Tackling health inequalities is a major priority for health and care providers, as demonstrated by NHS England’s Core20PLUS5 approach to inform action to reduce healthcare inequalities at both a national and system level. All integrated care systems (ICSs) have been tasked with addressing inequalities in outcomes, experience and access.
Genuine community involvement, lived experience and effective partnership working are essential elements in better understanding the issues and barriers faced by marginalised communities, so that we can change our approaches to providing access to services and treatment from a more equitable and person-centred perspective.
These were the key themes explored in one of the panel sessions at our Integrating Innovation conference in March.
Chaired by Abbey Mulla, Senior Manager for Personalised Care at NHS England South West, the session brought together colleagues involved in a wide range of work tackling different aspects of health inequality across the West of England.
Uncovering uncomfortable truths about institutional racism
Aisha Thomas is Director of Representation Matters, whose mission is to challenge the lack of representation and inequality in the education system. Aisha talked about being a founding member of our ground-breaking Black Maternity Matters collaborative, which is providing peer support, education and training, and coaching in quality improvement (QI) to help reduce the inequitable maternity outcomes faced by Black mothers and their babies.
Black women are four times more likely to die during pregnancy or in the postnatal period than White women, while stillbirth rates of Black and Black British babies are over twice those for White babies.
Aisha asked how this could be possible today in 2023, and highlighted the urgent need for us to really look at the society we live in: “We have to look at the structural inequalities,” said Aisha. “We must uncover some uncomfortable truths. It means that we have to look at things like whiteness and institutional racism.”
Aisha spoke about the importance of shining a spotlight on the disproportionality of these lived experiences to target our work, hearing and responding to the voices that are silent and hidden. “If we don’t understand that anti-blackness exists within the medical profession, if we don’t understand that anti-racism means that we have to focus on particular identities, then we can never move forward.”
Improving CVD treatment for under-served populations
Julie Davidson is Group Operations Director for Pier Health Group, a large super partnership of eight GP practices in North Somerset. Julie spoke about the project she’s leading in the Weston, Worle and Villages Locality as part of the Innovation for Healthcare Inequalities Programme (InHIP) with the West of England AHSN, Bristol, North Somerset and South Gloucestershire Integrated Care System (ICS) and local voluntary sector partners.
The aim of this project is to improve cholesterol management and reduce risk of cardiovascular disease (CVD) in some of the most deprived communities in North Somerset. “The people who live in these areas generally die eight to ten years earlier than their counterparts in less deprived areas,” Julie explained. “And it’s a large population – we look after over 96,000 patients. So this is not a tiny minority, this is significant proportion of our population.”
Using a community health and wellbeing worker approach, based on a Brazilian family health model, they are starting to target patients who have high cholesterol that is not currently optimised to see if they could benefit from new drugs, such as Inclisiran. Rather than waiting for people to come to their GP, community health and wellbeing workers will go out and visit households.
The hope is to create a more holistic approach to facilitate access to health care and to signpost to other community and social care services. “The community health and wellbeing workers will see if they can build a relationship and trust,” Julie explained. “Initially the focus will be trying to help people with their cholesterol. But they’ll then also look at other prevention opportunities for the individual and members of the whole household, like cancer screening and vaccinations, use of social prescribing and linking into council services.”
Using AI to tackle health inequalities in post-natal care
Chen Mao Davies, Founder and Chief Executive of digital health tech start-up Anya, talked about her app that utilises 3D interactive technology and artificial intelligence (AI) to support new parents during the first 1,100 days of their parenting journey.
An exciting new development for her company is the recent award of SBRI Healthcare funding to help tackle inequalities in maternity care.
Chen described how they have started work with different target communities (Black parents, young parents under 25, and White parents from deprived socio-economic groups) to understand the current gaps and challenges. In partnership with Somerset NHS Foundation Trust they have developed and launched a lot of new features based on findings from patient and public engagement, and are now evaluating the effectiveness via user studies for specific issues for the target groups.
