On developing more proactive primary care to improve race equality in health care outputs and health outcomes.

My last post celebrated how proactive primary care resulted from the use of the Qcovid algorithm to communicate with 1.7 million high risk, newly described, extremely vulnerable patients. By communicating with the specific patients with long-term conditions it identified to come and be vaccinated, it demonstrated the ability of primary care to be more proactive in helping patients.

I now want to look at how this proactivity could improve race equality in health care outputs and health outcomes.

Covid mortality rates have been higher amongst people from many black and minority ethnic (BAME) communities. These higher rates have many causes. One of them being earlier onset of debilitating prior conditions. If BAME people experienced the onset of long-term conditions at the same age as the average of the whole population, more would have survived Covid.

Yet, as with other inequalities, Covid mortality outcomes have shone a light on inequalities that we already knew about. Since the NHS prides itself on its equality principles, these Covid mortality disparities are a challenge for it to act to reduce the onset age of inequalities in morbidity.

Much of the earlier onset of long-term conditions amongst BAME people has causes that lie beyond the NHS health care system. Deprivation and discrimination impact people’s lives throughout wider economic and social relationships of society.

Whilst these determinants of health are broader than those directly relating to the NHS, the work of its partners comprising the new Integrated Care Systems (ICSs) could improve health equalities. Within these ICSs, the NHS commits to work with local Government and others to confront those aspects of deprivation and discrimination that create the earlier onset of long-term conditions. If they prove capable, these partnerships will have a positive impact on improving race equality of health outcomes.

On its own the NHS cannot ‘solve’ this problem of discrimination in health outcomes, but it can however play a much bigger role in reducing race inequalities in health care outputs. The unequal impact of the early onset of long-term conditions on the mortality of BAME people demonstrates an inequality that sits uncomfortably with  NHS equality principles and it will want to ensure that outputs of its own health care will better create race equality than they do at the moment.

Any better management of BAME health care would need interventions that would play a role both in delaying the onset of long-term conditions and better managing them afterwards.

The physical proximity of primary care teams to the lives of the individuals and communities they serve, will see them play a bigger role in this task than other parts of the NHS. Since its inception, primary care has grown a registered population that much better reflects local demographics than, say for example, hospital usage. There is therefore a practice to build on which has been enhanced by both the recent algorithm and the consequent vaccination programme.

To successfully delay the onset and subsequent management of long-term conditions, primary care will need very close relationships with BAME individuals and communities

To achieve this the expanded primary care team will need to provide health care which succeeds in changing many people’s behaviour. To be successful in behaviour change primary care will have to intervene, in partnership with others, in a more proactive and persevering way.

Given that primary care has developed greater capacity to become proactive in reducing ill-health amongst its registered population, how can it realise this ambition?

  • More specific targeting of interventions. In recent years health screening for older adults has become an important methodology in proactive medicine for primary care. If we want to make an impact on the onset of different diseases for different groups targeting needs to become much more specific. We know that elements of ill-health are specific to age and ethnicity. Diabetes and hypertension have high prevalence within some ethnicities, but not in others. It is therefore important to target interventions as carefully as the data will allow and not just adopt a “scatter gun” approach to the problem. This doesn’t just need different groups to be screened, but needs different interventions for different groups resulting from that screening. Screening should also occur at an earlier age with some diseases and ethnicities where a raised BMI is indicated.
  • Primary care needs persistent interventions that follow on from screening. Some results from screening discover problems that lead to straightforward medical interventions. But many need to be followed up by encouraging behavioural changes by patients which in turn have an impact upon their health. To be effective, primary care needs to work with others to help the patient make these changes. We have known for a long time that simply providing information is insufficient to help to bring about behaviour change. To help patients change there need to be more persistent interventions. The primary care team themselves may not have the resources to develop these persistent interventions but primary care needs to work with a wide range of other organisations to help develop them. Some of this has begun to happen – mainly with patients that are already sick – through social prescribing. This could be extended to other patients.
  • Utilising the whole primary care team. In recent years primary care has become a much wider experience than a consultation with a GP. Under the overall management of the GP, different members of this wider professional team can play a much more specific role in providing different interventions. There is already a national programme for those that have been diagnosed as pre-diabetic, where advice from the primary care team by involving social prescribing has led to better health inducing behaviour. As well as targeting interventions through age and ethnicity, we can also use very different targeted organisations to carry out those interventions.
  • Utilising the wider partnership relationships to provide content for the offer. Whilst the primary health care team do not have the resources to provide the services necessary to improve the health of patients from BAME communities, there are many local partners with which the team can work. Social prescribing has demonstrated how a networked primary care team can work with existing voluntary sector organisations. Primary care has other local partners with excellent relationships with many BAME communities. The Covid crisis has demonstrated how important local government can be in working alongside the NHS to provide services for vulnerable patients.

Recent events have demonstrated how a more proactive primary care can improve health care outputs. Give the race inequality that Covid has further uncovered, we now need to use that proactivity to improve race equality in health care outputs.