Addressing health inequalities through local authority and integrated care system assessments

Care Quality Commission
4 min readNov 9, 2023
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James Bullion, interim Chief Inspector of Adult Social Care and Integrated Care, gives his views on this year’s State of Care report. He also looks at our new responsibility to provide independent assurance to the public of the quality of care in their area by assessing local authorities and integrated care systems.

Last year’s State of Care report identified that access to care was a real issue for many people. This year’s report acknowledges that this is still an issue and the cost of living is making it worse. As a consequence, the risk of unfair care is increasing.

In this year’s report, we highlight some groups of people who are more likely to face inequalities in access to health and care services and in their experience when using services. Simply being unable to access services represents a massive indication of health inequalities. Being unable to access the care you need cannot be normalised.

Changes under the Health and Care Act 2022 means that we have new responsibilities to look at systems. Assessing local authority adult social care and integrated care systems (ICSs) represents the largest extension of our regulatory responsibilities in over a decade, and an opportunity for us to be louder and clearer in addressing health inequalities. An opportunity that must be grasped.

Our new role in assessing how well local systems are performing started in April 2023. It will enable us to present a more holistic view of health and adult social care services against the things that matter to people in that community.

We have reviewed data and publicly available evidence from all 153 local authorities in England, focusing on themes in 2 of our new quality statements:

  • care provision, integration, and continuity
  • assessing needs.

At a national level, we have seen evidence that local authorities are aware of increasing demand for care and support and complexity of need across all population groups. Local authorities are tackling workforce problems in adult social care and trying to address gaps in care as they plan for the future. But they will need to demonstrate an understanding and preparedness for the changing and complex needs of local populations.

Because inequalities vary by area, each area must have its own tailored response to meet the needs of its local population.

We will soon be publishing the findings from our 5 local authority pilots and starting to roll out our formal assessment approach. Reviewing the 2 quality statements has been key in allowing us to begin to understand the starting point from which services are operating.

ICSs were formalised in 2022, changing the architecture for the way our health and care services are delivered in England. ICSs comprise integrated care boards (ICBs) that run health services, and integrated care partnerships (ICPs) that agree the local strategy for improving outcomes and integrating around people.

We began looking at how ICSs are approaching their role of ensuring everyone has equal access to care in 2023. We did this through our equity in access quality statement. While recognising that ICSs are relatively new, there are some clear takeaways: it is vital to engage with communities and work with people to define strategic local-level and neighbourhood priorities for tackling health inequalities and to deliver trusted interventions at a local level.

Local systems should now implement plans to address unwarranted variations in population health and disparities in people’s access, outcomes, and experience of health and social care.

Moving forward, we will be looking at how services are working together within an integrated care system, as well as how systems are performing overall against the 4 key aims of:

  • improving outcomes
  • tackling inequalities
  • enhancing productivity and value for money
  • helping the NHS to support broader social and economic development.

We are piloting our assessment approach with Dorset ICS and Birmingham and Solihull ICS. I was part of the team that recently assessed Dorset ICS. During that pilot, I saw first-hand the vast scope of the work that the system covers — from hearing about how primary care networks are integrating care with secondary and community services, to the work the local colleges and universities are doing to foster a local healthcare workforce. It was a good opportunity to see the potential of ICSs on the ground. The full programme of ICS assessments will begin in 2024.

A better understanding of local need and the local population will allow us to intervene quicker to push quality in the right direction.

One of our core strategic ambitions is tackling inequalities in people’s access, experiences and outcomes when using health and social care services. To help fulfil this ambition, we are starting to look more at the different factors that affect health and care in our new assessments of providers and local systems. We need to be able to feed this back to integrated care systems to help reduce health inequalities and improve quality of care.

Our new responsibilities will enable us to take a closer look across a ‘whole system’ in a place and to see the journeys through the health and care system that people have to navigate, so we can see what is needed for improvement. Ultimately it is the local accountability and leadership that will make the difference in response to what we find, and whether we see improvements.

Portrait of James Bullion, blog author
Blog author: James Bullion, interim Chief Inspector of Adult Social Care and Integrated Care



Care Quality Commission

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.