Guidance

Addressing health inequalities across allied health professional (AHP) services: a guide for AHP system leaders

Published 9 May 2024

Applies to England

© Crown copyright 2024

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This guide has been developed for allied health professional (AHP) system leaders working across regions, integrated care systems (ICSs), local authorities and provider organisations. The guide focuses on what AHP leaders need to know and what actions they can take at a system level to address health inequalities.

The guide emphasises using a population health approach and leading change at scale, focusing on the breadth of AHP services rather than individual services or professional groups.

Part 1: a 4-step approach to addressing health inequalities

AHPs are well placed to address the wider determinants of health that give rise to health and care inequalities - defined by the King’s Fund as unfair, systematic yet avoidable differences in health between different groups of people. There are over 280,000 AHPs, support workers and students working across the lifespan, in a variety of settings, including health, social care, education, housing, emergency services and the justice system. This means there are many opportunities to make a difference.

Below are 4 steps that will support you as AHP leaders to systematically identify and address the priority issues in your geographical areas. The steps are part of a cycle, which should be repeated regularly as services develop and new data and evidence emerges, to enable continuous improvements, as shown in figure 1 below.

Figure 1: 4 steps approach to address health inequalities  

Adapted from the World Health Organization’s (WHO) Violence Prevention Alliance steps of public health approach.

Figure 1 shows a cycle of continuous improvement involving 4 steps:

  • understanding what problem you are trying to address
  • identifying the causes
  • working out effective solutions
  • then implementing interventions

The cycle highlights the need for continuous review and improvement when addressing health inequalities.

1. Identify the specific health inequalities in your area  

Health inequalities exist in most domains of health, so it is important to be clear about what you are trying to address. Start by looking at the available data and identify the needs of the population you are working with. Consider whether you want to look at inequalities in access to services, health outcomes or experiences of services. There are many sources of data that you could use, and often needs assessments have already been undertaken by your local authority and are readily available online.

The Office for Health Improvement and Disparities (OHID) fingertips platform is a good starting point for information. If you haven’t worked with population data before, there is guidance available on the site. It is important to note that some of this data may be several years old, so should be used as an indication of an issue and direction of travel, rather than a real-time picture. The platform includes a wide variety of public health profiles that provide useful information. 

Another source of information is your local authority joint strategic needs assessment (JSNA). This is a regularly updated document that often uses fingertips to produce some of the data. Most JSNAs contain neighbourhood profiles, which provide lots of information about a locality. These are extremely useful in identifying health inequalities.

Other sources include national data sets like the Healthcare Inequalities Improvement Dashboard (which also includes data for NHS England Core20PLUS5 (adults) - an approach to reducing healthcare inequalities) and other local links, such as the London Borough Data Explorer. Additional data sources are often cited in each area’s JSNA. You can also approach ICS colleagues to find out who collates health and care data and who leads on population health management and ask whether they can share key insights with you.

NHS England’s Digital Academy for Health and Care has commissioned the Chartered Society of Physiotherapy (CSP) to develop an online, interactive learning resource which introduces AHPs to health informatics and how technology can support their work.  

2. Identify the causes of the health inequalities  

It is important to interpret the data you have accessed within your local context, and investigate what factors are driving the inequalities identified. What does this data mean, and why is this happening? Skillful interpretation of data requires practice, and it is important to check your interpretations with others. You could approach your local authority public health team for support, or the knowledge and information service within your organisation.

Consider the causes of the issues and in turn, the causes of those causes. For example, if you identified a higher incidence of late diagnosis of breast cancer in a particular population within your area, you may consider one of the causes to be lower uptake of breast screening. You then need to identify why that might be. Is it linked to where services are delivered? Is there a cultural reason affecting whether people attend? Are the invitations for screening understood by this population? Or is there another reason?

Dahlgren and Whitehead (1991) introduce the model of health determinants (also known as the ‘rainbow model’), see figure 2 below, which you may find useful when considering and identifying the risk and protective factors for the causes of the issues. Note how different determinants of health could interact with each other and at different levels (for instance, at individual, relationship, community and societal level).

