Health and care services worldwide have faced an unparalleled challenge in responding to and managing the impact of Covid-19. No part of the population has been untouched, but the disproportionate impact of the virus has highlighted long-standing health inequalities. These are marked differences in health outcomes that have been described by The Kings’ Fund as “avoidable, unfair and systematic differences in health between different groups of people”, for example for people from areas with higher levels of socio-economic deprivation, or for those from Black, Asian and minority ethnic (BAME) communities.
The impact of the virus has been wide-ranging, with direct effects such as disproportionately higher infection rates and poorer outcomes among marginalised groups, and indirect effects including lower access to usual healthcare services and the effect on the wider determinants of health such as employment, housing, education and social connection.
With the challenges of the pandemic arises an opportunity for trusts to consider how their approach to recovering from Covid-19, restoring services and dealing with a second wave of cases can be done in a way that also addresses inequity in existing health outcomes and minimises the disproportionate consequences of Covid-19 on marginalised groups.
NHS England and Improvement have set an expectation that health inequalities will be front of mind in trusts’ recovery from the pandemic. A new framework, developed by the Provider Public Health Network and supported by Public Health England and NHS Providers, sets out a series of principles to support this action, sharing examples of how trusts are already working to strengthen their focus on health equality and working in partnership with other local players to meet the needs of their local populations. The framework will be of particular interest to the trust executive members who are leading organisational action to tackle inequalities, as part of Covid-19 phase 3 requirements.
The key to delivering interventions that help to reduce health inequalities and mitigate the impact of Covid-19 on disadvantaged populations is to work from a set of principles that govern everything trusts do in the wake of the pandemic, from ensuring health equity is considered as part of any proposed changes to services, basing interventions in integrated, person-centred care, and ensuring services are accessible to those at risk of exclusion because of personal, economic or social factors.
For example, Barts Health NHS Trust took the first step of identifying gaps in access, outcomes and experience using routine trust data, as part of their trust-wide commitment to addressing inequity as a core strategic objective.
But in order to have the greatest effect, the wider determinants of health will also need to be considered as part and parcel of a system-wide approach to health, with community assets funded and harnessed to help reach and support local communities. This can include libraries, community groups, education centres, leisure and sport facilities among other resources. NHS trusts as ‘anchor institutions’ can also make a significant contribution.
System working can be a helpful convenor for these conversations, with STPs and ICSs playing a useful role in bringing together and linking population level intelligence from key players across the system, to enable people’s needs to be met across all the areas where they may need support. In Barnsley for example, local health and social care partners pooled their analytical resources to create a vulnerability index, originally designed to identify those who were shielding due to underlying illnesses, but has since evolved to include information about financial difficulties or safeguarding concerns, in recognition of the impact of these issues on people’s health.
Drawing on existing data, trusts can begin to adapt their services to target their interventions where they will have the greatest impact for their local population. This can involve reviewing their model for core services like smoking cessation and weight management support, screening programmes, as well as other clinical services. East London Foundation trust, a mental health trust, set out to address a gap in access to virtual appointments and support. They refurbished old workplace smartphones and digital tablets to allocate to patients at risk of digital exclusion, along with support to familiarise their use, so they could continue to access services during the Covid-19 lockdown.
Trusts see their workforce as part of the communities they serve. In some areas, particularly areas with higher levels of socioeconomic deprivation, the health and care workforce forms seven to eight per cent of the local working age population. So as well as looking outwards to their patients, trusts can also consider the impact of health inequalities on their staff – factors like higher levels of occupational exposure to Covid-19 and overcrowded housing, can all increase the risk of worse outcomes.
Many trusts are considering how they can support their staff, both during the Covid-19 pandemic and beyond.
The Royal Free London NHS FT identified the need for a targeted workplace health approach for facilities staff within bands 1-2 on their sites, to maximise the uptake of health and wellbeing programmes among those at risk of poor health. Recognising that staff and their partners might be facing financial challenges, Northumbria Healthcare NHS FT undertook actions to help improve the wellbeing of their workforce during Covid-19 response, including providing a free hot meal and drink every day; promoting a financial wellbeing offer with a local community bank; and considering how to support staff identified in need.
All of this action is galvanised by leadership support for addressing health inequalities, and board-level sponsorship for this work is key. Trusts can make an important contribution to reducing inequalities as part of the recovery from Covid-19, and strong local and organisational leadership of this process can inform coal-face action and maintain and embed the focus on tackling inequalities amongst the local population as the health and care system continues to manage the challenges presented by the outbreak.