If we are intent upon answering our most serious questions, from climate change to poverty, and curing diseases to designing new products, we need to work with people who think differently, not just accurately. Matthew Syed, Rebel Ideas, The Power of Diverse Thinking
A wicked problem
Nationally, clinicians are working hand in glove with managers to address some of the biggest challenges facing the NHS in its 75-year history. Our NHS people rose to the challenge of responding to the Covid-19 pandemic, which compounded existing health inequalities. Those experiencing the worst health outcomes and experiencing the biggest inequalities, were those who bore the brunt of the pandemic and its social and economic legacy.
We now face, arguably, an even greater challenge: recovering services, supporting our workforce and bringing down the backlog of waiting lists for elective procedures. With our clarity of vision of the challenge ahead, we must ensure that we bring down the backlog of elective care in an equitable way, with a conscious commitment to narrowing the health inequalities that are driving our operational pressures and impacting on people’s lives across the country at a time when many are also facing economic hardship. Clinicians and managers facing this challenge will need to do so with the mindset of building new habits, working in partnership, asking questions about data, holding each other to account, to ensure the momentum sticks beyond the New Year. Health inequalities need to be more widely understood and remain at the forefront of focus for innovation and transformative change.
Scale of inequalities and the backlog of elective care
Reducing healthcare inequalities is an NHS priority. The COVID-19 pandemic highlighted stark health inequalities across England, exacerbated existing inequalities in life expectancy between the most and least deprived areas and had an unequal impact across ethnic groups.1 Action on health inequalities is essential for relieving pressures on health services, securing the future sustainability of the NHS and supporting economic growth. Health inequalities come with significant costs. The costs to the NHS associated with deprivation-related inequalities in hospital care were estimated at £4.8 billion per year at 2011/ 2012 levels.2
The NHS Elective Recovery Plan, published in February 2022, set out how the health service would address the backlogs that have inevitably built up during COVID. The first step in the plan was focused on those patients waiting two years or more by the end of July 2022.3 There were more than 22,500 people who had been waiting two years or more at the start of 2022, this was virtually eliminated by July, despite COVID and other pressures.4 As we bring in the financial New Year, further targets are within sight, including to return the number of people waiting more than 62 days from an urgent referral for suspected cancer back to pre-pandemic levels, by March 2023, and to eliminate routine elective waits of over 78 weeks by April 2023. These targets should be met with an understanding of where the health inequalities lie in the data.
The clinician/manager dynamic at the national level
Prof. Bola Owolabi, MRCGP MFPH(Hon), Director – National Healthcare Inequalities Improvement NHS England
As a GP working on the frontline in a Derbyshire practice, I see first-hand the impact of health inequalities places on our local people and communities. I am also privileged in my national role to meet with community leaders, faith groups, charities, and NHS teams around the country who are committed to working within their community to help mitigate the heath inequalities experienced by their communities.
In my national role I have been inspired by the role of clinicians in leading the innovation in practice and delivery, assessing waiting lists for inequality, working with data and improvement tools to deliver elective care in an inclusive way. Professor Kiran Patel, Chief Medical Officer at Coventry and Warwickshire NHS Hospitals Trust is leading the charge. Working with a multi-disciplinary team with clinicians, data analysts, population health management experts, data leads and public health leads, the team has developed a range of innovations, including the HEARRT clinical prioritisation tool, to support in managing the waiting list in an equitable way. The Trust also introduced a QR code process for blood pressure recording and monitoring as part of the pathway.
Alongside clinicians, leaders and managers are also paving a way for diverse collaborations of teams to inspire innovation and practical action to address health inequalities. Dr Owen Williams, now chief executive of the Northern Care Alliance, led the way in Calderdale and Huddersfield NHS Foundation Trust, bringing together clinicians and managers to review waiting list data to understand where health inequalities lie, and to take practical steps to address those inequalities, such as engaging the Board to better understand and co-design services for those with a learning disability and to eliminate long waits for elective care for patients with a learning disability.
Using local data, University Hospitals of Leicester NHS Trust, identified that many of those not presenting at appointments (DNAs) belonged to deprived communities and/or were of ethnic minority backgrounds. There are lots of reasons appointments are missed, many are outside of people’s control. Embedding a culture of curiosity, a team of volunteers and staff proactively contacted patients from population groups identified as being more likely to miss their appointment, offering support with travel costs and car parking, as well as longer appointments where needed.
Nationally, it has been powerful and impactful working in partnership with my colleague Paul Doyle National Programme Director for the elective recovery programme. Paul has been a champion and advocate, flying the flag for robust data and performance measures for clinical challenges and raising awareness amongst elective and performance managers of the importance of understanding how inequalities are impacting on our patients facing long waits for planned care.
Paul Doyle, National Programme Director for Elective Recovery
It is difficult not to be inspired and motivated by the work that Bola and her team have done to champion our need to address health inequalities. The Core20PLUS5 improvement approach they have developed is key to supporting NHS organisations to reduce health inequalities. It has rightly become the accepted wisdom on how to address health inequalities across the NHS.
