Promoting equality and reducing health inequalities through the NHS long term plan
Jabeer Butt and Samir Jeraj, Race Equality Foundation
Chadrack, a four year old with learning disabilities and autism, was found with his arms round his dead mother Esther in October 2017 in their Hackney flat. According to the coroner Chadrack had passed away about 12 days after his mother. He was unable to call for help. Esther, a lone parent, had epilepsy and appears to have passed away suddenly. According to the Multi-Agency Case Review, her GP had referred Esther to neurology. Although she had tired the telephone booking service, she had been unable to secure an appointment because of her limited English. Whilst the school Chadrack attended had engaged with his mother, they were unaware that she had epilepsy and did not investigate his absence until 5th October, three days later – when staff unsuccessfully attempted to enter their building. Esther and Chadrack were eventually found on 17th October when the police broke into their flat after being alerted by Esther’s cousin.
How much we can conclude from this case about the impact of inequality, may be open to debate. However, evidence of poorer life expectancy of people with learning disabilities is clear, with them dying more than 14 years younger than the general population. Poorer access to health services for migrants, lone parents and those with English as a second language is also well documented. Whilst the Index of Multiple Deprivation (IMD [DCLG, 2015]) suggests improvement across Hackney in comparison to the way deprivation was measured in 2010, Hackney is still the 11th most deprived area in the country. LSOAs that Esther and Chadrack lived in still ranked as the most deprived fifth of areas in the country. What no one can debate is that the failure to promote equality and reduce health inequalities has real and material impact.
Perhaps uniquely the legislative framework in England has many of the components to promote equality and address health inequalities already in place. The application of the Public Sector Equality Duty to health services, with specific duties for CCGs to agree and publish equality objectives has been in place since 2013. This has been accompanied by the health inequalities duties introduced by the 2012 NHA and Social Care Act, which included requiring the Secretary of State to annually report on progress in addressing health inequalities. Importantly, the NHS has not lost sight of its original focus on inequality, for example the focus of Principle One of the NHS Constitution is encouraging access for all by not discriminating. The decision to embed the Workforce Race Equality Standard in the standard contract or to require NHS organisation to start recording sexual orientation are recent examples of the focus on equality.
Repeatedly, however, testimony of service users and their carers as well as wider evidence suggests that the health care system has fallen short. Whether it is the evidence from the Winterbourne View, which showed systematic maltreatment of people with learning disabilities or the continuing evidence over representation of Caribbean men in secure mental health settings combined with poorer access to community mental health services. The biggest employer in England, appears to be still struggling to deliver equality. The persistence of the ‘glass ceiling’ has seen female doctors still not progressing or being paid as much as their male counterparts, whilst disabled workers across the NHS and workers of black and minority ethnic origin continue to experience comparatively poorer rates of promotion and pay.
It is possible to argue that addressing many of these inequalities are beyond the remit or reach of the NHS. For example, whilst health visitors could do better in improving breastfeeding rates (a key risk factor in infant mortality), it will only have a limited impact on communities where breastfeeding is above average already yet infant mortality is highest: babies born to mothers of Pakistani, African, Caribbean and Bangladeshi ethnic origin. Persistently, higher infant mortality rates for these communities appears to be particularly impacted by greater likelihood of living in areas of relative multiple deprivation (IMD) and would suggest we need wider action to address this health inequality. Furthermore, the need for wider action to address the social determinants of health has been the call since the publication of the Acheson report and more recently Marmot’s review.
Nevertheless, the NHS has a duty to promote equality and reduce health inequalities. The introduction of a formula from 2014/15 for the allocation of funding for primary care and CCGs which attempts to improve access to services and reducing health inequalities is welcome. However, as NHS England has recognised the lack of comprehensive data on unmet need across England has led to a pragmatic approach to adjusting the weighting of the formulae (15 per cent for primary care and 10 per cent for CCG). The most recent review has seen these weightings maintained, with the introduction of a 5 per cent weighting for ‘unmet need’ in allocations for specialised services.
Whilst it is perhaps not a surprise that NHS England’s most recent review has suggested the evidence of impact of the additional funding resulting from the inequalities weighting is inconclusive, particularly as the entrenched nature of many health inequalities would suggest it will take many years of action to deliver change. However, it is also not clear how the additional funds allocated to CCGs has been used to address equality of access or impact modifiable health inequalities, with the wide variation of community language interpretation services just one example.
What is clear is that the new investment in the NHS must build on the existing formula to ensure that sufficient money is allocated to improve access and ensure that healthcare contributes to modifiable health inequalities. This will require filling some of the data gaps, such as the lack of data sexuality. It will also mean reviewing whether the current ‘pragmatic’ weighting is sufficient to be transformative in addressing health inequalities such as the unacceptable level of cervical cancer screening offered to women with learning disabilities. It should also mean that we need to be able to monitor how resources allocated are actually being translated into change is service provision leading to improved access for group such as Gypsies and Travellers, homeless people, as well as migrants, amongst others.
