Webinar discusses ‘avoidable’ inequality in opportunities and support that has significant health outcomes
‘Unjust’ health inequalities can result in up to 50% more cases of chronic pain conditions in some areas of England – this was just one of the striking statistics discussed in Connect Health‘s latest Change webinar on Wednesday 16th March.
The panel event highlighted the extent of inequalities – for 61% of people, health information is too complex for them to understand, resulting in a barrier to healthcare from the outset and further exacerbating service gaps.
The webinar was chaired by Professor Edward Kunonga, Director of Population Health Management at North England Commissioning Support. He underlined the need to address the vast disparities in opportunities and healthcare access that impact on life expectancy, avoidable mortality, long-term health conditions, and the prevalence of mental ill-health.
[Health inequalities] are social injustice at its greatest level. They are systemic – no matter where you look, they’ll stare back at you, whatever data you look at.
Health inequalities are not just bad for the people experiencing them, they’re bad for all of us, so there is an imperative upon us to really understand…and to make sure we’re doing all we can to reduce the gap.
The first speaker on the panel was Dr Liz Lingard, Transformation Lead (North East & Yorkshire), NHS England and NHS Improvement. She outlined the NHS’s national vision to tackle inequalities, which includes the appointment of a director, Dr Bola Owolabi, and the setting of five core priorities – such as mitigating against digital exclusion, and strong leadership.
Unless we transform our services to ensure they’re equitable and accessible for all, we can’t hope to level up and improve our services for anyone, she said.
Liz argued that the right approach should be striving for health equity, rather than equality – providing more opportunities and tailored support for those at a disadvantage.
It’s not the right thing to provide equality…when people have different opportunities, whether it’s their internal factors, or whether it’s the wider determinants of where they live and work, we need to make sure we’re customising tools so that we’re addressing these inequalities in opportunities and in their own internal risk factors as well.
Now the much bigger public health piece is about fixing the system… it’s what our public health colleagues are working with, in local authorities and nationally within government.
She highlighted the need to address imbalances across the course of every person’s life, and at all stages across healthcare pathways:
We [need to] have a much greater focus on children and young people. These health inequalities start at the time of conception, and they magnify and widen as we go through our life course. If we can focus on children and young people and give them the best start in life, we’re also indirectly affecting the health behaviours of their families and communities as well.
Liz also underlined significant issues relating to low levels of literacy and digital literacy in accessing health care – nine million people in the UK can’t use the internet without help.
[These issues] are under-recognised by us in the healthcare system when we’re thinking about delivering interventions. It’s quite chilling to think that nationally, 61% of our population find health information too complex for them to understand.
Digital literacy is a massive challenge – it really is a worry for us, we know it’s exclusive by design, anywhere where you’re putting in digital interventions, you need to really be aware of the inequalities that [they] might [create]…and to mitigate against that.
Professor George Peat, Professor of Clinical Epidemiology, Primary Care Centre Versus Arthritis, School of Medicine, Keele University then discussed primary care data on MSK inequalities.
Data inform decisions. Data from primary care – where much of the formal healthcare for musculoskeletal conditions takes place – makes clear the scale of existing inequalities. In the most socioeconomically deprived neighbourhoods, rates of consulting for low back pain and osteoarthritis are 30-50% higher than in the least deprived areas. These inequalities are seen in every region of the country and have changed little over the last 15 years.
We already know that, relative to the levels of need in their populations, general practices in these deprived areas tend to be under-funded, under-doctored, and with lower patient ratings of accessibility and satisfaction. There is a clear challenge here to put resource where it is most needed and to look at what wider public health action can do to help reduce these inequalities.
Dr James Prentis, Consultant Anaesthetist, Freeman Hospital, Visiting Fellow Northumbria University discussed his interest in prehabilitation and the role it can play in improving or worsening inequality.
…with these interventions before operations, we’ve got potential to create a health inequality that wasn’t there before.
He spoke about an NHS colleague in another hospital who was “undertaking a surgery school” – getting patients in to talk about risk factors, and how they can improve their health before their planned cancer operation. She said that they were removing smoking cessation from the session, because only two patients were smokers. And in the next breath, she told me they can’t get anyone from socially deprived areas to attend.
