Today’s health inequalities are stark. The Inverse Care Law—where those most in need of healthcare are least likely to receive it—remains prevalent and damaging. Despite universal entitlement, many people do not equally benefit from NHS services. Without a progressive, person-centred evolution of our founding principles, we risk perpetuating the very injustices the NHS was designed to eradicate.

Universalism with Proportionality: Delivering What People Need

Universal access remains vital—but it must be delivered through proportional universalism. Healthcare should be available to all, but the intensity and type of support must vary according to need. Simply offering the same service to everyone, regardless of context, entrenches inequality rather than addresses it. Those facing complex challenges require more tailored, intensive support to achieve outcomes comparable to those with greater advantage.

This concept underpins the success of initiatives like Community Health and Wellbeing Workers (CHWWs). By proactively supporting households facing complex social, mental, and physical health barriers, CHWWs have demonstrated the transformative impact of working with people holistically, not just responding to clinical needs.

Yet, there are concerning signs that some areas are stepping back from this principle, citing concerns that communities supported by CHWWs are receiving more investment per head than others. While understandable on the surface, this view risks confusing equality with equity.

Treating everyone the same may seem ‘fair,’ but in reality, it disadvantages those who face greater barriers to good health. True fairness—equity—requires greater investment where the need is greatest. If we are to close the gap in health outcomes, not widen it, we must resist the temptation to retreat into a model of uniformity that ignores real-world differences.

Moving Beyond Clinical Need: Addressing Health in the Round

Basing care solely on clinical need is no longer sufficient. Clinical problems rarely occur in isolation. They are interwoven with social issues—poor housing, loneliness, unemployment—that drive ill health. Addressing only the clinical symptoms without the underlying causes leads to missed opportunities and avoidable harm.

Hospital admissions for conditions that could have been managed at home with better social support are a telling symptom. Treating pneumonia caused by damp housing without addressing the housing itself is not equity—it is system failure.

A person-centred NHS must be shaped around what matters to people in their lives, not just their diseases. CHWWs embody this approach, building trust, helping people navigate services, and reducing escalation to costly acute care by tackling issues earlier and more holistically.

Creating Health, Not Just Treating Disease

We must also confront the imbalance between treatment and prevention. Healthcare contributes only 10–15% to our sense of health. The rest is determined by social, economic, environmental, and behavioural factors.

A sustainable NHS requires that we invest far more heavily in creating health: enabling good nutrition, safe housing, social connection, good work, and community resilience. Programs like Living Longer Better for those over 50 demonstrate how proactive support can slow frailty and reduce demand.

Digital tools—citizen-owned health records, AI triage, adaptive home support—will play a role. But at its core, health creation depends on flourishing teams rooted in communities, working with people, not doing things to them.

Equity Benefits Everyone: The Economic and Social Case

Addressing health inequalities isn’t just a moral imperative; it’s an economic and social necessity. Health disparities impose significant costs on society. For instance, health inequalities in England cost the NHS an extra £4.8 billion annually and the UK economy between £31–33 billion per year in lost productivity. Additionally, they result in £20–32 billion per year in lost tax revenue and higher benefit payments.

Moreover, reducing health inequalities can lead to broader societal benefits. Improved health outcomes contribute to increased workforce participation, reduced demand on public services, and enhanced social cohesion. By investing in equitable health initiatives, we not only uplift disadvantaged communities but also strengthen the overall fabric of society.

Equity Means Embracing the Wider Determinants of Health

Equity demands that we acknowledge the interdependency of physical, mental, and social health. It requires us to move from a passive service model to a model of partnership and empowerment, where people are supported to become active participants in their health.

We must also evolve our measures of success: beyond service throughput to indicators such as:

– Increased activation and self-management across communities
– Reduced gaps in healthy life expectancy
– Stronger social connection and resilience

Such change takes courage. It asks us to resist short-term pressures to ‘level down’ by offering identical services to all. Instead, we must level up: recognising differences, targeting resources intelligently, and investing where it will make the greatest difference.

Conclusion: A Call to Renewal

The founding principles of the NHS were right for their time. But to truly meet today’s challenges, we must renew them for a more equitable, person-centred future.

This means:
– Modernising universalism to deliver proportionate support
– Moving beyond clinical need to whole-person wellbeing
– Prioritising prevention and health creation, not just treatment
– Empowering people as partners in their health

Equity, not simple equality, must sit at the heart of everything we do. Only then can we create an NHS that truly delivers on its promise — for everyone.