PHE review on the impact of COVID-19 on BAME communities

The review was announced following emerging evidence suggesting a disproportionate impact on people from BAME backgrounds. This briefing highlights the review’s key findings and details our view. It also highlights what we are doing to support our members to continue raising the issues and our work towards developing practical solutions as part of the NHS Reset campaign.

Key points

• The report is a descriptive summary of stakeholder insights into the factors that could be influencing the impact of COVID-19 on BAME communities. As well as a rapid literature review, the review also sets outs recommendations and actions.
• The literature review found some evidence to indicate that BAME groups are more likely to test positive for COVID-19 than those from white British backgrounds, and those dying from the virus were more likely to be of BAME backgrounds.
• The recommendations include improving data collection and carrying out research; making policy changes; the role communities can play in working on developing the right communication to improve health outcomes; and focusing on prevention.
• The stakeholder engagement revealed the deep dismay, anger, loss and fear that BAME communities felt about the emerging data and realities that these groups experienced by being harder hit by the COVID-19 pandemic than others, which exacerbated existing inequalities and the impact of the disease on their communities.
• The report recognises the critical role NHS organisations can play as major local institutions in tackling racial inequalities. Our members are clear there is work to do here across the health service, both to support staff more effectively and to reach out to communities to shape the services we offer and to engage patients in their care.
• The NHS Confederation is doing a number of things to support our members. This includes updating guidance for health staff on risk assessment (via NHS Employers), hosting the NHS Race and Health Observatory, contributing to the public debate on what the health and care system should look like post-coronavirus as part of the NHS Reset campaign, as well as playing a leading role in developing and sharing practical actions NHS leaders and boards can take to support BME communities and staff via our BME Leadership Network.

Background

The NHS Confederation’s BME Leadership Network published a briefing in April 2020 exploring the emerging evidence on the impact of COVID-19 on BME communities and health and care professionals. It provided a set of immediate actions for local and national NHS organisations to take to mitigate risks to patients and staff.

BME groups generally have less access to high-quality care along with poorer health and worse health outcomes than the overall population. For example, the risk of developing diabetes is six times higher in some BME groups. COVID-19 has shone a spotlight on health inequalities that have existed for several decades. Comorbidities and socio-economic status are being put forward as possible explanations for the high number of people from BME backgrounds affected, but it is important not to assume that correlation equals causation. Discrimination and racism also play a part in factors driving health inequalities, as evidenced globally.

The government announced various reviews looking into the issue, including this investigation by PHE. The first part of the review was a descriptive look at surveillance data on the impact of COVID-19 on risk and outcomes and confirmed that the impact of COVID-19 has replicated existing health inequalities and, in some cases, exacerbated them further, particularly for some BAME groups. The Office of National Statistics (ONS) also found that the risk of death related to COVID-19 is significantly higher among some ethnic groups than it is for those of white ethnicity. NHS England and NHS Improvement are also leading work on the impact of COVID-19 on the BME workforce in the NHS.

Key findings

Literature review

The rapid literature review looked at four questions about whether BAME groups were more likely to be tested or diagnosed for COVID-19; whether they are at risk of developing other severe illnesses; the links to mortality; and social and structural determinants of health that impact these disparities.

The literature review found that those from BAME group are at increased risk of dying due to COVID-19, with those from Afro-Caribbean background at a higher risk as well as more likely to test positive for the virus.

The review flagged that health inequalities like using public transport and overcrowding housing may increase the risk of transmission in BAME communities in England, while health issues like diabetes and other comorbidities may increase the risk of dying from the disease. Lockdown measures introduced to mitigate the pandemic may have led to further widening on economic and housing instability in particular, and future policy should take these inequalities into account.

Stakeholder engagement

Over a four-week period, 17 stakeholder engagements events were held over Zoom, Skype or MS Teams, involving more than 4,000 individuals in total. Written feedback was also received, and all feedback was analysed with key themes identified.

A clear message from the stakeholders was that COVID-19 did not create the health inequalities that had arisen, but that the pandemic had exposed and exacerbated the long-standing inequalities that were in place in the UK.

The increased risk that some BAME communities were in due to their occupations, including being key workers, was another key feature of the feedback. Stakeholders recommended increased protection for these groups, including risk assessment and provision of adequate PPE, as well as creating an environment for these workers to express their concerns and feel valued.

