If I was minister of health I would prioritise addressing all health inequalities

Before university, I always considered myself immune to the socio-political frenzy that captivated my peers. But as six years at medical school ticked by, I became increasingly inquisitive about National Health Service politics. I began engaging in conversations with nurses, doctors, physiotherapists and anyone who could spare a minute, eager to hear what their experience of the National Health Service had been and what they would do to improve it. But too many of these corridor conversations and frustrations are swallowed up by the daily grind of working life; their ideas and conclusions lost among the sea of people and squeaking trolley wheels. There is a lot to be changed within the National Health Service, but the most prominent health issue of today is staring us in the face; it is in our news and all over our social media; it is protesting in our streets and dominating our conversations. It is as poignant and topical as ever: it is inequality.

Minister of Health’s powers and duty to reduce inequality

If there is one sentence that dominates the coronavirus script it is: ‘We are living in unprecedented times’; but a closer look at the health inequalities revealed by the 2020 Marmot report ¹ suggest the current COVID-19 racial disproportionalities exposed by the recent Public Health England enquiry ² may be mere manifestations of the systematic racism that has pertained in the National Health Service for decades. Following his decade-long enquiry (2020 Marmot report), Sir Michael Marmot has called for action and reprioritisation of health inequalities by the Minister of Health as the health of people living in low socioeconomic areas is ‘faltering'. ¹ Widening inequalities tell us that society has not only stopped evolving, but it is devolving; and it is our government's role to change this. Legislatively, section 1 C of the National Health Service Act 2006 outlines a duty for the Secretary of State and the Minister of Health to reduce health inequalities. The current COVID-19 pandemic has shed light on the urgent need for our Minister of Health to:

Issue specific guidance for the National Health Service to reduce health inequalities;

Issue a direction to National Health Service bodies under section 8 of the National Health Service act to create public law duty to formulate a public response to the Public Health England report. ²

Health inequality and the current coronavirus pandemic

The first of five objectives in the Secretary of Health’s mandate is to ‘Support the Government to delay and mitigate the spread of COVID-19 … whilst ensuring that everyone affected by it receives the very best possible National Health Service treatment’. ³  What was not considered in Matt Hancock’s mandate was the potential for SARS-CoV-2 to disproportionately affect certain communities. Indeed, as the health activist Wayne Farah has eloquently put it: ‘”We are all in this together”, they declare. However, as the recently announced inquiry into the disproportionate impact of coronavirus on Britain’s Black communities illustrates, some of us are more in this than others.’

Public Health England’s ‘Disparities in the risk and outcomes of COVID-19’ ² report has confirmed previous data showing a disproportionate impact of SARS-Cov-2 on Black, Asian and minority ethnic communities. We now have the evidence that Black, Asian and minority ethnic patients are more likely to be admitted to the intensive care unit and to die from COVID-19, even after adjusting for age, sociodemographics and health. ⁴ Shockingly, 70% of front-line workers who have died are Black, Asian and minority ethnic, despite only representing 44% of UK doctors and 24% UK nurses. ⁵ The Public Health England report relays one key message: the urgent need to address the observed racial inequality in COVID-19 morbidity and mortality. As Sadiq Khan has rightly emphasised, ‘We need to know now why the virus disproportionately impacts these communities and crucially, what is being done to stop it’.

There are three ways that the Black, Asian and minority ethnic community is disproportionately affected by the coronavirus pandemic:

Higher rates of diagnosis

Increased risk-conferring comorbidities

Higher mortality

First, people from Black, Asian and minority ethnic groups are more likely to be diagnosed with COVID-19 than white people (Figure 1). Second, Black, Asian and minority ethnic communities are more likely to have co-morbidities that increase the risk of poorer outcomes from COVID-19; for example, people of Bangladeshi and Pakistani background have higher rates of cardiovascular disease than people from White British ethnicity, ⁶ which confers poorer COVID-19 outcomes. ²

Figure 1.

Age standardised diagnosis rates by ethnicity and sex as of 13 May 2020, England. Source: Public Health England Second Generation Surveillance System.

Third, death rates from COVID-19 are higher in Black, Asian and minority ethnic groups, with the highest mortality seen in Black and Asian ethnic groups, where people of Bangladeshi ethnicity were twice as likely to die than their white counterparts even after accounting for sex, age, deprivation and region (Figure 2).

Figure 2.

Age standardised mortality rates in laboratory-confirmed COVID-19 cases by ethnicity and sex, as of 13 May 2020, England. Source: Public Health England: COVID-19 Specific Mortality Surveillance System.

Public Health England have recounted clear racial discrepancies in health outcomes; however, they have not included any suggestions regarding how to address them. Therefore, if I was Minister of Health, I would issue the following guidance to act on and mitigate these health inequalities, while prioritising research that aims to understand why some ethnic groups experience greater risk from COVID-19. These proposals take the form of: prioritising minorities for COVID-19 prevention and treatment; addressing discrimination and systematic racism in healthcare; and widespread decolonisation of healthcare.

Proposal 1: Prioritising minorities for prevention and treatment of COVID-19

If I were Minister of Health, I would investigate and promote mitigation of the observed COVID-19 disease-burden inequality in the following ways:

Knowledge: We must deploy the best epidemiology, big data and clinical science to understand the underlying pathophysiology of the observed patterns of COVID-19, especially as the possibility of a biological basis for the observed disease inequality cannot be ruled out. For example, the receptor that coronavirus binds to to enter cells, ‘angiotensin-converting enzyme receptors’, has been shown to exist in higher quantities men, ⁷ African American and East Asian populations, ⁸ which may suggest the difference in response to SARS-Cov-2 from different populations under similar conditions.

