There is a belief that the NHS, because it addresses ill health, is the right organisation to address health inequalities. Hospital and community trust boards are generating papers describing what they are doing: reviewing waiting lists for inequalities, addressing internal inequalities through EDI programmes, collecting data linked to incentive payments. General practice is definitely collecting more data.
The counter-hypothesis is straightforward. The NHS is the wrong institution to sustainably address health inequalities in communities, towns, cities, and the nation. The current policy approach addresses the symptoms, health inequalities, and not the causes, the social determinants that produce them.
The social determinants are not medical
We know with certainty that health inequalities are the result of inequalities revealed through the social determinants of health. Education. Economics. Environment. Community. Culture. Add the word "poor" before each one and you have the explanation for almost every disparity the NHS is now being asked to solve.
The social determinants for the vast majority are decided at conception. We are not born equal. From birth to death, health inequalities are deteriorating. UK measures of social mobility show we remain at the wrong end of OECD nations. Your human potential, at least in these islands, is constrained and determined as you develop in the uterus. So too is your health potential.
The link between social mobility and the social determinants of health suggests we might be stuck. Not because the NHS needs more money to address health inequalities. Because the causes sit outside the NHS entirely.
What the NHS cannot do
Hospitals deal with disease. Walk-ins and referrals. The staff are not skilled to sustainably address social determinants, and the business models are not designed for it. Hospital business models accept, assess, treat, discharge. Right now they cannot do this well enough to avoid causing harm, with millions waiting, including for time-critical cancer care. The current NHS crisis is itself adding to health inequalities.
Primary care is collecting social determinant data linked to incentive payments. The question: so what next? GPs see more patients, do more work, but are not designed to act on the social determinants. A letter to housing is not new and is now less effective than ever.
The 20plus5 initiative aims to reach the 20% most deprived through NHS organisations that do not have the skills, capabilities, capacity, or business models to reach into those communities. We know where to look. The postcodes. But knowing the postcode and being able to change what happens inside it are entirely different capabilities.
What the NHS can do
The NHS is not powerless. It occupies a unique position as the largest employer in most communities. It has relationships with every citizen who walks through its doors. The question is how to use that position differently.
Local NHS organisations can join major local employers to procure products and services locally wherever possible, putting money back into the population, building community wealth. Pay the bills on time. Sharp practice stresses and bankrupts local businesses.
The NHS can work with other anchor organisations to identify those struggling with health inequalities because of identified social determinants. The patient walks in with the disease bag, and the human bag filled with inequalities. The latter has a huge impact on the former. NHS staff can connect the citizen to local services that meet needs. To do that work requires new capabilities, new capacity, and new business models.
At STRASYS, the Decision Intelligence engine for healthcare, this is where our work begins. Our Population Need Segmentation maps not just clinical need but consumer behaviours, motivations, and access patterns across populations. It reveals the human behind the patient record. The SMASH methodology then builds outward from those needs: demand modelling, workforce, services, organisation, finance, compliance, policy. In that order. Starting from the human, not from the policy.
We tested this at Alder Hey Children's NHS Foundation Trust. The trust moved from maintaining hospital services to improving the life chances of children and young people. That shift required understanding the population's needs at a depth that went far beyond clinical data. It required connecting health data with socio-economic data, educational outcomes, and community patterns. The result was a fundamentally different organising principle, one that positioned the trust not as a fixer of disease but as a contributor to better life chances.
Naeem Younis, STRASYS CEO and the architect of our inequalities framework, argues that the NHS can move from the fix-and-forget business model to improving the life chances of the people it serves. But only through new business models that take integration of local organisations and local democracy to a completely different level. And only with the analytical capability to understand needs that are not just clinical but social, psychological, and economic.
The NHS will not fix health inequalities. That requires politics and policy at a national level. But local NHS organisations, working with local anchor institutions, armed with the right data and the right decision infrastructure, can make a meaningful contribution. Not through more data collection. Through the capability to act on what the data reveals.