Intended for healthcare professionals


How trusts can deliver inclusive recovery across the NHS

BMJ 2023; 382 doi: (Published 25 July 2023) Cite this as: BMJ 2023;382:p1724
  1. Jonathon Holmes, policy officer for operational performance
  1. NHS Providers

The covid-19 pandemic has had a severe and lasting impact on our health. The newly published Health Index for England1 from the Office for National Statistics, shows it has also worsened pre-existing health inequalities.

This trajectory is worrying for the public and raises questions about sustainability for the NHS. Trusts are doing all they can to help tackle health inequalities and reduce care backlogs in elective care and in community and mental health services, but more can be done to support them.

The figures show that between 2015 and 2021, personal wellbeing, physical health, and the prevalence of unhealthy behaviours in England have all deteriorated since covid-19 emerged. On top of that, the pandemic exacerbated long-standing health inequalities2— such as people in more deprived areas having to wait longer for treatment and experiencing shorter healthy life-expectancy on average.

As the NHS continues to recover from the pandemic and restore core performance standards, tackling inequalities and improving population health must be central to the agenda. While there has been some improvement across measures, including personal wellbeing and physical activity, overall, self-reported health is down from 2019. People have reported worse physical and mental health, and the prevalence of “behavioural risk factors” such as harmful alcohol consumption3 and poor diet leading to obesity,4 have increased substantially during the pandemic.

Coupled with the delays in accessing care during the pandemic’s peak, this deteriorating population health will have likely contributed to the increasing acuity of need as well as record-high demand and long waiting times5 across urgent and emergency care during the winter of 2023/24. So, while we already know that the virus continues to have a direct impact on health and mortality, there is now evidence that the indirect impact of the pandemic—in terms of limiting access to healthcare, its influence on health behaviours, and its wider socio-economic effects—may have worsened population health.

In these trends we see how the indirect impact of covid-19 contributed to widening inequalities as well as the direct effects of the virus. Now driving population health improvements and tackling health inequalities are core priorities for the NHS, but they must equally be championed and resourced nationally and be central concerns for wider public services including housing and education.

While Integrated Care Systems can and should be playing a leading role, working with partners to help tackle some of the wider determinants of health, NHS trusts have a core role in improving equity of access, collecting and using population health data more effectively, as well as leveraging their role as an anchor institution.6

Tackling inequalities in access has been central to the approach some trusts have taken to recovering the elective backlog. For example, Calderdale and Huddersfield NHS Foundation Trust7 put access for people with learning disabilities at the heart of their elective recovery plans. Their approach has already narrowed inequalities and improved health outcomes for this group.

The University Hospitals of Coventry and Warwickshire NHS Trust has been noted for their data-led approach to managing their waiting lists,8 where clinicians are provided information and empowered to proactively reach out to people who may be more at risk of experiencing unfair health inequalities.

Separately, the ambulance sector is developing its role in reducing health inequalities9 as it works to recover core performance standards. This includes using the data that ambulance trusts hold to respond to demand proactively and realise the preventative role the sector can play.

However, despite the priority many trusts are placing on tackling inequalities and the need for health improvement to be a central theme in how services are delivered, rising demand and worsening health means capacity across the NHS is overstretched. Addressing chronic workforce shortages and bringing forward long term capital investment will also be vital to delivering recovery of core performance standards and tackling care backlogs.

Cross government commitment to improve health, narrow gaps in life-expectancy, and ensure equitable access to care will be key to embedding accountability at all levels across public services and employment, complementing the work trusts are already taking forward and ensuring lasting change.

While the pandemic exacerbated trends in deteriorating health and widening inequalities, the recovery from it could be a catalyst for positive change.


  • Competing interests: none declared.

  • Provenance and peer review: not commissioned, not peer reviewed.