The increased risk of complications and death from COVID-19 was another area that was flagged as part of the stakeholder engagement, and the pre-existing conditions that are more prevalent in some BAME groups. Strengthening and having targeted health improvement programmes to help with early diagnosis, having culturally appropriate care, as well as improving timely access to services, were identified as ways of addressing these issues in the future.

A root cause affecting health and exposure to risk was due to racism and discrimination experience by BAME communities and keyworkers in particular, according to the stakeholders involved in the engagement. Stigma associated with COVID-19 was also impacting whether to seek help from health services, as well as a feeling of fear of dying from the disease or, in particular, immigrants concerned about hostile environments and being trusting of professionals in case it impacted their immigration status.

Recommendations

The report sets out a number of actions and recommendations:

• Mandatory ethnicity data collection, including recording ethnicity data as part of death certificate, and undertaking research involving the community to understand the socio-economic impact.
• Improving the access, experience and outcomes for BAME communities of health services
• Ensuring risk assessments are culturally competent.
• Develop awareness, education and prevention and health promotion campaigns working with BAME communities to ensure that it meets the needs of these groups.
• Ensure that strategies focused on recovery in the aftermath of the COVID-19 pandemic take into account the wider determinants of health.

The full report can be found on the PHE website.

NHS Confederation viewpoint

This report provides further evidence of the disproportionate impact the virus is having on people from BME communities. There are several reasons behind this, as well as much we still do not know, but that must not detract from the need for decisive action. In particular, we have been calling for better data collection and for ethnicity data to be recoded on death certificates, and so we are glad to see these recommendations being put to the Equalities Minister.

As we emerge from pandemic there is a high likelihood that these inequalities will worsen and everything possible must be done to address both the immediate and longer-term issues.
The pandemic has led to a monumental backlog of screening activity, referrals, and scheduled operations, which again are likely to hit the most disadvantaged hardest.

The report also rightly recognises the critical role NHS organisations can play as major local institutions in tackling racial inequalities. Our members are clear there is work to do here across the health service, both to support staff more effectively and to reach out to communities to shape the services we offer and to engage patients in their care.

The prime minister has announced a cross-governmental commission to look at all aspects of racial inequality in the UK, including discrimination in the health system and that this review will report by the end of the calendar year. Our concern would be that any new commission to look at racial inequality would merely be delaying real action to bring about changes the need for which have already been identified, especially as there have been previous reviews in the past few years setting out recommendations for tackling race equality against which little progress has been made.

What we are doing to support our members

Through our NHS Employers arm, we have issued guidance for all NHS organisations on how to enhance their existing risk assessments, particularly for at-risk and vulnerable groups within their workforce. We will update this as further evidence comes to light.

We will be hosting the NHS Race and Health Observatory, which will aim to champion and lead the charge for a deeper understanding of the issues the report calls for, including greater use of community participatory research, as well as finding ways to tackle the specific health challenges facing people from BME backgrounds.

Our BME Leadership Network is playing a leading role developing and sharing practical actions NHS leaders and boards can take to support BME communities and staff. This includes publication of a briefing for leaders on the issue, which called for consideration to be given to make a change to death certificates so that ethnicity is recorded. In doing so, more accurate data can be collected to drive changes and improvement. The network has also submitted evidence to the Women and Equalities Select Committee inquiry looking at the impact of the pandemic on people with protected characteristics.

We will continue to support our members on this issue, including as part of the NHS Reset campaign. The campaign aims to contribute to the public debate on what the health and care system should look like post COVID-19.

It will support leaders to:

• Recognise both the sacrifice and achievements of the health and care sector’s response to COVID-19, including the major innovations that have been delivered at pace.
• Rebuild local service provision to meet the physical, mental, and social needs of communities affected by severe economic and social disruption.
• Reset our ambitions for what the health and care system of the future should look like, including its relationship with the public and public services.

Our themes for the campaign span a range of issues affecting how health and care services are planned, delivered and experienced across the UK. This includes looking at health inequalities and exploring how the health and care sector can help to address the geographic, socio-economic and socio-demographic inequalities exposed by the pandemic.

Find out more on our website and get involved in the campaign: www.nhsconfed.org/NHSReset