My view is that we have a big risk of getting fit patients fitter…how do we find patients who need help and support? How do we engage them, what do we do?
James then outlined work he is involved in which uses data to ‘find patients’ who need the support. He described how, in Newcastle, data of patients on waiting lists for elective care is being used to highlight that they have, for example, diabetes, or are smokers. These patients can then be targeted before and after surgery to encourage them to improve their health, though behavioural change interventions – such as exercise programmes and support to stop smoking.
It is using surgery as a golden moment of behaviour change. These patients are then more likely to engage in secondary care…it is a bit of a carrot and stick situation but it seems to be working.
Kerry Page, Project Development Manager, Keighley Healthy Living, talked through her work on a six-month pilot programme, which aimed to co-design and test a care pathway for a group of 44 patients in Keighley and Bradford, West Yorkshire, who are living with MSK conditions and high impact, chronic pain.
The aim was to connect their medical care, their GP care, with support in areas such as physical activity, diet and nutrition, pain management. When you’re thinking about people who are really isolated, mostly at home, not connecting with their community networks, getting them to talk to us about getting physically active, their diet, their social networks, pain management that isn’t medication… you think it’s going to be a really difficult thing to achieve.
The astounding thing was that from their initial MSK pain service referral, or their GP referral, not one of them put the phone down on us. Anyone who lives with pain will grab hold of help. The clinical referral from the GP was crucial in building that trust with us.
[We asked them]: ‘how do you want to receive information, what will you engage with?’ They told us really simple stuff – don’t give us loads of literature, don’t call me early in the morning, don’t tell me to look at a website.
People who have high impact pain are not light touch contact, this is not going to work for them…When we’re talking about tackling health inequalities, we’ve got to think about these people really differently, and we’ve got to give them time, energy, resource and it’s got to be funded.
In the end, staggeringly, out of 44 patients, 40 ended up in buildings, in community centres across Keighley.
Describing one of the attendees, Richard, Kerry said:
This was a man who walked into our centre, bent double, dishevelled, not working, he wanted to give up completely. The engagement took a lot of time, but he now attends seven exercise classes. We hooked him up with things that suited him, he lost two stone, he doesn’t reach for his medication the minute he opens his eyes…he now has a purpose and a role… you can see in his eyes that he is a completely changed man by being supported in his community.
Reiterating the need to move away from ‘light touch’ contact, and also to support patients with crisis management, such as helping them to deal with welfare and housing benefits, Kerry said: “We have to have really effective, active signposting. We’ve got to have people who really know and understand people in their communities. Prescribing them online support is not as effective – you have to dedicate time, money and resource and you will help these people, they will not turn you away.
The final speaker was Linda Hindle, Deputy Chief Allied Health Professional (AHP) Officer and Engagement Lead for the Emergency Services, OHID. She spoke of her work with the Kings Fund and NHS England in creating a framework for AHPs for aiming to support clinicians to reduce health inequalities.
I was getting a sense from clinicians that they were wanting to do something about health inequalities but they didn’t really know where to start; it seems like such an enormous issue that requires input at every level.
Linda outlined the six aspects within the framework that was developed in response: “It includes us as individuals, our own values and beliefs; the work we do with individual patients; the work we do as part of clinical teams and pathways; our work in networks and communities; the role we play within the systems we work in and the role we play in nurturing the future workforce.
Then within each of those aspects, we looked at what do we need to know, what don’t we know already, what should we know; what actions could we take and what further advocacy role could we play?
As an individual healthcare professional, it’s difficult to see what our individual contribution can make to that big picture – it’s like eating an elephant. Where do you start? One bite at a time.
To close the session, chair Edward asked all panel members for one ‘take-home message’.
- Liz: “Collaboration. Seek people out within your patch and collaborate with them.”
- George: “Use data to inform your actions but be critical of it. Keep pressing for more equitable data.”
- James: “Just do something.”
- Kerry: “Open our ears and listen to what patients say will help them, alongside their medical care.”
- Linda: “We’ve all got a role to play – see what you can do to make a difference.”