The NHS has rarely been more vocal about health inequalities. Reducing them is written into the mandate, the planning guidance and the language of every strategy. Yet a sequence of recent policy decisions, each reasonable when taken alone, is quietly assembling a system in which widening those inequalities is the path of least resistance. No one has chosen it. That is precisely the problem.

Start with the money. In 2022/23 NHS England created a ring-fenced £200 million allocation for tackling health inequalities. From 2023/24 it was folded into baseline allocations: still notionally present, rising with inflation, but no longer protected.[1] When the NHS Confederation and Leeds Beckett University asked what had happened, interviewing inequalities leads across twenty of the forty-two systems, only half had protected the funding in full. The rest had let some or all of it drift into the wider system budget, with the report finding that pressure to hit financial balance could take precedence over even the ring-fenced money.[1] Challenged in Parliament, ministers noted that the inequalities weighting in the allocation formula had risen from 10% to 10.2%.[2] A decimal point is not a fence.

This was not an isolated decision. For 2025/26, NHS England released most remaining funding ring-fences and rolled service development funding into core allocations in the name of local flexibility.[3] Flexibility is reasonable. But unprotected money, in a system under financial strain, has a predictable destination. Equity spending tends to lose these internal arguments, not on merit, but because its benefits are slow and diffuse while a deficit is immediate and concrete.

The incentives now point the same way. Providers have been told to cut their cost base by at least 1% and deliver 4% productivity.[3] And the new NHS Oversight Framework for 2026/27 makes financial performance the decisive measure. It scores every integrated care board and provider across dozens of indicators, sorts them into segments and publishes the results. Those segments determine the intensity of oversight, access to capital and freedoms, and even senior pay.[4]

Health inequality is, to its credit, in that scoring. Boards are now measured on deprivation gaps in early cancer diagnosis, in pre-term birth, and in the management of blood pressure and cholesterol. This is genuine progress. But look at how it counts. Those measures sit among more than forty indicators, averaged into a single judgement, while the framework contains one hard override: an organisation in deficit cannot reach the top two segments until that deficit is resolved, whatever else it achieves.[4]

Consider what that asymmetry does to a board with finite resources and both problems on its desk. A widening deprivation gap is survivable, offset by strength elsewhere. A deficit is not. So which is addressed first? The framework never instructs anyone to deprioritise inequality. It simply makes inequality the failure an organisation can afford.

Then there is scrutiny. The Health Bill before Parliament abolishes NHS England and moves its functions to integrated care boards and, crucially, to the Department of Health and Social Care and the Secretary of State directly.[5] At the same time it removes the bodies that would notice the drift. Healthwatch, the independent voice of patients, is abolished, its functions pulled into the very organisations it existed to challenge.[5][6] The Health Services Safety Investigations Body is folded into the Care Quality Commission, the regulator it was deliberately kept separate from.[5] It worked because it was confidential and blame-free, and that independence is now at risk. You do not make a hidden trade-off more honest by removing the people whose job is to see it.

None of these changes was presented as a decision to widen inequality, and that is the heart of the matter. Taken together they have built an architecture in which the financially rational choice and the inequality-widening choice are increasingly the same choice, made quietly, by people under pressure, with fewer independent eyes to hold them to account.

This is fixable, but only deliberately. If reducing inequality is a real priority rather than a stated one, it needs the same hard edges the system reserves for finance: equity funding protected rather than dissolved into the baseline; distributional outcomes given genuine weight in oversight rather than averaged away; independent scrutiny preserved so someone can name where the gap is growing. Above all it means the centre, which now holds the pen, owning the trade-off openly rather than letting it accrete through a hundred defensible decisions.

A health system delivers what it rewards. Right now it rewards the balance sheet and merely encourages fairness. Until that changes, the inequalities we say we are fighting will keep widening, and no one will ever quite have decided that they should.

References

1. NHS Confederation. Putting money where our mouth is? Health inequalities funding. 2024. https://www.nhsconfed.org/publications/putting-money-where-our-mouth-health-inequalities-funding
2. House of Commons. Reducing Healthcare Inequalities. Hansard, 11 February 2025. https://hansard.parliament.uk/commons/2025-02-11/debates/79022107-D269-4DAF-AE12-5F0D5192B540/ReducingHealthcareInequalities
3. NHS England. 2025/26 priorities and operational planning guidance. 2025. https://www.england.nhs.uk/long-read/2025-26-priorities-and-operational-planning-guidance/
4. NHS England. NHS Oversight Framework 2026/27. 2026. https://www.england.nhs.uk/publication/nhs-oversight-framework-2026-27/
5. House of Commons Library. Health Bill 2026-27. Research briefing CBP-10845. 2026. https://commonslibrary.parliament.uk/research-briefings/cbp-10845/
6. The Health Foundation. Briefing: Health Bill, Second Reading, Monday 1 June 2026. 2026. https://www.health.org.uk/news-and-comment/consultation-responses/briefing-health-bill-second-reading-monday-1-june-2026

Author

Andi Orlowski

Andi is a health economist and Director of the NHS Health Economics Unit, a NHS consultancy team that supports health and care organisations locally, regionally, and nationally.

He is also a Senior Advisor for NHS England and the World Bank, providing expertise in population health management, non-communicable diseases, prevention, and data analytics.

Specialising in population health analytics, health inequalities, and strategic commissioning, Andi lectures and is pursuing a PhD at Imperial College London. 

He serves as Vice-Chair at the Healthcare Value Institute at the Healthcare Financial Management Association (HFMA) and Deputy Chair at Kaleidoscope Health and Care.

Outside of work, Andi plays rhythm guitar in an NHS covers band called the HEUristics and in a heavy metal band called the Black Museum.

Declarations of Interest
AO has no competing interests. AO is employee of the NHS Health Economics Unit, a lecturer at Imperial College London, an advisor to the World Bank Group, Vice Chair of the HFMA’s Healthcare Value Institute and Deputy Chair of Kaleidoscope Health and Care.