Our aim in the elective programme is to have a fair recovery, not just a fast recovery. And it is easy to fall into the trap of focusing only on the numbers as target dates to eliminate long waits approach. But doing so would fail to recognise the integral operational role that addressing health inequalities makes to achieving our long waits ambitions. For example, we know that patients living in deprived areas are substantially more likely to
DNA than their counterparts from more affluent areas; travel costs can be a barrier to attending hospital appointments; and people on zero-hours contracts can struggle to attend outpatient appointments, which are mostly delivered during normal working hours. So organisations need put in place strategies to address these issue to both reduce health inequalities and deliver out long wait ambitions.
And many organisations are doing just that. The 3 trusts mentioned above are at the cutting edge of this approach, but basic interventions can be just as effective, from appointment reminder systems through to providing out of hours appointments.
In systems and multi-disciplinary, diverse teams is where change happens
Progress to understand and take action to address health inequalities is made where we work in diverse teams, bringing together managers, data analysts and clinicians to deliver solutions.
Clinicians and managers working beyond traditional boundaries, sparks innovation and progress. Amongst the learning in these relationships. we have seen two critical ingredients for success in taking action to address health inequalities in elective care.
1: Data is absolutely crucial
Operational teams and data specialists excel in establishing the right data architecture, to collect and analyse a robust set of data. Clinicians, equipped with this data, can then turn this into actionable insights on the front line, and sharing those insights and practical approaches far and wide with teams, patients and communities, outlining in a meaningful way what the data is telling us about health inequalities for people on our waiting lists. Leeds Teaching Hospitals NHS Trust has developed a set of population health management tools that enable each clinical service to understand its patient population. The trust built a dashboard that helped reveal health inequalities by using patient-level information, with postcode and other demographic details. The tool has helped to develop targeted services to support more effective service utilisation, such as a pain management clinic which reduced the number of people on the spinal surgery waiting list who were tipping into the UEC pathway. This discovery was only possible through finance, analytics and clinician cooperation in building, interrogating the dashboard for insights and then operational staff supporting clinicians with the business case for new services/service reconfiguration.
2: Narrative builds understanding, momentum and change
The clinical voice in many trusts has proved time and again how change can happen through mobilising their peers, demonstrating not only why an inclusive recovery matters, but also setting out the productivity case for delivering care efficiently to patients. In Newcastle Hospitals NHS Foundation Trust, a leading consultant worked with analysts to triangulate primary care data with the elective waiting list, identifying the reasons for procedure cancellations. These included iron deficiency anaemia, uncontrolled hypertension and sub-optimal diabetes control. The secondary care consultants worked with their primary care counterparts to optimise long term condition management to avoid the risk of late theatre list cancellations, thus enhancing productivity.
Call to action
Recovering our core services inclusively and recovering our productivity can only be done when embedding a health inequalities lens and focus.
Health inequalities meet the 10 criteria of Rittel and Weber’s5 1973 definition of a wicked problem. In this context of complexity, making improvements in access, experience and outcomes can only happen when clinicians and operational leads work together and walking in one another’s shoes as we collectively see the day to day impact of health inequalities at the front line.
Clinicians can mobilise their peers in understanding the importance of why health inequalities matter, morally, ethically and on a productivity basis. With a disproportionate burden of disease falling on our most underserved communities, our lowest paid workers and fuelling operational pressures, there is also opportunity in those trusted relationships between clinicians, their patients and their communities.
Managers can complement this work by creating the conditions for innovation, a relentless focus on data and QI approaches to deliver service improvements to improve equity of care.
1Public Health England. Health Profile for England: 2021, September 2021.
2Asaria 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 Health. 2016 Oct;70(10):990-6.
3, Except where they chose to wait longer, did not want to travel to be seen faster, or for very complex cases requiring specialist treatment.
4As per the Elective Recovery Plan ambition this excludes 1,579 people who opted to defer treatment and 1,030 very complex cases. NHS England » NHS marks milestone in recovery plan as longest waits virtually eliminated
5Dilemmas in a General Theory of Planning Author(s): Horst W. J. Rittel and Melvin M. Webber Source: Policy Sciences, Vol. 4, No. 2 (Jun., 1973), pp. 155-169 Published by: Springer Stable URL: http://www.jstor.org/stable/4531523 ; 1973 Rittel and Webber Wicked Problems.pdf (sympoetic.net)
Paul Doyle is currently the National Programme Director for Elective Recovery in NHS England. He is responsible for running the elective recovery programme, which aims to progressively eliminate long waits, starting with 104 week waits by July 2022, and culminating with eliminating 52 week waits by March 2025. Paul joined NHSE in January 2022.
Prior to joining NHSE, Paul worked for Imperial College Healthcare NHS Trust where he held a number of roles including NW London Programme Director for Specialist Services Consolidation, Deputy Director of Transformation and Deputy CFO. Paul joined Imperial in 2016.
Before joining the NHS he spent 15 years in the Civil Service, primarily in HM Treasury, in a number of roles including Deputy Director for Health, and leading the Treasury and Government’s analytical work to make the case for Scotland remaining part of the UK in the run up to the 2014 referendum.
Paul was awarded an OBE for services to economic analysis and policy making in the 2015 Queens Birthday Honours.
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None