Accountable Care Systems and the Spectre of Health Inequity

In August this year NHS England (NHSE) published a paper titled ‘ACOs and the NHS commissioning system’.[1] In it, NHSE described its vision for commissioning set within the context of Accountable Care Systems (ACS) and Accountable Care Organisations (ACO).

One of the most striking features of the document was the inclusion at the very beginning of an ‘Equality and health inequalities statement’. The inequalities part of the statement is reproduced here…

“Given regard to the need to reduce inequalities between patients in access to, and outcomes from healthcare services and to ensure services are provided in an integrated way where this might reduce health inequalities.”

Few would argue that there is an urgent need to address health inequalities. In truth, there is nothing new here.

In August 1980 the then Department of Health and Social Security (DHSS) published the report of the working group on inequalities in health. ‘The Black Report’ showed in detail the extent to which ill-health and death are unequally distributed among the population of the UK, and — rather alarmingly — suggested that these inequalities had been widening rather than diminishing since the establishment of the NHS in 1948.

2010 saw publication of the Marmot review[2] into health inequalities in England, and Professor Marmot expands upon the theme in the must read ‘The Health Gap’[3] published in 2015.

The debate on health inequalities has therefore been with us for decades. Less has been written on the subject of health inequity.

The late Barbara Starfield (Distinguished Professor, Department of Health Policy and Management, Johns Hopkins University) articulated the issue brilliantly in her 2011 article, The hidden inequity in health care[4].

The distinction between inequity and inequality is nuanced but worthy of note.

Professor Starfield writes that inequality is a broad term “generally used in the human rights field to describe differences among individuals some of which are not remediable.”

Inequity, she states, is “the presence of systematic and potentially remediable differences among population groups defined socially, economically or geographically.”

The emphasis is mine.

Professor Starfield speaks of two types of inequity:

  • Horizontal inequity, where people with the same needs do not have access to the same resources.
  • Vertical inequity, where people with greater needs are not provided with greater resources.

This is important.

Starfield was insistent that different population sub-groups have different needs and some of these sub-groups have greater needs than others. She argued passionately that inequity was built into western health systems because such systems were designed around a view of health needs based on single diseases.

This approach discriminates against those population sub-groups who have greater needs, because these groups are more vulnerable to and suffer from more combinations of diseases. Her contention was that “most illness nowadays is multi-morbidity” and that socially disadvantaged groups bore the greater burden of multiple diseases.

This idea that “most illness nowadays is multi-morbidity” is certainly borne out in Sollis’s population health analytics work with Clinical Commissioning Groups and Sustainability & Transformation Partnerships. See our STP Population Health Overview.

If we accept multi-morbidity as the normal state of affairs then we must also accept that this has implications for the future development of new models of care.

Starfield pointed out the fallacy of building health systems around a disease-oriented view of the world. With multi-morbidity in mind she was adamant that a “whole-patient orientated view of disease is more accurate than a disease orientated view.”

Multi-morbidity — rather than single disease — approaches are borne of a whole-person view of the individual. A whole-patient orientated view allows for a much more detailed understanding of health needs and can therefore offer a more precise and relevant means of addressing issues of equity.

If we accept this analysis then we accept also that population health analysis should focus not on single disease conditions, but on the burden of multi-morbidity observable in a local population.

Though I never met Barbara Starfield, I am sure she would have shown a keen interest in the development of Accountable Care Systems here in England. I am equally sure that she would have been a powerful advocate of the role of primary care in such systems.

For Starfield the route to a more equitable healthcare system lay in a strong primary care system. It is here that multi-morbidity is best understood. It is primary care, which is person and population focused rather than disease focused, that is best placed to understand the interventions that need to be put in place in order to address the needs of multi-morbid populations and socially disadvantaged groups.

If Accountable Care Systems are serious about addressing the continuing problem of health inequity then for me there are at least two stand out actions:

1. Use data to gain insight

The starting point must be to fully understand the different levels of need that exist in the population and sub-populations that Accountable Care Systems exist to serve. As they embark on their Population Health Management journey, one of the key roles of Accountable Care Systems will be to quantify and describe these different needs.

The focus should not be on single disease conditions, but on the burden of multi-morbidity observable in a local population. Undertake a forensic analysis of whole systems data. From data comes insight. Only this way will ACS stakeholders gain insight into vertical and horizontal inequity across a population.

2. Put primary care ‘front and centre’

Primary care — and General Practice specifically — provides the first point of contact for care. It provides person and family focussed care across a range of common health needs, including chronic disease.

One of the central benefits of primary care is that it is person and population based rather than disease focused. As Starfield states, “Primary care must inevitably assume increasing importance in health systems because it is far superior in dealing with multi-morbidity over time.”

Primary care is naturally predisposed to a whole-patient orientated view of the world and as such allows for a much more detailed understanding of health needs. In doing so it offers possibilities for a more precise and relevant means of addressing issues of equity.

In Simon Sinek’s ‘Start with Why’[5], Sinek asks the question “Why do you do what you do?” He invites leaders of organisations — profit and non-profit — to ask themselves the questions: Why does your organization exist? Why does it do the things it does?

It is Sinek’s contention that it is the leaders’ natural ability to start with Why that enables them to inspire those around them and to do remarkable things.

It is my contention that the Why of those leading Accountable Care Systems should be to exorcise the spectre that is health inequity.


[1] ACOs and the NHS Commissioning System: Accountable Care Organisation (ACO) Contract package  – supporting document – August 2017 https://www.england.nhs.uk/wp-content/uploads/2016/12/1693_DraftMCP-6_A.pdf

[2]  ‘Fair Society Healthy Lives’ (The Marmot Review) February 2010 http://www.parliament.uk/documents/fair-society-healthy-lives-full-report.pdf

[3] The Health Gap – The challenge of an unequal world – Michael Marmot – September 2015 https://www.bloomsbury.com/uk/the-health-gap-9781408857991/

[4] The hidden inequity in healthcare – Barbara Starfield – April 20111 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3094214/

[5] https://startwithwhy.com/

2 thoughts on “Accountable Care Systems and the Spectre of Health Inequity

  1. Hi Nigel,
    Fabulous blog post!
    Would love to cite it in an assignment I’m writing about inequality and inequity in healthcare. Need your last name to do so if you don’t mind me having that information.
    Also the lovely infographic at the top of your blod post- is it your/your organisation’s work? If not could you point me in the direction of the orginal source?
    Thank you for your time!

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