Authors: Liz Herrieven / Editor: Charlotte Davies / Codes: CC16, SLO12, SLO7, SLO8, SLO9 / Published: 12/04/2021
Inequalities in health are nothing new. Throughout history various groups have had increased morbidity (illness) and early mortality (death) compared to others, with common reasons being the same as some of those faced today – poverty, poor diet, limited access to green spaces and clean air, overcrowding or lack of knowledge about infection control, for example. Whilst many things have improved with time, the COVID-19 pandemic has thrown some of the most stark differences in to light.
Early in the pandemic it was clear that Black men were at greater risk from this illness than White men – 3.3 times more likely to die, for all ages (ONS, UK2). A similar pattern has been seen in women, with Black women 2.4 times as likely to die compared to White women (all ages). Some of the difference may be explained by differences in region of the country or population density, for example, but with these factors taken into account, along with socio-economic status and household characteristics (using census data) there was still an increased risk of mortality for Black men (2 times) and Black women (1.4 times) compared to White. Men of Indian, Bangladeshi or Pakistani ethnic background were 1.6 times more likely to die compared to White men, when differences in socio-demographic status, region, population density and household characteristics are taken into account. That difference wasn’t, however, seen in females.
Men generally have been at higher risk than women, when all other relevant factors are taken into account. Differences are seen, too, with regards to occupation, for those of working age3. Men in “elementary” occupations (performing simple and routine tasks which may involve hand-held tools and considerable effort – Standard Occupational Classification 2010) and those in caring, leisure or other service occupations had the highest death rates. For women, again those in caring, leisure or other service occupations were more likely to die, with increased mortality also seen in those working as process, plant or machine operatives. Some of these occupations will bring employees into closer contact with each other and with people likely to be infected with SARS-CoV2, but there may also be differences in the understanding and availability of PPE, along with being unable to work from home. Employment (and more importantly pay) is also likely to have an impact on whether an individual is able to easily take time off work to isolate when needed. Age-standardized mortality rates for deaths involving COVID-19 in the most deprived areas of England have been twice that of the rates in the least deprived areas4. There may of course be many linked factors involved here – multi-morbidity, poor nutrition, obesity, smoking, inability to work from home or isolate, crowding and lack of access to green spaces or clean air just some of them.
Another group who have been more at risk during the Pandemic are those with learning disabilities. LeDeR, the Learning Disability Mortality Review Programme based at the University of Bristol, reviews the deaths of people with LD over the age of 4 in England. In November 2020 it released a report5 reviewing the deaths of a cohort of people with LD from the same year. The majority (79%) of those deaths were due to COVID-19, with a much younger age profile than that seen in COVID-19 deaths in the general population – 4% of deaths in people with LD were in those aged 85% or more compared to 47% of those in the general population. A third of those with LD who died with COVID-19 lived in residential care settings – rising to 50% when those with Down syndrome were reviewed. LeDeR reviewers grade the care received by people with LD in the time preceding their death. Only 56% of those reviewed had received care which was considered to have met or exceeded good practice. Particular issues included a lack of reasonable adjustments – those adjustments required by the law under the Equality Act, 2010, such as providing easy read information, accessible healthcare appointments, allowing an accompanying carer despite visiting restrictions, or extra time and support for PCR testing for example. Difficulties with coping in isolation or with social distancing, particularly for individuals reliant on others for their activities of daily living, are likely to be a huge factor, along with access to PPE for carers. For those with sensory processing difficulties, who may interpret sensations abnormally and become very distressed by sensations that others can tolerate easily, things such as wearing a face mask, frequent hand washing or having a nose or throat swab may be very challenging. Symptoms such as cough or fever may be obvious to carers, but for people with communication difficulties alteration in the sense of taste or smell may go unnoticed.
Another area noted by LeDeR was that of DNACPRs and inappropriate use of the Clinical Frailty Scale, which, for example, can wrongly score an otherwise healthy person with LD as being frail because they need help with activities of daily living. In several cases, “learning disability” was given as a reason not to resuscitate a person. LeDeR is very clear that this is not an appropriate reason for deciding not to resuscitate someone. Quality of life can be very good, and a person may be fit, happy and fulfilled despite poor communication and understanding6.
