• Tara Humphrey

An Introduction to Health Inequalities for Primary Care Network Leaders

Whether you are part of the PCN Management team, a Clinical Director, or a member of the PCN team funded via the additional role reimbursement scheme, this blog will provide a practical approach to reducing health inequalities in your primary care network.


In this blog, you will find:


1. A short definition that simply describes what health inequalities are and why this area is so important

2. The Primary Care Network Service Requirements and the Impact and Investment Fund domain linked to health inequalities

3. Four practical health inequality resources and articles for Primary Care Networks

4. Four ideas to help approach health inequalities in a meaningful way from Dr Bola Owolabi, the Director of Health Inequalities at NHS England and NHS Improvement.


Let's get started!



What are health inequalities?


Health inequalities are differences in health outcomes closely linked with socioeconomic or demographic factors.


In other words, more economically disadvantaged people tend to have worse health outcomes than those who are better off.


These differences can be seen in a variety of ways, that includes life expectancy, infant mortality, and rates of chronic disease. Many complex factors contribute to health inequalities, and collectively, health, social care, education, community groups, voluntary organisations, businesses and beyond have a part to play in narrowing the health inequality gap.


Health Inequality Service Requirements for Primary Care Networks


Within the PCN DES Impact and Investment Fund, you will find the prevention and tackling health inequalities domain which includes;


  • Increasing health checks for our patients on the learning disability register

  • Recording ethnicity data

  • Identifying a population experiencing inequality in health provision and/or outcomes and creating and implementing a plan to tackle the unmet needs of that population.

Rather than looking at the following indicators and domains in isolation;

  • Cardiovascular disease prevention

  • Vaccinations and immunisations

  • Early cancer diagnosis

  • Social prescribing

  • Access

  • Enhance health in care homes

  • Medication reviews and medicines optimisation

  • Anticipatory care

  • Environmental sustainability

There will be segments in our communities where we have the opportunity to proactively address health inequalities and not just look at one cohort of patients to tick the domain.


As a starter for 10, start with running an audit which could be linked to age, gender, ethnicity, postcode, last contact with the surgery, or where translation services are needed to identify your cohort.


Also, Speak to your colleagues, walk around your community and speak to community leaders to help you identify where you could make a meaningful contribution and look to maximise Making Every Contact Count ( MECC).

MECC enables the opportunistic delivery of consistent and concise healthy lifestyle information and allows individuals to engage in conversations about their health at scale across organisations and populations.


Practical Health Inequality Resources for Primary Care Networks


1. Tackling inequalities in healthcare access, experience, and outcomes

On 21st July, NHS England released Tackling inequalities in healthcare access, experience, and outcomes. The paper can be found here.


The document provides checklists to set out the conditions needed to support sustained action for:

  1. System leaders in Integrated Care Boards (ICBs), Integrated Care Partnerships, provider collaboratives and within individual NHS bodies to consider whether they are creating the necessary conditions for improvement.

  2. Service teams to assess whether they are working within an enabling context.


Whilst recommendations in the paper may be for ICB boards, Primary Care Networks can ensure at the very least;

  • Leadership is committed to the cause.

  • We start with data.

  • We co-design solutions.

  • We approach reducing health inequalities with an action, test and learn mindset.

  • We keep communicating the lessons learnt.

2. Core20PLUS5 – An approach to reducing health inequalities

Core20PLUS5 is a national NHS England and NHS Improvement approach to support the reduction of health inequalities at both the national and system level. The approach defines a target population cohort – the ‘Core20PLUS’ – and identifies ‘5’ focus clinical areas requiring accelerated improvement.


The five areas are:

  1. Maternity: ensuring continuity of care for 75% of women from Black, Asian and minority ethnic communities and from the most deprived groups.

  2. Severe mental illness (SMI): ensuring annual health checks for 60% of those living with SMI (bringing SMI in line with the success seen in learning disabilities)

  3. Chronic respiratory disease: a clear focus on Chronic Obstructive Pulmonary Disease (COPD) driving up the uptake of COVID, flu and pneumonia vaccines to reduce infective exacerbations and emergency hospital admissions due to those exacerbations

  4. Early cancer diagnosis: 75% of cases diagnosed at stage 1 or 2 by 2028.

  5. Hypertension case-finding and optimal management and lipid optimal management: to allow for interventions to optimise blood pressure and minimise the risk of myocardial infarction and stroke.

More information can be found here.


3. An Introduction to population health management via Elearning for Health


This FREE course for health care professionals aims to equip learners with the basic knowledge required to understand what is meant by population health management, drawing on case studies to bring this to life.


It describes what population health management aims to achieve and explores the relationship between population health management and the broader concept of population health.


More information can be found here.


4. Reducing health inequalities in your local area: a toolkit for clinicians

This toolkit is intended to support clinicians and medical students across the UK. Access the tool kit here.


The challenges faced by primary care networks (PCNs) in addressing health inequalities


I had the pleasure of interviewing Dr Bola Owolabi, the Director of Health Inequalities at NHS England and NHS Improvement. She also works as a General Practitioner in North East Derbyshire.


One of the questions I asked her was how do Primary Care Networks approach health inequalities meaningfully when in her own words, “There is so much to do and not enough people to do it”.


Here is what she said. Click on the video to listen.


To listen to the whole interview, please click here and listen on your favourite podcast player.


For Action

  1. Who could you share this blog with to help raise awareness of this important topic? What ideas can you implement to support the health inequality agenda in your area?

  2. Have you included all of your PCN team in health inequality discussions?

  3. We hope this helps!





I'm Tara; I am the founder of THC Primary Care, an award-winning healthcare consultancy specialising in Primary Care Network Management and the host of the Business of Healthcare Podcast, where we have now published over 200 episodes.


I have over 20 years of project management and business development experience across the private and public sectors, and I have supported over 50 PCNs by providing interim management, training and consultancy.


I have managed teams across multiple sites and countries; I have an MBA in Leadership and Management in Healthcare, I'm published in the London Journal of Primary Care, and I am the author of over 250 blogs.


I have 3 children. My eldest has Asthma, my middle child has a kidney condition called Nephrotic Syndrome, and my youngest daughter has Type 1 Diabetes, so outside of work, healthcare plays a huge role in my life.