The need to ‘level up’ the country has featured heavily in political discussions over the last few months, even if what it actually means in practice is seemingly still being worked out. The new Secretary of State for Levelling Up, Housing and Communities recently referred to it as improving public services, raising living standards and strengthening local leadership. This followed earlier commitments from the Prime Minister, who talked about reducing inequalities through boosting regional economies and making sure that nowhere is left behind.
At a simple level, “levelling up” is about addressing regional inequality. A white paper outlining how the government intends to achieve this is now expected in the new year. The NHS should feature heavily in those discussions, but different parts of the country face unique issues when it comes to delivering health care.
Here we outline five particular issues that could affect the levelling up agenda within the health service.
Different areas, different challenges
Much of the focus in the wake of the 2019 general election has been on so-called ‘red wall’ areas of the country, where people have on average a lower healthy life expectancy and where tackling the wider determinants of health will be crucial to address inequalities. But, when it comes to delivering health care, the issues such places face may not be the same as those seen in other areas like rural Cornwall or the Kent coast. Understanding how these different challenges manifest across the country will be crucial to the success of the levelling up agenda.
Some rural and remote areas face particular challenges with staffing and funding, which Covid-19 has only emphasised further. Smaller and more spread out populations with fewer younger people and greater competition for locum or agency staff can impact on their ability to recruit. Specialist services – possibly more attractive to those looking to progress in their careers – also tend to be located in urban areas.
Services can be spread across a large area, making practical access for both patients and staff more difficult – such as ambulances needing to travel longer distances to reach the people who need them. This year's annual report from the Chief Medical Officer also drew attention to coastal areas and the unique challenges they face, such as an older population living with multiple conditions, deprivation and having difficulties attracting staff.
The size and type of organisation also matters, regardless of geography. Smaller hospitals – found in both rural and urban areas – are different from larger teaching hospitals, and have unique challenges around staffing and resources, as well as a perceived threat to their viability. This can have significant consequences, as shown by the challenges of providing maternity services in smaller hospitals, which have led in some places to their closure.
Deprivation has an impact on health care
Pre-pandemic analysis across multiple measures of health care quality and access found that people living in more deprived areas had worse experiences and outcomes. We also know that the number of people waiting for planned care is now worse in the most deprived areas of the country, reflecting these long-standing issues.
The reasons why are complex and the wider determinants of health (such as quality of housing, poverty and education) will be significant. But service factors are also relevant. When looking at the relationship between deprivation and access to primary care services, the variation in funding, ability to recruit and a population’s characteristics (such as a higher prevalence of long-term conditions) are all likely to be important.
The Health Foundation recently argued that to level up general practice, action must be taken to account for the challenges delivering primary care in more deprived parts of the country. Their analysis showed that, once weighted for need, GP practices serving more deprived populations receive around 7% less funding per patient than those serving more affluent populations, despite a GP in these areas being responsible for 10% more patients.
Disparities between NHS organisations
Wide variation exists in facilities, with outdated buildings and equipment requiring significant investment to bring them up to date. London has the largest share of backlog maintenance issues. This includes Charing Cross Hospital with over an estimated £320 million in high and significant risk backlog, which is more than the figure for the whole South West region.
These issues have been highlighted by the pandemic, with older buildings characterised by narrow corridors and shared accommodation meaning it’s been more challenging to implement infection control measures within hospitals. Such problems can be exacerbated by wider regional challenges that were known about before the crisis – with limited public transport, inferior travel infrastructure and poorer access to broadband or telephone signal only making the situation worse.
Digital health care is a particular worry. Concerns have been raised about digital inequalities within the population and its subsequent impact on health, with Lloyds Bank estimating that around 16% of the UK population are unable to use the internet by themselves.
But digital maturity within NHS organisations is also highly variable, with some places still using out-of-date IT systems that cannot talk to each other, while also struggling to get both the money and specialist digital staff needed to make progress. The recent evaluation of the Global Digital Exemplar programme (which provided funding to the most digitally advanced trusts) called for action to address this divide.
Workforce education, recruitment and retention
Workforce shortages are one of the most pressing challenges facing the NHS, and an absence of adequate national and regional workforce planning has not helped.
NHS organisations can also help to offer solutions to wider issues, with the potential for some to act as anchor institutions in their local communities already recognised, to “positively influence the social, economic and environmental conditions in an area to support healthy and prosperous people and communities”.
Across hospital and community services, the highest vacancy rates are currently in London (8.5%), compared to 3.9% in the South West and North East/Yorkshire. The distribution of NHS doctors is also disproportionate to the needs of local populations. There is a greater number of geriatricians in London compared to other NHS regions, for example, despite it having a lower proportion of people aged 65 and over.
We’ve also recently shown how, accounting for need, the numbers of people per GP vary across the country. But it’s not just about differences between areas. Vacancies also vary by trust type, and workforce role. Across regions, nursing vacancies are highest within acute trusts, followed by mental health.
Training and education are also relevant but the availability of courses and placements varies widely. Given that people are more likely to work in the place where they study, this issue is important. Our research found that for mental health nursing, there is wide variation in the availability of courses (including postgraduate options and apprenticeships), which neither supports areas with the greatest workforce needs nor provides opportunities for people who might want them.
Location can also be a factor influencing where people choose to work. Proximity to London, for instance, with its appeal as a multicultural capital and many well-known teaching hospitals, was considered a draw in our recent analysis on overseas nurses. But others associate it with a higher cost of living, leading them to opt for surrounding trusts or those in smaller cities.
This highlights the need for tailored and targeted workforce planning, which recognises the unique issues facing different areas, the needs of the local population, as well as the factors that influence where people choose to work and study. The Interim People Plan stated that a national programme board would be established to address geographic and specialty shortages in doctors, including developing new staffing models for rural and coastal hospitals, but the outcome of that remains unclear.
Action to address workforce pressures within the NHS has also tended to focus on the distribution of doctors and dentists, rather than other parts of the workforce, which also require attention.
NHS funding should, in theory, be driven by the needs of the local population, but in practice that is problematic. Policy-makers seek to avoid destabilising local health economies by making large changes in funding, so allocations are still largely affected by historical funding levels. As a result, some areas receive over £100 more per person than their population need suggests, whereas funding for other areas falls below their fair share (see chart).
The way funding is allocated to local areas has certainly created inequalities. Our previous work on rural health care, for instance, suggests that some of the unavoidable additional costs of delivering services in remote areas – such as being unable to benefit from economies of scale – may not be fully reflected in the way allocations are calculated.
In future, funding will be allocated to integrated care systems that cover a bigger area than clinical commissioning groups currently do. There is therefore also a risk that this means money will be less precisely allocated within an ICS region. What’s also unclear is how the funding generated by the recently announced health and social care levy, as well as additional funding for the NHS announced in the Spending Review, will be allocated to address the elective backlog.
The NHS and the levelling up agenda
We have outlined here just some of the ways that regional disparity features in how the NHS provides care to its population. While Covid-19 may have put these challenges into sharp focus, they have existed for a long time.
Tackling the wider determinants of health will be crucial for levelling up to be a success, however, and we must also recognise that disparity occurs in multi-faceted ways across the health service as a system. With more details to come on how the levelling up agenda will become reality across the country, now is a significant opportunity to address those issues.