Prevention: Prevention, testing and tracing needs to be prioritised for those in vulnerable categories, with close partnership with ethnic minority groups in communities to foster better education and prevention in the community.

Mitigating risk: I would issue a direction to National Health Service bodies under section 8 of the National Health Service act to create public law duty (rather than guidance) for all National Health Service trusts to carry out risk assessments ⁹ and utilise the ‘Risk Reduction Framework’ ¹⁰ for all Black, Asian and minority ethnic staff.

Treatment: I would issue up-to-date, clear guidelines for the National Health Service regarding how to prioritise minorities in emergency and intensive care, with special attention to reducing Intensive Care Unit admissions to the intensive care unit and mortality.

Proposal 2: Addressing discrimination and systematic racism in healthcare

Black, Asian and minority ethnic staff are more likely to be harassed by managers and subjected to disciplinary procedures by their Trusts, Royal Colleges and regulators. ¹¹ In a survey with more than 2000 Black, Asian and minority ethnic health professionals, 50% felt discriminatory behaviour has played a role in the high death toll seen in COVID-19, with 20% claiming they have experienced it personally. ¹² As Health Minister, I would give full consideration to the extent to which such fears prevented Black, Asian and minority ethnic clinicians from challenging managers over personal protective equipment or any disproportionate allocation to COVID-19 wards. ⁵ Further, racism experienced or feared by Black, Asian and minority ethnic communities has cultivated a lack of trust of National Health Service services resulting in their reluctance to seek care ¹³ ; therefore, it is imperative that these barriers in access to healthcare are removed. A second, unpublished report by Public Health England (disclosed to the British Medical Journal) states that factors such as racism, discrimination and social inequality may have contributed to the increased risk of death from COVID-19 among ethnic minority groups. ¹³ The Health Minister has a duty to address any such discrimination and systematic racism.

Education: We need to engage with and respond to people’s lived experiences. Therefore, I would issue guidance to National Health Service trusts regarding how to record and collate Black, Asian and minority ethnic staff and patients’ discriminatory experiences. This could take the form of posters around the hospitals and in the communities, with helplines clearly labelled

Support: We must streamline whistle-blowing procedures by listening to Black, Asian and minority ethnic staff about what discourages them from reporting misconduct and targeting these barriers. We need to fully commit to a zero-tolerance policy for discriminatory behaviour, by ensuring Black, Asian and minority ethnic workers are better represented in the ‘Freedom to Speak Up Guardians’ network, as well securing ring-fenced time for guardians to carry out their responsibilities effectively

Proposal 3: Widespread decolonisation of healthcare

Even preceding the recent Public Health England ‘Disparities review’, racial discrepancies in healthcare have prevailed insidiously in the statistics; for example, black women are five times more likely to die in childbirth than white women ¹⁴ and black patients are 50% less likely to receive pain medication than white patients. ¹⁵ The reports of racial discrimination of National Health Service staff ¹² not only cultivate a fearful and toxic culture for Black, Asian and minority ethnic staff, but they also adversely impact the quality of care to patients. These injustices call for widespread decolonisation of healthcare.

Decolonise health advice: The National Health Service must provide culturally and linguistically appropriate communication for patients, including alternative patient advice leaflets with consideration of ethnicity and language, with particular attention to the services that demonstrate highest rates of racial inequality among patients.^14,16 Advice leaflets must reflect epidemiology and disease presentation in different ethnicities, such as cardiology, ⁶ psychiatry ¹⁶ and dermatology. ¹⁷ For example, photographs of skin conditions may appear vastly different on patients with different skin colours. ¹⁷ Every patient needs a personal form of care that acknowledges ethnic disparities in disease pathology.

Diversification and inclusion: Using the powers of Minister of Health, I would issue a direction to National Health Service bodies to diversify National Health Service leadership. Human Resource Directors groups need to submit regular progress reports to the National Health Service Equality and Diversity Council, which need to be independently cross-examined in order to address the lack of Black, Asian and minority ethnic representation at senior levels. ¹⁸

Adapt: With the movement towards digital healthcare, we must review inequalities in access to these technologies, with special attention given to those with no access to the ‘online consultations’ depicted in the National Health Service Long Term Plan. ¹⁹

Conclusion

Tragically, we have seen healthcare inequalities in pathologically high resolution during the recent COVID-19 pandemic. The Public Health England report released in June 2020 confirms that the devastating impact of COVID-19 has highlighted and even intensified existing health inequalities. We must issue practical steps to address all health inequalities, with urgent attention to those exacerbated by the COVID-19 pandemic. The Minister of Health is legally obliged to address healthcare inequalities as per section 1C of the National Health Service Act 2006 and Health and Social Care Act 2012; therefore, he has a duty to combat the evident institutional racism and discrimination in healthcare. Fundamentally, the National Health Service needs to be led by the people, for the people. We need an National Health Service that puts patients at its centre, issuing focused responses to inequalities in access, quality and outcomes of care, while removing the barriers that prevent staff from working to their full potential.

We have the proof of need for these directives. The Minister of Health has a responsibility to implement them. Now is the time for real action rather than words. As the 1945 Minister for Health and founder of the National Health Service, Aneurin Bevan, wisely stated: ‘Illness is neither an indulgence for which people have to pay, nor an offence for which they should be penalised, but a misfortune the cost of which should be shared by the community.’

Supplemental Material

sj-pdf-1-jrs-10.1177_0141076820975367 - Supplemental material for If I was Minister of Health … 

Supplemental material, sj-pdf-1-jrs-10.1177_0141076820975367 for If I was Minister of Health …  by Hayley Pillai Johnson in Journal of the Royal Society of Medicine