Figure 2: Dahlgren and Whitehead model of health determinants

Figure 2 shows:

  • personal characteristics occupy the core of the model and include sex, age, ethnic group and hereditary factors
  • individual ‘lifestyle’ factors include behaviours such as smoking, alcohol use and physical activity
  • social and community networks include family and wider social circles
  • living and working conditions include access and opportunities in relation to jobs, housing, education and welfare services
  • general socioeconomic, cultural and environmental conditions include factors such as disposable income, taxation and availability of work

3. Identifying which approaches work and for whom  

Once you have a comprehensive understanding of the issues in your area, you can start thinking about how your service might address them. At this stage, it would be helpful to involve others (if you haven’t already) for an innovation session. Involving organisational partners and wider stakeholders is essential to whole systems change. A shared understanding of the issues, and a collective vision for action, can increase impact.

There will be things that you can do within your service, and then things that your service can contribute to tackling more widely. Developing collaborations and partnership working with the public and different parts of the health and care system is essential to addressing health inequalities within AHP services and sharing insights into local needs and available support.

Stakeholder analysis

Start by identifying stakeholders and potential collaborators. The first section from the stakeholder analysis document (PDF, 69KB) produced by NHS England can support with this, as it allows you to consider your categories of stakeholders, including:

  • commissioners: those who pay the organisation to deliver AHP services. Examples include NHS England, the ICS or integrated care board (ICB), local authority, or other funders. You may specifically want to include those with a responsibility for addressing adult and child health and care inequalities in the ICS or ICB (such as commissioners, directors or programme leads)
  • customers: those who use or potentially use your services, such as patient groups, members of the public, local Healthwatch, or patient and public involvement and engagement (PPIE) group
  • collaborators: this is a big section and requires holistic systems thinking. It includes those with whom you work to deliver health-fulfilling and -promoting services. Collaborators could include:
    • service leads for acute services
    • the public health team and social care team at the local authority (which may include those with responsibility for adult and children’s social care (directors or programme leads within the local authority)
    • elected councillors
    • local primary care network (PCN) and GP Federation leads
    • local community services leads
    • local care homes
    • voluntary, community and social enterprises (VCSE)
    • organisations supporting homeless people, or people living with disability, mental health conditions, or frailty
  • contributors: those who contribute to your service. Examples include:
    • the local quality improvement (QI) team
    • the local equality, diversity and inclusion (EDI) leads in your organisation or ICS
    • the local research and development (R&D) team
    • the local research network
    • academic institutions
    • population health management leads in the ICS
  • commentators: those whose opinions of the service are heard by customers and others, like local news organisations, charities and non-governmental organisations (NGOs)
  • champions: those who believe in and will actively promote your services and/or overall aims, such as charities and NGOs
  • competitors: those working in the same area who offer similar or alternative services

Engagement and co-production

Do not make assumptions about what people and communities that experience health inequalities want or need. Speaking to service users and people with lived experience (who may not currently access your service) is important to help identify issues, ideas and solutions together. Speak to your local authority public health team or Healthwatch organisation to see whether they are aware of any existing engagement work - this can help ensure that professionals are not asking the same groups of people the same questions multiple times, which is not good for relationships, or a good use of time or resources.

These resources may be helpful for co-production:

If you do not have the time or resources to do full co-production you can still use co-production principles to help co-design solutions.

Learning from others

In addition to connecting with stakeholders and co-production, it is important to learn from interventions implemented in other areas previously, and those that are currently running. Being an active part of local, regional and national networks allows you to share your own work and gain understanding from other areas. This enables you to understand the likely impact of what you choose to implement, and to consider the lessons learned from other areas in the design of your intervention. Sharing the knowledge that you gain from these networks with others is an important practice to develop. 

Levels of action

At an innovation session you will want to encourage creative thinking and use the time to be innovative and ambitious. You may want to start by focusing on one AHP profession or on a specialist area (such as mental health), or you may want to generate ideas which could apply to all AHP services. You could then think through each idea or action and sort them into levels, as follows:

  • level 1: this is what we could do within current resource
  • level 2: this is what we could do with a few changes and perhaps small or one-off investment
  • level 3: this is what we could do with further investment and resource

Using the breast screening example from earlier:

  • level 1: it might be possible within current resource to adapt invite letters to make them more understandable by the population
  • level 2: repositioning the mobile mammography unit would take a one-off investment
  • level 3: a community engagement project might be needed to address any cultural barriers, this is likely to need further investment and resource

It is important to understand from budget holders and staff which options are possible, taking everything through your usual approval processes.

