The Core20PLUS5 approach is seen by system stakeholders to be a credible and useful framework with which to tackle healthcare inequalities. It has helped systems to focus their efforts and align partners across shared local priorities.

What did we evaluate?

Core20PLUS5 is a national approach designed to support healthcare systems to focus their efforts on reducing inequalities. We have previously described the Core20PLUS5 approach and the Strategy Unit’s process for conducting a national longitudinal evaluation. In this first phase of the mixed-method evaluation, we explored the progress made by Integrated Care Systems (ICS) in delivering the Core20PLUS5 approach. Specifically, we were interested in:

1. How the design and delivery of the Core20PLUS5 approach was perceived and received
2. How the Core20PLUS5 approach was operationalised
3. Whether any aspect of the Core20PLUS5 approach could be changed or improved?

We drew on interviews with 110 strategic and operational stakeholders across the 13 ICSs and survey responses from 1039 staff working on health inequalities across 41 ICSs (survey conducted by Ipsos).

Readers interested in the full evaluation report are encouraged to request access to the Healthcare Inequalities Improvement Programme NHS Futures workspace.

What is the context and what did we find?

The approach became an increasingly explicit mechanism for systems to deliver on their mandatory duties around healthcare inequalities, without directly being funded to do so. Instead, from 2022/23, systems were expected to use their additional allocation (based on individual system’s health inequalities status) from a national £200 million budget, to address healthcare inequalities.

Three clear themes emerged for the system delivery of the Core20PLUS5 approach:

1. Systems perceived the approach to be a credible way of tackling healthcare inequalities, in line with legal requirements. It was understood as a ‘brand’ and allowed systems to identify and prioritise activities to address healthcare inequalities and to engage wider system partners. However, understanding of the component parts of the approach varied between systems and stakeholders.

    

2. Some systems adapted the Core20PLUS5 definitions to suit their local context when adopting the approach. This was because they understood the approach to be an underpinning principle rather than a framework to fully adopt. Adaptation of the approach facilitated systems to deliver on pre-existing commitments to tackling wider health inequalities, including those caused by the social determinants of health. Adoption of the approach was through integrating it with strategic planning and governance processes; using it to effectively shape local programme design and guide clinical priorities; and applying it to design targeted interventions.

    

3. Delivery of the Core20PLUS5 approach was not yet embedded as business as usual by systems. This was partly due to a lack of formal accountability for systems to improve on healthcare inequalities specifically. Alongside this, the local definitions of success, and the measures for demonstrating improvements when addressing healthcare inequalities, were still in development.

What do the findings mean?

Local autonomy to define how the Core20PLUS5 approach is used to address healthcare inequalities is a strength of the approach. This local tailoring is expected to allow system health inequalities leads to align their use of the approach with changing national and system remits.

Based on the evaluation findings to date, our interim recommendations are for systems and national agencies to work together to:

• Strengthen governance and accountability to formalise delivery of interventions which address healthcare inequalities
• Provide clearer expectations on system outcomes and guidance for measuring these
• Allocate direct resource for delivering interventions such as the Core20PLUS5 approach, to provide a financial mandate for addressing system healthcare inequalities.