUTIVE SUMMARY AND RECOMMENDATIONS

—  All parts of the health and social care system have a specific role to play in assessing and delivering services designed to reduce health inequalities in access, outcomes and life expectancy.

—  Recruiting the best clinicians to work in highly deprived areas is often a problem for NHS organisations. PCTs in these areas need to find ways to incentivise and support clinicians to choose to practise in areas of high deprivation. By understanding clinicians' financial and professional motivations, PCTs need to design schemes which will improve recruitment and retention in these areas.

—  Addressing health inequalities requires a partnership approach between the NHS and other organisations such as local authorities. To achieve effective partnership working, the new Local Area Agreement system should be allowed time to develop and embed. Also, the Joint Strategic Needs Assessment has a central part to play and must be a robust and inclusive process to ensure that the needs of all communities are addressed in service plans.

—  Consideration should be given to whether there would be advantages to making some of the resources for tackling health inequalities directly available through the Local Strategic Partnership (LSP).

—  The funding of primary care needs to be reviewed to incentivise action to address unmet need and health inequalities, for example by incentivising practices to actively seek out new patients from deprived communities. As part of this, the Minimum Practice Income Guarantee (MPIG) should be replaced in its current form or phased out relatively rapidly in conjunction with the establishment of a target capitation figure for practices.

—  Under the Local Government and Public Involvement in Health Act 2007, certain NHS organisations have a statutory duty to partnership through the LSP. This affects NHS trusts, primary care trusts and foundation trusts but not other providers such as GPs or independent providers. However, it is important that all organisations involved in NHS services play their part in the commissioning and delivery of local services designed to reduce inequalities relating to access.

—  The wider implications of geographical differences, for example rurality and its impact on equitable access to services,as well as challenges in urban areas, need to be recognised in funding allocations.

—  There are great benefits to be had from joint appointment of public health specialists at both local and regional level.

—  The strengthening of local partnerships should be mirrored across Government to ensure coherence of policies which impact on health inequalities.

—  The PSA targets for health inequalities should be revised to reflect health inequalities evident between the key diversity strands.

—  The Single Equality Bill should include a legal definition of "positive action".

THE NHS CONTRIBUTION TO REDUCING HEALTH INEQUALITIES

  Health inequalities is a term with many different definitions. For the purposes of this inquiry, we suggest that it covers:

—  Inequalities in access and the opportunity to use healthcare

—  Inequalities in the outcomes from healthcare

—  Inequalities in life expectancy and quality of life.

  While the NHS Confederation would argue that the health service can do more about inequalities in access, less can be done by the NHS alone to improve inequalities in outcomes from healthcare. Inequalities in life expectancy and quality require a broader range of partners to be actively involved and will be the most intractable of the three areas in which to measure positive change in the short to medium term.

  The NHS Confederation believes that all parts of the health and social care system have a role to play in assessing and delivering services designed to reduce health inequalities. This includes primary care and general practice, NHS commissioners and the providers of NHS services and specialist public health practitioners at PCT and regional level. Without strong local, regional and national partnerships, change cannot be brought about.

  For the NHS to reduce health inequalities significantly the development of high quality commissioning will be vital. PCTs, working with the Department of Health (DH), have developed a programme to deliver the commissioning skills required. The programme aims to obtain the best value and health outcomes for local citizens by understanding their needs and then specifying and procuring services that deliver the best possible health and social care outcomes within available resources.

  In addition to strengthening commissioning through the World Class Commissioning programme, to tackle inequality in access the NHS must prioritise finding the people who are not accessing the services they need. This requires significant investment nationally and locally in sophisticated data and disease mapping to enable a better understanding of who and where the missing people are. This investment should include incentives for primary care to "case-find"—identifying those at greater risk of certain conditions.

  Improving access is also a crucial part of tackling health inequalities. We must change the incentives in the NHS to better serve those patients from poorer backgrounds at the early stages of disease. In these early stages, it may be possible to improve outcomes; however those from poorer economic backgrounds are failing to access preventative and proactive services. Three first steps to improve access to services would be to:

—  Remove the minimum practice income guarantee which prevents equitable distribution of resources.

—  GP practices are given around £600 million a year according to their historic levels of funding rather than the real needs of patients. Known as the minimum practice income guarantee (MPIG), this payment may disincentivise practices from case-finding and should be abolished.

—  Change the formula for paying GPs to ensure practices in deprived areas don't lose out.

—  The Quality and Outcomes Framework (QOF), a new method of rewarding performance, pays practices with high disease levels at a lower rate per patient than practices with low disease prevalence. This means that the existing payment system has disadvantaged certain practices, which may be those in deprived areas.