Key to changes that need to be delivered by the new long term strategy is primary care in areas of multiple deprivation. Primary care in inner cities and urban areas is facing particular pressures around workforce, sustainability and quality. Urban areas have a smaller number of doctors relative to population, whilst often having greater levels of health inequalities. The combination of these factors places greater pressures on healthcare in general and primary care in particular.
The evidence suggests poorer access in areas experiencing multiple deprivation is getting worse. There were 8,207 GPs working in areas containing the most deprived 20% of the population in England in 2008, but by 2017 that had fallen to 7,696 compared to a small increase in richer areas. This is likely to deteriorate as Health Education England found in 2014 that a disproportionate number of older GPs nearing retirement work in more densely populated urban areas. A BMA survey in 2016 found more than a third of practices said they had GPs who had firm plans to retire in the next 12 months. Worryingly, the Care Quality Commission has also found a higher proportion of ‘Inadequate’ and ‘requires improvement’ ratings in urban areas.
The 2016 BMA Survey found London had by far the worst figures for financial stability, with the highest level of GP practices concerned their services were unsustainable (14 per cent), the largest proportion reporting their overall financial position was weak (41 per cent) and the lowest number of GP practices reporting their situation as “strong” (2 per cent). In Tower Hamlets at the end of 2017, sixty-two GPs wrote to Jeremy Hunt to raise the issue that they had seen an increase in population of around 12% but the funding to the local Clinical Commissioning Group only covered two-thirds of that increase. This equated to a cut of £12.5m compared to five years earlier.
NHS England’s Five Year Forward View, launched in October 2014 promised a “new deal for primary care General practice”. The review both acknowledged the great strengths of GPs and the severe strain they are under from rising demand and under-investment, leading to a workforce shortage. Evidence from the UK shows good access to GPs is crucial in reducing health inequalities. For example, flat distribution of GPs across Scotland meant people living in deprived communities had less time with their GP and had poorer outcomes from appointments (Norbury et al, 2011). Therefore, a key change that the long term plan had to deliver, is the transformation of access to primary care services in urban and inner city areas. This transformation has to be accompanied by improvements to the quality of services provided too.
The continuing evidence of comparatively poorer experiences and outcomes for people with mental health problems, combined with often inadequate support for their families and carers has been a key driver for efforts to deliver change, including the initiatives promoted under the ‘parity of esteem’ banner. However, the limits of change are widely evidenced. The experiences of black and minority ethnic people in mental health crisis care underline the need for better access and quality of services at an early stage. CQC’s review of crisis care found just over half of people said they received the help they needed in a timely way from GPs (with Ambulance, Police, and voluntary organisations being rated higher), but that GPs were only second to voluntary organisations in other aspects of care such as being listened to, compassion, and non-judgemental.
Black and minority ethnic people continue to be at greatest risk of being detained in the mental health system. CQC noted this in another report that the Mental Health Act focusing specifically on the growing levels of detention. It reported staff as saying improving access to mental health services at an earlier stage for black men in particular was key to reducing detentions. This persistent inequality in use of detention was explicitly recognised by the Prime Minister in launching the Independent Review of the Mental Health Act as part of its stated purpose.
Improving Access to Psychological Therapies (IAPT) had been tasked with this across the population in England, specifically for adults with depression and anxiety. At present, IAPT services reach 15% of people with anxiety and depression, with the goal that they will reach 25% by 2020 (this equates to around 1.5m people each year). IAPT had an early focus on black and minority ethnic communities, with services encouraged to develop and implement good and best practice, for example Birmingham’s Health Minds ran a scheme focused on South Asian women. However, there continue to be challenges, black and minority ethnic people are less likely to be offered talking therapies, waiting times can be several months, and outcomes are still unequal. Moreover, the black and minority ethnic led voluntary sector, which was rated best in the review of Crisis Care, is facing existential challenges with several specialist and many generalist organisations collapsing in the past decade.
Once again, everyone recognises that we need to address the wider determinants of health to ensure that fewer people experience of poor mental wellbeing, but this must be accompanied by better access to support, particularly support that allows people to continue to live in their communities. In delivering this change, the long term plan for the NHS has to ensure that it promotes equality of access and reduces health inequalities which results in real change in the experience of black and minority ethnic communities as a whole, and Caribbean men and South Asian Women in particular. NHS action must be accompanied with coordinated and integrated action across public services, so that we avoid a repetition of the experience of children like Chadrack and his mother Esther.
An edited version of this will be published by National Voices as part of their discussions on ‘The Long-Term Plan’