Evaluation and measuring impacts

Before you implement any changes, it is important to decide how you will measure impact and success. You will need clear aims and expected outcomes to measure this against. You may want to lay this out in a logical model. You will also need to explore what service data you currently collect and what else you could record to demonstrate the impact of your changes. A useful resource for exploring impact pathways is available on the Royal Society for Public Health (RSPH) website.

Public health indicators (in the JSNA and fingertips) may not show changes in real time and the effects for public health interventions in a short period of time. There may be a need to consider how to interpret routine data with local insights if needed as part of the development and implementation stages.

For example, if you were attempting to address language barriers, differential reading ability and learning difficulties by implementing easy read letters, you could measure impact by monitoring whether attendance at appointments increased (while considering other reasons for changes in appointment attendance). You could also ask people who attended their appointments for their views on the letters and record any comments they made. This would be easy to measure and demonstrate change quickly. Some further case study examples are provided below.

AHP example case studies - measuring impact

Diversifying the workforce

The project Developing and diversifying routes into allied health professions (AHP) in East London aimed to provide equality of opportunity to the AHP workforce and ensure that staff are drawn from the local area and are more representative of local communities.

Outcomes were measured in this case study by collecting demographic information about recruits (such as ethnicity) and comparing this to local population demographics.

Targeted AHP support for vulnerable communities

The service in this case study, Occupational therapy leadership within the Fire Service to reduce fire risk and address health and wellbeing in vulnerable communities, gathered information on:

  • number of visits completed
  • % of visits to households with at least one resident aged 60 or over
  • % of visits to households with a disabled resident
  • % of visits to single person households
  • number of referrals made to partner services offering interventions for falls prevention, fuel poverty, smoking cessation and social isolation
  • feedback from service users and other organisations

Enabling adults with learning disabilities to understand their health recommendations

Outcomes were measured in this case study, Enabling adults with learning disabilities to understand their health recommendations (PDF, 755KB), by gathering feedback from service users and carers using a 5-point Likert scale, to determine understanding of health recommendations and confidence in following these.

4. Scale-up effective policy and programmes 

Once you have agreed the service changes and ways to measure impact, you can start the implementation phase.

Before scaling up, you will probably need to carry out a trial, collecting data against the aims and expected outcomes (unless the evidence for the change is already clear, in which case you can skip the trial and move straight to scaling up). During the trial, regularly review and analyse the data to create the desired impact with no unintended consequences.  

Making improvements based on feedback and evidence collected during the trial phase is essential to ensuring that the changes you make to your service have the desired impact. If you are not seeing the results you expected, there may be an adjustment needed, or you may decide to do something completely different. Iterating is an essential part of this process, to ensure that your resource investment is impactful.

Once the changes to policy and practice that you have made are working well and having the desired impact, you will begin to ‘scale up’ by expanding what you’re doing to other areas and/or other services. For example: you have carried out a trial of easy read letters in one service, resulting in a rise in attendance rates. You then decide to implement easy read letters in all services that you lead and influence other areas of the system to implement them as well, using the data that you collected during the trial as a means of demonstrating the benefits to your service and to patients.  

Using quality improvement (QI) techniques can help to optimise and scale service improvements. There are many QI tools available, including the Embedding Public Health into Clinical Services - e-learning for healthcare toolkit and workbook. This toolkit produced by the NHS Confederation is also a practical guide for ICB system leaders that will help to inform future spending on health inequalities and support implementation of high-impact changes to address health inequalities within ICBs.

Part 2: change ideas - 8 target areas to help reduce health inequalities within AHP services

This section outlines change ideas to help reduce health inequalities within AHP services. It was informed by conversations with chief AHPs and AHP system leaders in England that explored what would help most in their mission to reduce health inequalities. From these conversations, 8 strategic priorities emerged that enable action to address health inequalities. Each of these is described below.

  1. Increase collaboration and partnership working
  2. Improve AHP education and training in health inequalities
  3. Ensure services are accessible to all
  4. Provide equitable and responsive care
  5. Capture outcomes and impact
  6. Increase visible AHP leadership
  7. Align AHP values and behaviours to equality and social justice
  8. Ensure AHP research addresses health inequalities

Using these examples, you could identify ideas to implement at each of the levels of action in section 1. 

We explore these 8 strategies in more detail below.

