Injustice in Healthcare by Chandraa Bhattacharya

The COVID-19 pandemic has shone a bright light on the seriousness of health inequalities within England, exacerbating the significant discrepancy between healthy life expectancy that is known to exist between the least and most deprived areas of England.  A national approach to reduce health inequalities and narrow the life expectancy inequality gap, has been developed by Dr Bola Owolabi and the Healthcare Inequalities Improvement Team at NHS England. This approach, known as ‘Core20PLUS5’, is to be implemented at both a national and system level. It defines target population cohorts – the ‘Core20PLUS’ and identifies ‘5’ focus clinical areas that require accelerated improvement as a priority due to their contribution to the life expectancy inequality gap and the 20% most deprived from the whole population. 

This is part of a series of blogs, written by clinical / policy fellows on secondment at NHS England and NHS Improvement and Healthcare Quality Improvement Partnership (HQIP), explore the ‘5’ focus areas, the links between health inequalities and the invaluable contribution of leadership to narrowing the life expectancy inequality gap. The ‘5’ focus areas are cardiovascular disease, cancer, chronic respiratory disease, maternity and mental health.

Of all the forms of inequality, injustice in health care is the most shocking and inhumane” – were the words of Dr Martin Luther King Jr. in 1966 at the Convention of the Medical Committee for Human Rights in Chicago. Fifty-five years later, in today’s England, inequalities in the quality of care of ‘inclusion health groups’ still remain a great concern.

One of the most marginalised groups in our society can be defined by contact with the criminal justice system including people in prison and other prescribed places of detention as well as those living in the wider community. This group experiences health inequalities which are well above the average experienced by the general population. Their multiple complex physical and mental health, and social care needs are attributed to their adverse childhood experiences, poorer opportunities, life chances and not prioritising or valuing their own health and not accessing health and care support proportionate to their needs. Those in prison are likely to suffer from higher rates of infectious diseases with 15%[1] suffering from respiratory illnesses like asthma and COPD, significantly higher than their peers in the community. Lung cancer is common and rates of latent TB are high. Prisons are identified as high risk environments for respiratory disease and have a recent history of potentially serious flu outbreaks. The current Covid-19 pandemic has further highlighted these inequalities: in the first wave, there were almost 8 cases per 1000 people in prisons compared with 5 in the general population; between 2020 and 2021, there were 121 Covid-19 related deaths which was over three times the rate among people of the same age and sex in the general population[2].

Health inequality was a golden thread in the NHS Long Term Plan 2019[3]. It highlighted the importance of preventative initiatives to tackle ill health and to improve the gap in outcomes between the richest and the poorest. Focussing on the adults, children and young people in prisons, the Plan showcased some of the great work with prison populations, including the RECONNECT service for improving continuity of care as people are released back to the community. While Covid-19 might have slowed the progress of some of the Plan’s ambitions, the Core20PLUS5 approach has provided us with a great opportunity “for focused approach enabling us to gain traction thus demonstrating impact in reducing health inequalities” in the words of Dr Bola Owolabi, Director of Healthcare Inequalities at NHS England and NHS Improvement.

People involved in the criminal justice system because of their offending behaviours, are one of the population target cohorts of Core20PLUS5. In order to tackle their life expectancy inequality gap, there is an urgent need for whole system collaborative partnership to bring about sustainable change. Active collaboration at the national and system levels is crucial to understanding the current state of play and stocktake on access, experience and optimal outcomes. Covid-19 has shone a light on digital innovation for improved healthcare access, better care quality and cost savings which we need to carry on building. Equally important is data to drive interventions to bring about improvement thus generating the intelligence about what works. Focussing on the greatest risk of poor health outcomes, it is vital we work together to accelerate preventative programmes that proactively engage this population group. Key to all this is the strengthened leadership and accountability for supporting this population across the whole health landscape. NHS Systems Leadership Development Framework[4] stresses the importance of ‘developing a learning system and common understanding where being inclusive and seeking contributions from all stakeholders including citizens and communities helps to enable greater understanding’. There are already examples of good work e.g. pulmonary rehabilitation programmes, health trainers and peer to peer support programme on healthy living and behaviour change. Work has also begun through the Health and Justice Core20PLUS5 group to join up system-wide conversations to develop a co-ordinated, efficient and effective approach.

Most of the socio-economic disadvantages of those in or at risk of being in prisons and probation are linked to their potentially traumatic childhood experiences, backgrounds of poverty, indebtedness, unemployment, poor education and homelessness. As the Marmot Review 10 Years On Report[5] highlights, being a perpetrator or victim of crime is closely associated with deprivation and exclusion resulting in lifelong impacts on health. Although the relationship between health and social influences on offending and re-offending behaviours is complex, attention to these issues will help to bring about reduction in re-offending, health improvement and increase in life expectancy.

Therefore, as leaders, the responsibility to tackle the health injustice of this vulnerable group falls directly and collectively on our shoulders. We need to champion learning and insights across the system, building an inclusive leadership around quality improvement principles and reflect on our own evidence-based practice. Together, we can narrow this life expectancy inequalities gap through our shared vision, priorities and collective action embedded throughout the system.


[1] Public Health England Health and Justice Annual Review – 2018 to 2019 (


[3] NHS Long Term Plan

[4] Developing-Systems-Leadership-July-2017.pdf (

[5] the-marmot-review-10-years-on-full-report.pdf (


Chandraa Bhattacharya 

Chandraa Bhattacharya has recently joined the NHS England and NHS Improvement Healthcare Inequalities team on a training placement. She works in Her Majesty’s Prison and Probation Service (HMPPS) as the Senior Healthcare Inequalities Improvement Policy Delivery Lead – Justice Populations. She is currently on the HMPPS Senior Leader’s Programme. Previously, she was the Head of HQ Diversity and Inclusion in HMPPS leading on age, disability, equality analysis, Public Sector Equality Duties addressing disproportionate outcomes for prisoners, people on probation and staff.. Chandraa has over 15 years public health experience having previously worked at local (Enfield, Barnet, Haringey councils, South East and South West London STPs) regional (PHE East of England) and national roles (PHE Mental Health and refugee mental health in the Home Office). She also has international experience having worked at the World Bank and the International Monetary Fund in Washington DC working on gender inequalities in poverty reduction and economic management strategies. Chandraa has a M.A. in International Relations and Global Development Policy from Syracuse University, USA and a MPhil in Population and Demographic Studies from the London School of Economics.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.

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