Inequalities in healthcare have long plagued the NHS. Previous research suggests that those living in areas with lower educational attainment wait 9-14% longer for NHS care, and those living in lower income areas wait 7% longer.  Importantly, these differences arise within hospitals, rather than between hospitals. NHS Digital have recently published hospital activity data by deprivation decile which highlights that during 2019/20 the most deprived decile had 7% fewer admission for elective procedures, but 51% more emergency hospital admissions than the least deprived.  Asaria and colleagues estimated that inequalities in emergency and elective admissions cost the NHS £4.8 billion per year. 
Cancelled appointments and procedures during lockdown have led to the number of patients on waiting lists rising to record levels with more than 2.15 million patients waiting more than 18 weeks from referral to treatment in July 2020.  The triple whammy of cancelled procedures, reduced bed capacity and additional time needed for healthcare workers to use personal protective equipment (PPE) and sanitise has left planned care with a waiting list that could reach 10 million by the end of the year. 
Dealing with this backlog efficiently and effectively is a priority over the coming months. On 1st October 2020, NHS England and NHS Improvement published their framework and support tools for the “clinical validation” of surgical waiting lists.  This sets out that waiting lists should be validated by 1) checking the patient’s condition and any additional risk factors; 2) establishing the patient’s wishes regarding treatment; 3) providing good communication with patient and carer and GP; and 4) giving patients the option to postpone surgery, but remain on the waiting list. The document makes it clear that the aim is not to reduce numbers on waiting lists, but make the best mutually agreed decision. One of the principles in the document is to narrow health inequalities, giving examples such as supporting people with communication difficulties, making arrangements for those with a learning or behavioural difficulty or supporting those with a mental health problem that may compromise capacity.
The plans, as set out, fall considerably short of what is needed and risk unintentionally worsening inequalities. Previous research suggests that initiatives which require high agency, or more individual effort, tend to increase inequalities because those with the personal, financial or social resources or the practical know-how are more likely to benefit.  The clinical validation process may mean that those who are best able to articulate their health problem and the impact on their lives or are able to attend further diagnostics or clinical assessment are more likely to be prioritised.
Fundamentally local healthcare systems need to take a data-driven approach to health inequalities which starts by looking at the existing inequalities in referrals, diagnostics, waiting lists and procedures. For example, this can be done using routine data by looking at activity by deprivation quintiles. Without this information it is impossible to start to address inequalities. Second, local healthcare systems need to address system-level inequalities such as workforce, funding, diagnostics and infrastructure. This does not necessarily mean re-distributing secondary care facilities, but it does mean having one waiting list across the local system so that all patients access planned care equally irrespective of place of residence. Third, waiting lists should be prioritised based on clinical need, not length of time waited, using objective assessments that give higher weighting for those living in disadvantaged areas to reflect their overall greater health need while also helping to narrow the historical gap in inequalities.
While it is welcome that health inequalities are mentioned in NHSE’s framework document, this case highlights a broader and more profound point; the current discourse on health inequalities is a great motivator, but policy makers find it difficult, if not impossible, to meaningfully operationalise it. The Inequalities in Health Alliance has just been launched bringing together nearly 80 organisations to express widespread concern over health inequalities and support for urgent action. The NHS needs to further develop its approach and thinking about healthcare inequalities—avoiding the fantasy that downstream healthcare interventions will be the solution to inequalities in life expectancy, or the sense of powerlessness that wider determinants of health are outwith its control.  The NHS needs to understand the various healthcare inequalities that exist, taking action to address them, while also working in partnership with non-healthcare organisations and being an inclusive and fair employer. In doing so the NHS will not only reduce healthcare inequalities, but also play its part in addressing wider health outcome inequalities.
John Ford is a clinical lecturer in Public Health at the University of Cambridge and led the development of the Cambridgeshire and Peterborough Health Inequalities Strategy.
Alex Gimson is a consultant transplant hepatologist at Cambridgeshire University Hospitals and Chair of the Cambridgeshire and Peterborough Clinical Communities Forum.
Cheng-Hock Toh is a professor and consultant haematologist at the University of Liverpool and Liverpool University Hospitals and the Academic Vice-President at the Royal College of Physicians London.
Competing interests: None declared.
1 Laudicella M, Siciliani L, Cookson R. Waiting times and socioeconomic status: Evidence from England. Soc Sci Med 2012;74:1331–41. doi:10.1016/j.socscimed.2011.12.049
2 NHS Digital. Hospital Admitted Patient Care Activity 2019-20 – NHS Digital. https://digital.nhs.uk/data-and-information/publications/statistical/hospital-admitted-patient-care-activity/2019-20 (accessed 8 Oct 2020).
3 Asaria M, Doran T, Cookson R. The costs of inequality: whole-population modelling study of lifetime inpatient hospital costs in the English National Health Service by level of neighbourhood deprivation. J Epidemiol Community Heal 2016;70:990–6. doi:10.1136/JECH-2016-207447
4 Griffin S. Covid-19: Waiting times in England reach record highs. BMJ 2020;370:m3557. doi:10.1136/bmj.m3557
5 NHS Confederation. Public reassurance needed over slow road to recovery for the NHS – NHS Confederation. 2020.https://www.nhsconfed.org/news/2020/06/road-to-recovery (accessed 8 Oct 2020).
6 NHS England and NHS Improvement. Clinical validation of surgical waiting lists: framework and support tools. 2020. https://www.england.nhs.uk/outpatient-transformation-programme/patient-initiated- (accessed 8 Oct 2020).
7 Adams J, Mytton O, White M, et al. Why Are Some Population Interventions for Diet and Obesity More Equitable and Effective Than Others? The Role of Individual Agency. PLOS Med 2016;13:e1001990. doi:10.1371/journal.pmed.1001990
8 Scott-Samuel A, Smith KE. Fantasy paradigms of health inequalities: Utopian thinking? Soc Theory Heal 2015;13:418–36. doi:10.1057/sth.2015.12