So far, their insights have uncovered three key themes. “Parents are struggling with not having continuity of care,” Chen explained. “They want a joined-up antenatal and postnatal care pathway; they want someone to know their history. People also want personalised support – they want to see themselves represented in publications and materials. And parents also want 24/7 support. We’re using neural network technology to allow AI to provide personalised and empathetic answers for antenatal and postnatal questions.”
Hearing ‘seldom heard’ voices
Chief Executive of Inclusion Gloucestershire, Vicci Livingstone-Thompson spoke about her organisation, which is run by disabled people for disabled people and the majority of staff have a range of disabilities and long-term health conditions. They undertake a wide range of work, including delivery of community-based services, training, quality tracking, research and influencing.
Much of their work is focused on reducing health inequalities. “People with a learning disability are dying on average 25 years younger than the general population,” highlighted Vicci. “And intersectional factors mean that the median age of death for males who are Black and have severe or profound learning disabilities is just 33 years. That compares to the age of 59 for White people with multiple learning disabilities.”
Vicci had vast amounts of learning and insights to share about effective community engagement. “We think it’s really important to engage people through networks and spaces that are comfortable and familiar to them – not always expecting people to come to us or engage in a way that’s easiest or most comfortable for us,” said Vicci. “We also think it’s really important to be clear on whether you’re co-producing, so bringing people in at the very start without a preconceived idea of what you think of service might look like, with a completely blank sheet of paper, or whether you’re engaging, so that’s seeking consultation or feedback, or you might already have a plan.
“There’s space for both within healthcare. But to maintain trust, it’s important to be clear and transparent about which one you’re doing.”
‘Seldom heard voices’ is a phrase we hear frequently. But Vicci argued that disabled people are not hard to hear: “You just need to come and find us and hear us. Tailor how you engage with different groups of populations. So have the building blocks in place, whether that is information for individuals who might have learning disabilities or interpreters if English is their foreign language. Most importantly, have an open mind to ask communities what works best for them in terms of involvement.”
Starting from the perspective of communities
The final panellist was Jane Moore, Director of Equalities, Innovation and Digital Enterprise for Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board (BSW ICB).
Jane has been involved in inequalities work for around 20 years, in some of the most diverse and deprived areas of England. This included being Director of Public Health in Coventry, helping to set up the first ever Marmot City in response to Michael Marmot’s review of health inequalities across England, commissioned by the British government.
Jane described the three strands to the approach BSW ICB is taking to tackle health inequalities. The first strand is building inequalities into everything BSW does because it’s everyone’s responsibility. The BSW Academy is fundamental to how they support colleagues with training to build awareness and capability.
The second strand is about having the right intelligence. “As health services, we’ve been really bad at trying to understand what the problem is around health inequalities,” said Jane. “That’s having the right intelligence, and that’s not just data. Data is an important part of that but also do we understand and are we actually listening to that soft intelligence from our communities, about their real experiences and what it means for them?”
The third strand about starting “from the perspective of communities rather than from our perspective in developing things going forward”. It’s about community involvement, co-design and co-development. “The NHS has had a huge wake-up call from Covid,” Jane said, which has demonstrated we need to move away from community engagement as a ‘tick box’ exercise. “We’ve got to change the dial from engagement to involvement. This is really difficult but it’s something we’re passionate about.”
A reflection, a rant and a challenge
Abbey Mulla closed the session with what he described as “a reflection, a bit of a rant, and a challenge”:
“The reflection is let’s really pay close attention to when we say we co-produce or co-design something with the community – have we really? Second is the rant. 35 years ago, when I was a youth worker, we talked about racism in the police. 20 years ago, in local authority we used Indices of Multiple Deprivation (IMD) data to talk about how deprived wards were: we got funding, but did we do anything? No. Ten years ago, we talked about deprivation in health and inequalities in charities and now we’re having the same conversations.
“But what are we going to do about it? If we are really going to tackle this, then we need to challenge our previous approaches and release the time and resources to do it properly and to listen to each other.”
Thank you to all our panel members for sharing their examples and insights, and to all our delegates for their thought-provoking and challenging questions.
None of us have all the answers, but by continuing to compare approaches, share ideas and best practice and being led by people with lived experience, we can go some way in exploring together how we can overcome common challenges.
Posted on March 30, 2023