The pandemic hasn’t just revealed inequalities in morbidity and mortality due to infection with SARS CoV2, but has also opened up other differences which will have long-lasting effects. Mental health presentations are, at the time of writing, a year into the pandemic, rising in number in EDs across the country, including in young people. Lockdown has disproportionately affected those who live in crowded environments, have reduced access to green spaces and less disposable income to spend on luxuries and treats. Rising unemployment as businesses struggle and close will leave greater numbers of people vulnerable. Children in homes without access to individual laptops or tablets will have had less opportunity to continue their education. In homes with multiple children, or in which staying at home wasn’t an option, parents may have been less able to spend time supporting their children. Non-accidental injury and domestic violence are a concern, as are delayed presentations and missed treatment for serious and life-limiting illnesses. Those most likely to present late in the course of a disease are those with reduced access to GPs (there are fewer GPs per patient population in more deprived areas), those who can’t afford to take time off work to make appointments and those who may not understand or recognise new symptoms. Coincidentally, these are often the same people who may have a poorer diet, be more likely to smoke, have a greater number of comorbidities and be at greater risk from disease as a result.
I was lucky enough to attend the RCEM study day “More action on prevention and reducing inequalities in EDs” recently. I can thoroughly recommend it for anyone working in Emergency Medicine. The themes mentioned above continued throughout the study day.
Dr Sarah Smith, Public Health Consultant and Programme Director for Improving Population Health, West Yorkshire and Harrogate Health and Care Partnership, spoke about reducing health inequalities from an ED perspective. Those inequalities are not limited to pandemics. There are differences in access to healthcare, quality of healthcare and in the outcomes achieved between different geographical groups, socio-economic groups and ethnic groups, to name but a few. For some individuals, more than one or sometimes several vulnerable factors may exist at once. Reduced life expectancy and increased morbidity can be seen particularly in relation to circulatory disease, respiratory disease and cancer (particularly lung).
How does this affect us as ED clinicians? EDs can be seen as a gauge for social inequality. People living in more deprived areas are 2.5 times more likely to come to the ED with a preventable emergency admission compared to those living in the least deprived areas. Those in more deprived areas are also more likely to report a negative experience of Primary Care – these areas have fewer GPs per head of population, lower rates of elective admission and higher rates of emergency admission. Sarah explained that Asian patients are more likely to report negative experiences of making appointments to see their GP and of getting through to their practice on the phone. Black patients are least likely to have used online services to access Primary Care. More on the health inequalities between different ethnic groups can be found in a recent King’s Fund article7.
Professor Sir Muir Gray, Founding Director of the Oxford Centre for Triple Value Healthcare and Optimal Ageing Programme Director, spoke of similar things. Use of elective services, including outpatient services, is greater in populations from wealthier areas – those better able to work the system and those who don’t lose out by taking time off work. Those in more deprived subgroups are more likely to need to resort to emergency services.
Professor Julia Sinclair, NHSE National Specialty Advisor for Alcohol Dependence, talked about the importance of preventative medicine in the NHS Longterm Plan. The most vulnerable and most deprived in society are most likely to be affected by alcohol, drugs and tobacco. This area was also emphasised by Greg Fell, Director of Public Health for Sheffield. We may think of smoking or drinking or gaining weight as lifestyle choices, but are they really? Are they sometimes, instead, the result of a series of traumatic experiences?
Greg also spoke passionately about the inequalities in health seen even across his own city – a 20-25 year difference in life expectancy depending on which part of Sheffield someone lives in. That seems very difficult to understand, in an age where the world seems so much smaller. Life expectancy is, in some areas, even starting to fall. Infant mortality, which seems an historical problem, is also increasing in some areas of the UK, whilst continuing to fall in other, more affluent areas. We have seen local governments having to make difficult decisions in recent times of austerity. Less resources often means fewer green spaces, reduced social care spending, reduced public health services, with those in more deprived areas suffering the biggest consequences – those with the greatest need for healthcare and those with the least access.
Types of death can be classified into avoidable or not, and those causes of avoidable deaths further classified into those which should be preventable, and those which should be treatable. Preventable causes of death include those which could be prevented by road safety laws, anti-smoking advice, and so on. Treatable causes of death include things which, in most cases, should be treatable and so not lead to death – infections, some types of cancer, for example. Preventable causes of death and those causes which should be amenable to treatment are those which are disproportionately more common in vulnerable groups. According to LeDeR, people with a learning disability are approximately 5 times more likely to die of something which should be treatable, compared to those without a learning disability. The reasons for this are many and varied – more difficulty in understanding how to stay healthy, knowing who to contact and how to express your symptoms and needs, sensory processing difficulties making visits to Primary Care and ED more challenging, diagnostic overshadowing meaning that your acute problems are overlooked, healthcare professionals who struggle to understand how to communicate with you….8.