—  Design local services that reach out to the community and don't expect the community to come to the service.

—  Extending opening hours in the evenings and at weekends is of course important. But improving access to traditional services may not be the most effective way to tackle health inequalities in some excluded groups. Getting behind the reasons for inequality requires a much more sophisticated approach.

—  Many PCTs are using new ways of reaching out to local communities. For example, in Tower Hamlets there were plenty of dentists, but people weren't using them. The introduction of a mobile screening service to travel round the local community, proved to be the solution—30 per cent of those attending had never been to a dentist before. And more than half went to a high street dentist within a month of visiting the mobile service.

DISTRIBUTION AND QUALITY OF GP SERVICES

  Concerns have been expressed about the relative distribution of GPs since the creation of the NHS in terms of both numbers and quality. In general, the distribution and quality of GPs has reflected the inverse care law, which means that fewer GPs are available in deprived areas. Whilst there is very good primary care in deprived areas there appears appear a wider range in terms of quality. This has continued despite an overall increase in the total number of GPs and the availability of financial incentives to those willing to commit to working in deprived areas. When investigating the issues which were most important to those London GPs considering a practice move, a survey in the late 1990s demonstrated they were most disinclined to work in practices with high deprivation among the patient population.

  In the future, improving access to primary care services needs to be locally responsive, grounded in both clear needs assessment and through high quality public and patient involvement in the design of services. In parallel with this, it is important for PCTs to understand both the financial and professional motivations of clinicians choosing to practice in areas of high deprivation and create schemes which enable these clinicians to flourish and attract others with similar values.

  There would be an advantage to reviewing the funding formula to ensure that there are effective incentives for practices to identify those at greater risk of certain conditions, especially within deprived communities. In addition to this is the future of the MPIG. Competition between practices to provide high quality and accessible services can be used as a method of improving quality and access. This can be achieved by encouraging new entrants and, where lists are not full, selectively contracting existing practices. This is not only another reason to replace MPIG or phase it out relatively rapidly, but also implies that practices should be rewarded for the number of patients they have registered. In addition, walk-in centres and out-of-hours providers should be encouraged to register patients and therefore also become eligible for these rewards.

THE ROLE OF THE QUALITY AND OUTCOMES FRAMEWORK

  The relationship between the Quality and Outcomes Framework (QOF) and health inequalities is complex. Current results are conflicting with some studies showing an association between poorer QOF performance and higher levels of deprivation. Others do not show this link. QOF achievement can also be adversely affected by other characteristics of the practice, patients, practitioner and local area, for example practice size; the proportion of practitioners aged over 50 years; the proportion of practitioners who trained outside of the UK; and the proportion of patients over the age of 65.[324] Conversely higher QOF achievement has been found to be associated with other characteristics including training practices, group practices and a higher ratio of practitioners to patients[325]. Practices with these characteristics may be less likely to exist in socially deprived areas.

DIFFERENT TYPES OF QOF INDICATORS

  QOF indicators themselves can generally be characterised as either process or outcome measures. Process measures are those which relate to activities performed by the clinician such as recording of a blood pressure measurement within a specified time period. Outcome measures are those which measure whether the patient achieves the desired result, for example the optimal control of blood pressure, and are not usually within the control of the clinician to the same extent as process measures.

BASING INCENTIVES ON THE RIGHT INDICATORS

  While providing a financial incentive for the achievement of health outcomes seems sensible, there is limited evidence that this has the desired effects. This is due primarily to the fact that the relationship between healthcare and health outcomes is not direct and is dependent on some factors out of the control of healthcare providers. This may be why most incentive schemes focus on technical care measures.

  That said, there is an emerging evidence base for "tightly linked" process measures[326], which have a stronger relationship with the desired health outcome and allow for the targeting of those at highest risk. While these have a more complex indicator construction, it is argued that they are superior to simple process measures and outcome measures for the following reasons:

—  They recognise and encourage organisations to do the right thing especially in regard to those patients who may never achieve the ideal target

—  They identify those patients at highest risk of poorer outcomes and therefore most likely to benefit from the intervention

—  And because of the strong link between the process and the outcomes the intervention most likely to improve the outcome is explicitly incorporated into the measure.

  The potential for QOF to be a comprehensive indicator of health outcomes is limited for the reasons outlined above. This means that there are likely to be greater health gains across the wider population by focusing QOF on appropriate measures rather than those based solely on outcomes. The main risk to the delivery of these gains relates to the concept of exception reporting. To date, evidence[327] of gaming in the implementation of exception reporting is limited but the management of exception reporting forms a key element of the PCT role in the monitoring of the QOF.

