Abstract
I would take to my knee for the immigrant nurses and healthcare workers, the British-born, third-generation Black, Asian and Minority Ethnic medics, the receptionists, cleaners, porters, pharmacists and paramedics who came to work every day and night, fearful and bewildered by a virus that threatens their homes and communities. My right knee touching the ground and fist raised in solidarity would be a humble acknowledgement of the inequalities ethnic minorities have had to endure, long before this pandemic. Taking the knee would say to my colleagues and the public: ‘I see you. I hear you. I am with you’.
Then, I would start to rebuild.
‘Coronavirus does not discriminate’
On the 27th of March 2020, Michael Gove stood at the podium for the daily briefing and declared to the United Kingdom public that the ‘virus does not discriminate’. We might all be able to recall several moments throughout this pandemic when we have questioned this bold statement.
As he addressed the nation, Dominic Cummings, the Chief Advisor to the Prime Minister was en route to Durham, 260 miles from London, with his son and symptomatic wife. This was an offence that many have been fined for. It was not long after Gove's declaration that his symptomatic daughter was given a COVID-19 test, all amid the resounding pleas from the frontline to increase testing of its healthcare staff so that they could get back to caring for the nation. Despite a Government announcement for essential international travel only, Stanley Johnson, the Prime Minister's father made a non-essential international trip to Greece to prepare his rental property for the holiday season, without retribution. The virus itself might not discriminate, but it has certainly exposed the social class inequalities that still exist in the United Kingdom, more concerningly so when it comes to healthcare.
National Health Service England is supported by 108,946 doctors; 44.4% identify themselves as non-White, of which 34% are Black and Asian. 1 The Office for National Statistics, Institute for Fiscal Studies and Public Health England all concluded that Black, Asian and Minority Ethnic people are disproportionately impacted by COVID-19. Black people are 1.9 times more likely to die from COVID-19, while Bangladeshi and Pakistanis 1.8 times, and those of Indian origin 1.5 times. 2 Of the 119 National Health Service staff known to have died in the pandemic by April 2020, 64% were from an ethnic minority background. 3 The higher prevalence of obesity, diabetes and heart disease in these populations has been linked to these figures and may represent an as-yet unknown underlying pathobiology of the problem. 4 However, Black, Asian and Minority Ethnic people are also the most likely, out of all ethnic groups, to live in the most deprived 10% of neighbourhoods in England and the death rate from COVID-19 was twice as high in these communities.5,6 Health inequalities due to socioeconomic factors cannot be ignored.
A report by Public Health England published in 2015 showed that the life expectancy for women in Kensington and Chelsea, a more affluent London borough, was 3.8 years higher than that in Barking and Dagenham, a relatively deprived borough. Infant mortality rates were higher in babies of mothers born in the Caribbean, compared with those born within the United Kingdom. Similar variations were seen in immunisation uptake, childhood obesity, educational attainment, smoking prevalence, sexually transmitted infections and cancer mortality. These findings are echoed across the country and it is unsurprising that we have witnessed a similar pattern during this pandemic. 7
Healthcare inequalities stem from a complex interaction of social, economic and political factors influencing the environment in which an individual is born, raised, educated and employed. Reducing homelessness, improving education, protecting the environment and creating better job prospects in deprived areas will help narrow the health gap. Public Health England published a five-year strategy to tackle this. In the proposal's foreword, Chief Executive Duncan Selbie outlines contributors to good health as: ‘simply put - a job, a home, a friend’. 8 Targeting these fundamental issues requires a drastic reassessment of priorities, and this attempt should be applauded. If we level our society's basic needs in an individual's life very early on, we can prevent entry into the vicious cycle of poverty, ill health and eventual need for a healthcare service.
In a 2018 health inequalities strategy statement released by the Mayor of London, Sadiq Khan, he alludes to the minimal influence of the National Health Service and care services on the disparities in health across the region. 9
I strongly disagree.
‘Accountability and responsibility for proven bias’
The stark differences in accessibility and delivery of various healthcare services across the country, and the consequent effect this has on health in some communities, is neither minimal nor negligible. Mental health, for example, is a sector that has seen progress with increasing investment and pioneering of integrated models of service delivery, such as the Improving Access to Psychological Therapies (IAPT) programme. 10 Despite this, commissioning of the majority of mental health and support services remains slow and fragmented, with inflexible block contracts not reflecting the evolving demand. There is a persistent concern that funding is not always based on the populations that need it most. 11
Furthermore, the pandemic has ‘exposed and exacerbated’ problems in our fragile social care system. COVID-19 was implicated in 19,394 care home deaths, representing 29.3% of all care home resident deaths. 12 At the end of 2019, workforce shortages within social care were around 122,000 with high staff turnover rates and a quarter of staff on zero-hour contracts. 13 The impact of these shortages pre-pandemic was described as a deeply embedded challenge with a ripple effect across other sectors. Delivering improvements in care was highlighted to politicians embarking on the General Election trail in 2019, but COVID-19 has placed stress on an already-stretched sector, so much so that it can no longer cope.