Equality sounds like a good thing to aim for, but actually some people need more than this. Reasonable adjustments may need to be made to ensure that there is equity9.
What has any of this got to do with the ED? What can we, as Emergency Physicians do about Public Health issues? Dr Ling Harrison, Chair of the RCEM Public Health Special Interest Group, reminded those at the Health Inequalities study day that the ED is often the first point of contact for healthcare for the most vulnerable in society.
Data is important. Helen Hughes, Senior Epidemiology Scientist, Public Health England, talked about ED Syndromic Surveillance. Using ECDS data (that coding you have to do for every patient) we have an almost real time view of ED attendances. This data has helped with early warnings (RSV spikes, COVID-19), situational awareness and, sometimes, reassurance. It was, at least in part, responsible for giving us the early information that COVID-19 was disproportionately affecting males, those of older age and those of Black or Asian ethnicity. The system needs accurate data though, so one thing we can all do is ensure we record and code appropriately.
We can also be curious. Look for the challenges people face and consider how we can make reasonable adjustments for them. For those with learning disability, consider allowing extra time for our consultations, ensure a quiet, less stimulating environment, concentrate on good communication and listen to the concerns of carers and families.
Do our departments have the cultural competence to be able to support people with different backgrounds and different needs? Does our workforce represent those we serve? Do we actually know our local population and what makes them unique?
The GMC tells us that all doctors have a responsibility to engage in health promotion10. In the ED this may seem impossible – we have queues to bust, resus to sort – but making the most of teachable moments, picking the right patient at the right time, can make a huge difference.
The answer to health inequalities is not easy or straightforward, but if we do our little bit in the ED, making small, relevant changes, those changes could have a huge impact.
As an editor’s addition, I thought it was useful to briefly mention a health inequality not mentioned at this study day. And that’s gender inequality. I’m not talking gender pay gaps, and progression of women – I’m talking medical care of women. Think for a moment. If a suspected testicular torsion attends the ED, what’s the pathway? If your ED is like mine, they’re triaged straight away, a senior doctor reviews them, and then urology are summoned to review if there is even a sniff of a potential for a torsion. Then, the senior doctor asks for a WBPA to cover UP4 or UC5 of the new curriculum.
Now think of the pathway for a possible ovarian torsion. The patient is likely in the waiting room, a P3 or P4. A doctor sees them, tries analgesia maybe, before referring to gynae who maybe pop to see them in between emergency deliveries. The doctor considers an ObP1 WBPA ticket.
Other differences include the “atypical” chest pain presentations that are actually typical for women and drugs that prolong the QTc reaching QTc prolongation threshold earlier in women. Sex matters covers some of these things, and is aimed at empowering the patient.
Huge thank you to Ling Harrison, Najeeb Rahman, Kirsty Challen, Adrian Boyle, Alex Elliot, Charles Gallaher, Lindsey Stevens, Julia Sinclair, Greg Fell, Sir Muir Gray, Helen Hughes, Sarah Smith, Geoff Wykurz and everyone else involved in the RCEM Health Inequalities study day.
You may like to read this blog on reducing child poverty together from PaediatricFOAMED, and you may like to listen to the Kings Fund podcasts, especially the one on leadership & diversity, healthy places and quality ratings.
You can now complete RCEMLearning SBA on Health Inequalities. Please log in to access it.
- What are health inequalities? Improving health.
- Coronavirus (COVID-19) related deaths by ethnic group, England and Wales: 2 March 2020 to 15 May 2020. Office for National Statistics.
- Coronavirus (COVID-19) related deaths by occupation, England and Wales: deaths registered between 9 March and 28 December 2020. Office for National Statistics.
- Deaths involving COVID-19 by local area and socioeconomic deprivation: deaths occurring between 1 March and 31 July 2020. Office for National Statistics.
- Deaths of people with learning disabilities from COVID-19. The Learning Disability Mortality Review(LeDeR) Programme. University of Bristol.
- If we don’t count, they don’t count – Numbers and stories about COVID, vaccines, and developmental disabilities in Canada and the UK. Health Care Access Research and Deveopmental Disabilities (HCARDD). March, 2021.
- The health of people from ethnic minority groups in England. The King’s Fund. February, 2021.
- Learning Disabilities in the ED. RCEMLearning. 2018.
- Here’s why we should care more about equity, not equality. Muslimgirl (MG). 2018.
- Generic professional capabilities framework. General Medical Council.