FOCUSING RESOURCES TO AREAS OF HIGH MORBIDITY

  The value of a QOF point at a practice level is adjusted both for the number of registered patients and for the number of patients on the individual disease register (prevalence). This reduces variation in payment between practices and targets resources at areas of high morbidity, and therefore indirectly addresses some aspects of health inequalities. Using Scottish data, researchers have examined the effect of using this method to calculate payment.[328] They have found that, while its use is successful in reducing variations in practice income, it did not achieve its secondary objective of focusing resources to areas of high morbidity. Therefore, the QOF prevalence adjustment should be reviewed to incentivise action to address unmet need and health inequalities.

THE SUCCESS OF NHS ORGANISATIONS AT CO-ORDINATING ACTIVITIES WITH PARTNERS

  Solutions to address the causes of inequality require a broad coalition of action that goes well beyond the NHS to address poverty, employment and housing (please see appendix one for an example). A concerted effort from both health and local government will be especially important and they will need to use their newly strengthened statutory duty of partnership to improve local services by working closely together.

  The multifaceted nature of health inequalities requires a partnership approach including joint needs assessment, planning and service delivery. This would be best achieved through utilising the LSP as the co-ordinating body at local level. In addition, active NHS participation will be necessary in the development of local outcome measures and the delivery of Local Area Agreement improvement targets. In this, we would stress that a robust process for Joint Strategic Needs Assessment is a vital part and we welcome the recent guidance supporting this new development. We hope that the new system will be given time to embed into local processes and that good practice will be shared through bodies such as the Care Services Improvement Partnership and other regional presences.

  However, the system needs to ensure that this collaboration is not undermined by excessive bureaucracy. Planning and reporting processes must be streamlined to ensure that partnership is encouraged rather than seen as an additional and onerous task. A duty of partnership in the Local Government and Public Involvement in Health Act (2007) does not recognise the importance of all providers of NHS services, including independent sector, general practices or third sector providers, having the same duty of partnership. We believe it is important that all providers of NHS services play their part in the commissioning and delivery of local services designed to reduce inequalities, whether covered by the duty or not.

  Funding should not be ring-fenced to specific issues where inequalities exist, such as stroke or obesity, as the underlying causes of inequality will vary from PCT to PCT area and ring-fencing can lead to investment in areas of less priority to the detriment of more pressing local issues. However, consideration should be given to whether there would be any advantage to making some of the global resources for tackling health inequalities directly available through the LSP. Doing so would mean funding decisions can be made that are locally sensitive and agreed by all partners. The development of the Comprehensive Area Assessment supports this by enabling accountability and transparency to be assessed at partnership rather than individual organisational level.

  However, the Confederation is concerned that the wider implications of geographical differences are sometimes not recognised in funding allocations. For instance, in rural areas deprivation can be related to "churn" for example of migrant workers, whose needs may not be picked up in needs assessments and for whom case-finding can be difficult. Similarly the ability to address these inequalities may be compromised by the increased costs of travel and, hence, of service delivery particularly for long term, low level interventions in sparse populations. These local differences between LSPs should be taken into account in framing any new incentives within the existing system.

THE ROLE OF PUBLIC HEALTH SPECIALISTS

  The NHS Confederation considers that joint appointment of public health specialists at both local and regional level should reap great benefits (please see appendix two for an example). In particular, their expertise and input to joint needs assessment and service planning is crucial when designing effective services aimed at addressing health inequalities. They can also serve as a bridge between local government and the NHS and enable the wider implications of health inequalities to be taken into account in planning other local services. However, whilst the case for these joint appointments is intuitively strong we would like to see formal academic evaluation of these initiatives and their impact on key decisions.

CO -ORDINATING POLICY BETWEEN GOVERNMENT DEPARTMENTS TO COMPLEMENT LOCAL PARTNERSHIP WORKING

  The NHS Confederation believes, there should be a strengthening of cross-governmental arrangements to mirror local partnership working, such as the dual key system for children's services. This would ensure that departmental policies support and enhance local partnerships rather than produce guidance in isolation. We welcomed the cross-cutting Public Service Agreement (PSA) targets recently announced as part of the Comprehensive Spending Review and hope that these will encourage further an inter-departmental approach to policy-making. These are challenging targets. Sustainable reductions in inequalities require a long-term approach that enables cultural and economic aspects to be addressed alongside those over which the NHS has more direct impact.

  The NHS Confederation believes that national target setting on a few key areas must not be considered in isolation. While continued improvements are obviously to be welcomed, in the most deprived areas, dramatic improvements may still leave a PCT area as an outlier nationally. This can have an impact on morale and on overall performance ratings which cancel out some very innovative approaches and prevent learning from examples of good practice in some cases.