We need a radical change in our social care system.
‘I’m sorry, I didn't plan for this’
Doris’ 80-year-old husband Mark has just been diagnosed with dementia. They live together in a two-bedroom house and have been independent up to this point. However, Doris is now finding it increasingly difficult to look after Mark. His children are all strangers to him. Like any loving spouse, Doris wants the best care for her husband, but it comes at a cost. Doris ends up selling their home and she recalls Mark, in a rare moment of lucidity, apologising for ‘not planning well for this’.
When the National Health Service was founded in 1948, its core value was providing a quality service for all, regardless of ability to pay. 14 The social care system is just as old as the National Health Service; however, the challenges of social care reform have been evaded by consecutive governments. Adult social care spending fell by almost 10% between 2010 and 2017 and cuts in local authority social care budgets have led to an increased use of emergency department services by people aged 65 years and over. Initiatives such as the ‘Better Care Fund’ and the council tax precept have unfortunately failed to solve the problem, particularly in the care for older people. 15 The United Kingdom now has an increasingly ageing population and one in six people over the age of 80 (of which 70% of those in care homes) has dementia. 16 We cannot soothe the pain of watching vacant stares piercing us, nor find palatable ways to explain who we are to a loved one. What we can do is provide the same excellent care, to those who need it, regardless of how much they can pay. This remains part of the National Health Service constitution and the current set of principles guiding the National Health Service.
The National Health Service belongs to the people.
Lessons from COVID-19
It is now unacceptable to have any debate about healthcare without discussing the impact of COVID-19, arguably the biggest healthcare and economic crisis of our generation. Author Yuval Noah Harari reflected on the effect of this pandemic on the world moving forward. In his hopeful piece for the Financial Times, he calls for global unity among all the uncertainty. 17 Admittedly, I initially found this too optimistic; however, global events over the last few months have reignited my own optimism. Society has embraced activism on issues that have plagued our communities, and indeed healthcare for far too long: racism; gender inequality; LGBTQ +rights; and climate change among others. It is worth noting that historically, global crises have led to a significant shift in ideology; the bubonic plague was followed by the Renaissance, World War II gave birth to nuclear weaponry and the accelerated developments in science and technology. As Minister of Health, I would take heed of the very important lessons emerging from this pandemic.
Rapid adaptations in service delivery have fuelled innovation and the results have been astonishing. In primary care, general practitioner video consultations have proved highly effective in triaging patients and directing focus towards those who require it more. In secondary care, remote monitoring of chronic conditions like cystic fibrosis and diabetes has proven now more than ever the benefits of widening access to technology in the National Health Service. In 2017, The Medical Technology Group published a report highlighting how increasing patient access to eight medical technologies (including insulin pumps, compression bandages, implantable cardioverter-defibrillators, hip replacements, etc.) could save the National Health Service over £476m per year. 18
Although the private sector has for a very long time successfully contributed services, to the National Health Service, it has not been without controversy. The Health and Social Care Act of 2012 led to an increase in the number of contracts awarded to private providers. The extent of their involvement varies within various areas of care and between different regions across the country. Details of individual contracts are not always available, making it difficult to draw accurate conclusions on private sector spending. 19 However, COVID-19 has provided fresh insight.
The United Kingdom Government has spent £10 billion on test and trace services including a £45.8m private sector contract with Serco. Serco has recently been fined £1m for failures on another Government contract and has previously been fined nearly £23m for understating profits from its electronic monitoring contracts with the Ministry of Justice.20,21 Therefore, it is unsurprising that we still do not have an effective test and trace strategy. The last few months have emphasised the value of an expert opinion and so the Government should start drawing on existing experience within the National Health Service and public health teams before outsourcing profitable services from private companies.
As we heal the National Health Service, we must be wary of returning to the old ways of doing things. It is vital that we integrate the clinically effective, cost-efficient lessons that we are learning from COVID-19.
In the nation's favourite poem, Rudyard Kipling wrote: ‘If you can…watch the things you gave life to, broken,
And stoop and build 'em up with worn-out tools'
then
‘Yours is the Earth and everything that's in it’.
