Stark realities

Equity release

Equality is about doing the same for everyone. Equity is about making sure we tailor our approach to people’s needs,’ says Dr Habib Naqvi. ‘We need to be inclusive in the way we take these matters on board, in a way that will lead to better outcomes for everyone.’

Dr Naqvi has worked in the NHS since 2001. He is now the director of the NHS Race and Health Observatory, an independent body whose prime function he explains as ‘bringing together evidence and insight around health inequalities in health and healthcare; making policy recommendations on the basis of that insight; and supporting the healthcare systems and NHS to implement those recommendations.’ Importantly, its work looks not just at the existing inequalities but at what is causing them – and what can be done to redress them. 

The stark realities of health inequalities ‘The fact is,’ he says frankly, ‘that there are inequalities in access, experience and outcomes. They span areas as diverse as genetic counselling, maternal health, artificial intelligence – and they’re set against higher rates of conditions that we are all aware of such as diabetes, vascular disease, specific cancers and mental health issues, as well as the disproportionate effect of the pandemic on ethnic minority communities and on staff from those communities.’ 

For physiotherapists, one very obvious example is the fact that while Black and Asian people are less likely to be diagnosed with chronic obstructive pulmonary disease (COPD) than white people; if they do develop COPD they are less likely to be referred for pulmonary rehabilitation. 

The causes, clearly, are not just limited to health systems alone. ‘The NHS has probably the biggest role in terms of health outcomes, but it cannot achieve these ambitions on its own. 

‘Racial inequality needs a global response bringing in education, the legal system and all the other structures of society. Then there are other areas which overlap. For instance, we’re just beginning to do some work on access to healthcare for people with learning disabilities from an ethnic minority background. That intersectionality in terms of ethnicity and disability is very significant and we hope that will be an impactful piece of work.’ 

Every number tells a story

However, the NHS obviously has to play its crucial part in investigating and tackling health inequalities. And on the positive side, Dr Naqvi points out, the UK’s health systems are actually very well-equipped to do that. 

‘We have a long history of migration, going back centuries, so we have large and growing ethnic minority communities. We have robust legal frameworks. And we’ve always had high levels of investment in health research in the UK, which again goes back centuries – the Covid vaccine is just one example of cutting-edge innovation in medicine that has been migrated from this country.’ 

There are new opportunities for making wide-ranging change, too. The NHS has recently announced that all 
NHS organisations need a named executive board member responsible for tackling inequalities, and the Observatory will support this with research into how to make these posts most effective. 

The new integrated care systems present what Dr Naqvi terms a ‘unique opportunity to bring together the different “anchor institutions” across society’. And the recent independent health and social care review from Gordon Messenger and Linda Pollard is also highly welcome, he adds.

‘The critical element will be how this is implemented, and whether we can focus on equality, diversity and inclusion (EDI) in a way that makes it the business of everyone within the organisation.’

However, Dr Naqvi points out, a lot of work to date has been fairly fragmented. ‘Specific units have been set up to set on issues, but those are arguably surface-level issues without focusing on the root causes.’ The Observatory can make a unique contribution to more far-reaching responses, for several reasons. Perhaps most importantly, it is working with data: measurable, quantitative information about what is actually happening. 

‘We don’t just say ‘we think this is happening’, we say ‘here is the evidence’. That evidence is then backed up with the Observatory’s engagement with communities. 

Data is fantastic but the lived experience, the qualitative aspect, is what brings the data to life. Every number has a story behind it.’ And finally, this is an independent body, set up outside the NHS and able to be objective.  

Services fit for purpose

‘The NHS has a number of priorities at the moment, and workforce and finance and the Covid response will be at the top of those,’ Dr Naqvi says.

‘However, the focus on reducing inequalities is not distinct from those challenges. Over the pandemic we’ve seen that the concept of trust within communities is fast becoming a new determinant of health, and that is impacting people’s choices in terms of what they do or don’t do in terms of healthcare. There is work to be done in terms of building and rebuilding trust and confidence in our communities with regards to healthcare. 

‘What’s more, if we focus on closing down the gaps and the disparities, which will help to make the system more efficient, because it will lead to cost savings: it’ll be spending less money on drugs and interventions.’

So what changes do Dr Naqvi and his colleagues want to see in order to make that possible? 

‘At a very practical level it’s about ensuring that our services are designed and rolled out in a way that is as fit for purpose as they can be for the diverse communities they are here to serve. That means getting the processes and structures right to deliver – and monitoring the ethnicity of the patients at a very granular level to see how they experience the outcomes.’ 

This last involves, for example, breaking down a ‘high-level label’ like ‘south Asian’ to be as specific as possible (does ‘Tamil’, for example, mean South Indian Tamil or Sri Lankan Tamil?). 

Alongside this, they want to see crucial changes made in the workforce delivering those services. 

‘Things can be done at organisational level to make sure that our workforce is looked after: inclusive recruitment purposes; a real focus on closing down the gaps in disciplinary processes where people from ethnic minorities are often over-represented; and support for career progression. 

‘We need to clean up the “sticky floors” which mean that far too many practitioners from ethnic minorities are stuck in bandings lower down the scale – staff should be represented at all levels, including the most senior.’

Mending the social contract

‘The NHS is perhaps the most visible expression of a shared social contract between people. It’s a unique and fantastic institution,’ Dr Naqvi concludes.

‘But to be proud of it is not to be blind to some of the imperfections within it. These issues around disparities and inequity, and the challenges that different parts of our workforce encounter, are some of those imperfections and they need to be tackled head on. Through the work of the Observatory, I feel we’re now beginning to make a difference in people’s lives.’