  The Confederation believes that targets should be formulated which reflect the inequalities in access to healthcare, quality of delivery, and appropriateness of provision which exist for all of the diversity strands—particularly, disability, age, gender, race, religion or belief.

  At a practical level, the specific legal obligation to develop equality schemes and to carry out equality impact assessments has the potential to help shape local priorities. Conducting and using the evidence to create meaningful dialogue with communities is central to effective commissioning and service provision. However, we believe that the processes, as currently defined, can prove overly bureaucratic and time-consuming for NHS organisations to support. We would therefore welcome a re-evaluation of the approach, with a view to simplifying the requirement.

  The harmonisation of the current equality legislation proposed in the Single Equality Bill and the creation of the new single regulatory body (Equality and Human Rights Commission) should help to clarify the actions needed to be taken by NHS organisations. This in turn should result in a more consistent approach to tackling health inequalities locally and nationally, which is to be welcomed.

  Current legislation permits the use of "positive action" (or balancing measures) to address an imbalance in employment opportunities among targeted groups. While this is undoubtedly a potentially powerful lever in addressing aspects of inequality there is some confusion across the NHS about its legitimate use. Our own research suggests that employers would welcome the clarity and reassurance that a widely accepted—or even legal—definition of "positive action" would bring. In our formal response to the recent Discrimination Law Review consultation, NHS Employers set out our working definition of "positive action" as a contribution to the debate.

USING THE POWER OF THE NHS AS A CORPORATE CITIZEN

  The NHS employs 1.3 million people, more than any other organisation in the UK. The power this gives the NHS as a local employer could be used much more effectively to tackle inequalities.

  As part of the local community, the NHS has a considerable role to play working with other agencies to find broader solutions to health inequalities. Harnessing collective power, services must work together locally to put health inequalities at the heart of local priorities. Tackling the root causes of health inequality such as, employment, poverty and housing is only possible when the relevant organisations work together.

  And the NHS must ensure it offers equal opportunities in employment. Through flexible employment, the procurement and local sourcing of goods and services, and in supporting its employees to put back into the community through volunteering, the NHS can enable local communities to reduce health inequalities for themselves.

NHS Confederation

January 2008

Case study: partnership working in child and adolescent mental health

  The review of mental health services for children and adolescent, recently announced as part of the Children's Plan, will allow for a greater focus on preventative measures in child and adult mental health services (CAMHS) and there is certainly more to be done in this area.

  In our Maintaining the momentum report, we highlighted how investing in these services can prevent problems persisting into adulthood, with the accompanying vicious circles of social exclusion, lost productivity and heavy service use. Studies have shown that public service costs incurred in adulthood, by individuals diagnosed with mental health problems in childhood, can be up to ten times more than the cost of people with no such history—these include costs related to health services, social care and the criminal justice system. These findings highlight the long-term benefits of investing in prevention and education initiatives, as well as early intervention.

  The National Institute for Health and Clinical Excellence (NICE) is producing guidelines about primary school interventions by teachers and other school professionals both at whole-school level (for example, mental well-being classes) and at targeted level (for vulnerable children and those with emerging problems). If such initiatives are correctly resourced, there is potential for improved recognition and early intervention when problems first surface, ensuring fewer children are referred with mild problems and children who really need help are referred in a timely manner.

Case study: joint appointments leading to better preventative work

  Increasing numbers of PCTs and councils are jointly appointing directors of public health. When Blackpool PCT and the council appointed their joint director of public health, they analysed the area's position as having the second-worst life expectancy for men in England and Wales. They found several reasons for this, including injuries and a range of falls prevention and road safety activities for older people reduced the number of people admitted to hospital.

325   Ashworth M and Armstrong D. The relationship between general practice characteristics and quality of care: a national survey of quality indicators used in the UK Quality and Outcomes Framework, 2004-05. BMC Family Practice 2006; 7:68 doi:10.1186/1471-2296-7-68 (http://www.biomedcentral.com/1471-2296/7/68 accessed 27July 2007). Back

326   Kerr E, Krein S, Vijan S, Hofer T, Haywood R. Avoiding pitfalls in chronic disease quality measurement: a case for the next generation of technical quality measures. Am J Manag Care 2001; 7: 1033-1043. Back

327   Doran T, Fullwood C, Gravelle H, Reeves D, Kontopantelis E, Hiroeh U, Roland M. Pay for performance in family practices in the United Kingdom. New Engl J Med 2006; 355: 375-384. Back

328   Guthrie B, McLean G and Sutton M. Workload and reward in the Quality and Outcomes Framework of the 2004 general practice contract. Br J Gen Pract 2006; 56: 836-841. Back