Commissioning for equity in the NHS: rhetoric and practice

Background: This paper reviews evidence on equity as a policy goal of resource allocation in the English NHS, focussing on the role of clinical commissioning groups (CCGs) as purchasers of health services since 2013 and their capacity to achieve equity through the process of commissioning.

Sources of data: A systematic search of literature published since 1990 and review of grey literature, including policy documents published by CCGs and other organizations in the healthcare system.

Areas of agreement: Despite a stated policy commitment to equity of access in the NHS, the 2012 reforms have created a structure that allows and encourages great variation between devolved purchasers of care.

Areas of controversy: Evidence suggests that CCGs, which are structurally separated from public health, have limited capacity and incentives to commission for equity. Concepts of equity of access and health inequalities lack consistent definitions and may not be implemented. However, it remains unclear whether variation between CCGs implies inequity.

Growing points: The 2012 reforms have sought to contain costs and improve quality, thus achieving efficiency gains, while equity has remained an afterthought. The NHS should be expected to work towards equity of access to healthcare and can contribute to reducing health inequalities; however to achieve a more equitable distribution of health, wider social policies are also needed.

Areas timely for developing research: Additional assessments of structural capacity should be complemented by further development of indicators of equity of access and studies that quantify inequities. Research should also explore how an equity principle can be embedded in commissioning, which currently revolves around cost containment and efficiency.