Conceptualisation of health inequalities by local healthcare systems: A document analysis.

In 2019, local healthcare systems in England were asked to develop formal plans to reduce health inequalities. Here, we explore plans to understand how local healthcare systems conceptualise health inequalities and why. A broad Internet search and targeted search of NHS websites were conducted to identify all publicly accessible healthcare planning documents (National Health Service (NHS) Long-Term Plan (LTP) response documents) produced by local health partnerships in England. A thematic document analysis of the accessible plans was undertaken in NVivo by coding text relating to health inequalities. Of the 44 documents developed, 13 were publicly accessible. These 13 local plans were submitted to NHS England for review between September 2019 and January 2020 and averaged 167 pages (range: 41-273 pages). Only one document contained a chapter dedicated to health inequalities. After analysis, five themes were identified: (1) variation and (2) vagueness explained how health inequalities were conceptualised and (3) use of value judgements, (4) lack of prior conceptualisation and approach and (5) a lack of commitment to action in the documents to reduce health inequalities explained what led to the overall vagueness and variation. Local healthcare systems were found to conceptualise health inequalities in a vague and varying manner, and their conceptualisations did not reflect established health inequalities frameworks. A clear conceptual national framework for addressing health inequalities is needed to support local healthcare systems, so they can address health inequalities meaningfully and sustainably.

Transforming health systems to reduce health inequalities.

Never before in history have we had the data to track such a rapid increase in inequalities. With changes imminent in healthcare and public health organisational landscape in England and health inequalities high on the policy agenda, we have an opportunity to redouble efforts to reduce inequalities. In this article, we argue that health inequalities need re-framing to encompass the breadth of disadvantage and difference between healthcare and health outcome inequalities. Second, there needs to be a focus on long-term organisational change to ensure equity is considered in all decisions. Third, actions need to prioritise the fundamental redistribution of resources, funding, workforce, services and power. Reducing inequalities can involve unpopular and difficult decisions. Physicians have a particular role in society and can support evidenced-based change across practice and the system at large. If we do not act now, then when?