1. Increase collaboration and partnership working between AHPs, communities and other sectors, to understand population needs and assets

Increased collaboration and partnership working could mean:

  • use of co-design or co-production, to understand and address local health inequalities and identify local assets
  • local support networks, community groups, social prescribing and community champions form part of the care provided by AHPs
  • AHPs collaborating with the public, across the NHS, the voluntary sector and local government, to share insights and plan services
  • AHPs working with and supporting the wider workforce in multidisciplinary efforts to reduce health inequalities

Change ideas include:

  • developing collaborations and partnerships to understand and address inequalities within AHP services, share insights into local needs and available support, and ensuring a diverse range of opinions and input from diverse perspectives as well as roles. For example, with the following:
    • the public
    • different parts of the health and care system
    • local government
    • public health
    • research and development (R&D) departments
    • population health management leads
    • research networks
    • QI teams
    • volunteers
    • charities  
  • developing and/or participating in local health inequalities networks or action learning sets

2. Improve AHP education and training in health inequalities

Improved AHP education and training could mean:

  • the AHP workforce are:
    • skilled and knowledgeable in public health and health inequalities
    • aware of local data and evidence on health inequalities
    • aware of ways to address this in their practice 
  • AHPs are aware of, and can demonstrate, how they meet the updated Health and Care Professions Council (HCPC) standards

Change ideas include:

  • promote nationally available resources for continuing professional development (CPD), such as:
  • create a local forum for AHP students on public health placements and AHPs working in public health roles, to share their learning with AHPs, support workers and other students
  • explore opportunities to expand student public health placements locally
  • universities: embed health inequalities into pre-registration education encompassing the AHP public heath curricula guidance framework and nationally available resources

3. Ensure services are accessible to all - including people who need services but do not present for them

Ensuring services are accessible to all could mean:

  • referral processes are accessible, flexible to meet needs and capture relevant information on health inequalities
  • communication is in the most accessible format and language, to allow people with learning disabilities, low literacy levels and for whom English is not their first language to understand information shared
  • all services have a policy for supporting attendance and do not default to discharge following non-attendance
  • the environment and service location optimise care closer to home and access, and are adapted to the preferences of the community where needed
  • there is a local policy to mitigate issues with digital access and/or digital poverty for online appointments or services

Change ideas include:

  • review all online and written service information, including how accessible it is and how and where information about the service is shared
  • ensure that all AHP sessions delivered in groups create inclusive environments, ask about specific access and/or neurodivergent needs, review the location of services. Consider re-positioning clinics to be closer to underserved communities, perhaps in places they already frequent as part of a co-location effort with community groups and other health services
  • consider setting up outreach programmes to help underserved groups to access services (such as those with mental health issues and learning disabilities)
  • support people to attend appointments by creating a pathway to ask what support is needed to attend (for example, different appointment times, reminder text or call, easy-read letter)
  • consider:
    • health literacy levels and access to information
    • review information (letters, care plans, reports) and communication processes for improving accessible support
    • sending easy-read communications as standard to overcome language barriers, reading ability, learning disability and brain injury or other neurodiversity
    • where information needs to be translated
  • review ‘did not attend’ (DNA) rates, where these happen (geography) and groups most at risk and establish drivers of non-attendance. Create policies and solutions to prevent DNA and support attendance for groups at risk
  • consider where appointments could be offered outside of normal working hours, to prevent children missing school, or allow people on zero-hours contracts, or those with caring responsibilities, to attend appointments
  • make the outpatient environment welcoming for those with children, ensuring that toys and books are available to entertain them, to encourage people who have no access to childcare to attend their appointments
  • mitigate against the impact of digital exclusion, for example by offering choice of online and face-to-face, checking digital literacy and access, and offering training or guidance on the use of online services

4. Provide equitable and responsive care

Equitable and responsive care could mean:

  • AHP services provide or signpost to further support for people who need assistance with finance, housing, social connections, employment, and so on. This also includes social prescribing
  • AHP expertise is used to support people to stay in or return to work and optimise self-management
  • for waiting lists: that there is consideration of equity of access and impact of waiting on life, caring responsibilities and work, and people are supported (for example, with self-management or employment advice) while they wait
  • services are culturally competent and meet specific needs to prevent attrition or poor outcomes
  • AHPs proactively identify opportunities to work differently or change ways of working to have a wider impact and enhance outcomes for communities (examples: integrated care, upstream approaches, proactive rather than reactive services)

Change ideas include:

  • ensure that staff undertake cultural competency training (see Cultural Competence eLearning tool under section 2 above)
  • implement Making Every Contact Count (MECC) across staff groups. AHP case studies, including of MECC, are available on the Royal Society for Public Health AHP hub. Identify opportunities within AHP services for:
    • screening
    • early identification
    • awareness-raising
    • signposting
    • secondary prevention (for example, for hypertension, obesity, smoking, alcohol intake, physical activity)
  • ensure that services link with social prescribers and link workers and provide local signposting information (such as for housing, finance and social connections); consider how services can identify carers and support them
  • review waiting lists to identify people at increased risk of health inequalities and offering proactive management of issues and/or signpost to other support options while people wait. Consider prioritising waiting lists according to vulnerability and impact on life. See the London South Bank University (LSBU) report (2022) for examples of how services can support people on waiting lists. The Strategy Unit has also created a ‘systems dynamics’ model of waiting lists for planned care (including explanatory videos) which can be used by NHS organisations
  • over time, consider how AHP roles can move from reactive to proactive care, to address the needs of local population groups. See RSPH case study examples and a toolkit designed to support leaders and service managers to embed public health into clinical services

5. Capture outcomes and impact

Capturing outcomes and impact could mean:

  • AHP services collect, monitor and act on data to ensure there is equality across outcomes and quality of care received between different population groups, and in geographical locations, for example across an ICS
  • AHPs share knowledge, methods, quality improvements and best practice in reducing health inequalities

Change ideas include:

  • ensure that referral systems and assessments capture:
    • the wider determinants of health. For example, information on ethnicity, languages spoken, as well as people’s wider circumstances (such as caring responsibilities or employment)
    • interventions which involve prevention and health improvement (such as MECC) or address health inequalities (such as signposting to financial support). The RSPH Everyday Interactions toolkit can be used to capture this type of information

As discussed in part 1, information captured should be used to guide service improvements. For example, taking action if data highlights different outcomes between groups, or using information on wider circumstances to help prioritise waiting lists.

  • undertake a local evaluation of outcomes, paying particular attention to interventions which involve public health and/or wider determinants of health
  • write case studies on local interventions and outcomes and share on the RSPH AHP hub
  • arrange local CPD activities to review best practice and identify areas for improvement

6. Increase visible AHP leadership

Increasing visible AHP leadership could mean:

  • AHPs promote public health within existing roles
  • health inequalities are business as usual, integrated into AHP service transformation, policies, workforce planning and workforce development
  • AHPs are strategically connected at ICS and/or regional level to influence health inequalities and make the best use of the AHP workforce skills
  • AHP leadership supports and raises awareness of health inequalities
  • AHP contribution to health inequalities is recognised and valued
  • AHPs in leadership positions reflect the diversity of the local population

Change ideas include:

Leaders embed:

  • health inequalities
  • population data
  • case studies
  • qualitative data
  • co-production

into:

  • service improvements
  • service design
  • outcome measures
  • high-level meetings and reports

7. Align AHP values and behaviours to equity and social justice

Aligning AHP values and behaviours could mean:

  • AHPs are knowledgeable in the causes of health inequalities and can identify personal-professional contribution to this
  • AHPs are aware of EDI, personal bias and how to take action to address bias or discrimination
  • AHPs take responsibility for promoting, improving and protecting the health and wellbeing of individuals, communities and populations
  • staff are not financially disadvantaged and are supported in their career progression and development regardless of background qualifications, protected characteristics or caring responsibilities

Change ideas include:

8. Ensure AHP research addresses health inequalities

Ensuring AHP research addresses health inequalities could mean:

  • AHPs can quantify and demonstrate their impact in reducing health inequalities, and are able to capture outcomes
  • AHPs learn what works in addressing health inequalities for different populations and communities
  • innovative solutions are scaled and spread and research into practice is expedited
  • research continues into new ways of working, novel interventions to address health inequalities and measurement of AHP outcomes

Change ideas include:

  • regional outputs and progress measured through the Allied health professions (AHP) Strategy for England: AHPs Deliver 2022 to 2027
  • collecting and sharing local data on AHP impact and outcomes
  • use of evidence to inform practice or service improvement in health inequalities
  • higher education institutions to create opportunities for AHP research in health inequalities and public health through grant applications, student research and so on

Further information

Further resources that support reduction of health inequalities are available on the RSPH allied health professionals hub. The resources include training and e-learning and profession-specific case studies.

The topics in this guide have also been covered in a webinar recording, which can be accessed here: RSPH blogs, webinars and podcasts.

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