Abstract
BACKGROUND: Despite policy prominence and frameworks focusing on health inequalities, healthcare leaders do not feel they have the skills and knowledge to reduce health inequalities. This comparative case study explored four areas in England to understand the challenges, opportunities, and drivers of local health systems addressing health inequalities and what ‘good’ practice might look like. METHODS: Interviews were held with 46 people working in health care services across the NHS, local authority or voluntary, community, social enterprise sectors. Key documents (n = ~ 10) in each of the four areas relating to reducing health inequalities were analysed using documentary analysis methods. Interviews and documents were coded and analysed independently before being integrated to synthesise findings. Analysis was conducted using a two-stage approach - firstly, an inductive analysis of emergent themes; secondly, to build knowledge on each case studys’ system approach of reduction of health inequalities, principles of the Action Scales Model were used. RESULTS: Nineteen themes were identified across the four case studies; some themes were not apparent in all the case studies, nor in either the documentary analysis or interviews. These themes allowed us to compare between cases to explore what might be contributing to good practice. Themes identified included: understanding the local context; facilitators of how to tackle health inequalities and improve health and wellbeing; and future concerns. The secondary analysis highlighted potential levers for action from each case study; these included optimising retention and recruitment of workforce and allowing time and resources for longer-term planning. Two case study areas which appeared to have system resilience, demonstrated having a shared vision, strong partnerships, understanding of the system, and putting people and communities at the heart of decision making. CONCLUSION: This comparative case study makes a crucial contribution in the understanding of health systems addressing health inequalities in their local areas. The combined interview and documentary analysis findings provide rich insights of local systems’ documented strategies, plans and what is happening ‘on the ground’. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12913-025-12956-7.