Health Inequalities Q&A
The following are some suggestions by the RCGP`s Health Inequalities Group on actions we can take as GPs in order to promote health equity and reduce some of the impact of health inequalities during the COVID-19 pandemic.
With thanks to the contributors: Gemma Ashwell, Lucy Chiddick, Gilles De Wildt, Katy Hetherington, Patrick Hutt, Catriona Morton, Anne Mullin, Rachel Steen, Andrea Williamson.
Editorial team: Simon Gregory, Carey Lunan, James Matheson, Victoria Tzortziou Brown.
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This wide-ranging interview explores many areas relating to health inequalities, particularly within the context of the COVID-19 pandemic and focuses on the critical role that GPs and RCGP can play in mitigating the worst effects of health inequalities for our patients.
Everyone matters equally, this is fairness. Population groups at very high risk of COVID-19 are being identified and advised to self-isolate. Primary care has been asked to identify and contact vulnerable people in their practice populations to check on them and provide COVID-19 related advice. Primary care teams may be aware of people who will be vulnerable for social reasons including marginalised and excluded groups who may not be within already defined high-risk groups but may still need extra support. It is important to consider the needs of these groups and to avoid excluding them.
Writing about healthcare for homeless people, the King's Fund encouraged services to find and engage vulnerable people and go above and beyond existing service limitations. (https://www.kingsfund.org.uk/publications/delivering-health-care-people-sleep-rough). This accords with the principle of flexibility.
Clinicians should consider creating a list of those deemed most socially vulnerable - people with severe mental health issues, the increasing homeless population, people living in poverty or driven into it by COVID-19's economic effects, those with substance dependence, those at risk of abuse and with safeguarding needs- and contacting them to give them advice and let them know how to access care and support as services narrow their focus.
Guidance on services for people experiencing rough sleeping is now available on the gov.uk website, recommending reduction measures for transmission of the virus within temporary/emergency accommodation venues. Prior to this, this group of people who developed a cough were being denied access to some night shelters and other facilities.
People who are experiencing homelessness have the lowest life expectancy, which also means the greatest potential gain from interventions. Housing and appropriate support are probably the most effective interventions. This group of people have no ability to stockpile. Their day to day survival depends upon being mobile and sociable to obtain money, food and shelter. They have little ability to self-isolate. As such, they have been identified as significant vectors for disease spread. Some areas have helped large numbers of people experiencing homelessness into hotel accommodation. The government has made available funding to support this. It would be important that such efforts continue after this specific public health crisis passes.
People become homeless for many reasons but there are common themes of multi-morbidity, social vulnerability and often addiction. People still have these problems in a hotel room. For many, now in accommodation, the move has been a major dislocation geographically, socially and from services. Needs should be assessed urgently, and services assembled around people to meet these needs. Services cannot rely on people with chaotic lives to come to them. Practices and those who commission services with people who are newly accommodated (previously homeless) should rapidly identify what the needs are and how these will be met.
From a GP perspective, it is important to be reminded that people do not need proof of address to register with a GP. Relevant information for practices and the Safe Surgeries Toolkit can be found at: https://www.doctorsoftheworld.org.uk/what-we-stand-for/supporting-medics/safe-surgeries-initiative/safe-surgeries-toolkit/#
Dr. Al Story, Clinical Lead and Manager for Find&Treat and Professor Andrew Hayward, Professor of Infectious Disease Epidemiology and Inclusion Health Research, University College Hospitals NHS Foundation Trust give a briefing on the implications of Coronavirus for homeless populations at Pathways from Homelessness 2020.
A large proportion of GP consultations are about mental health issues. People with severe mental health conditions are known to have poorer physical health outcomes. They are also at higher risk of loneliness and social isolation. In deprived areas, mental health problems are more prevalent.
Many practices have replaced their routine appointments with on-the-day urgent access slots. There is therefore a risk that people with mental health issues are only assessed at times of crisis. The pandemic and its consequences may result in a marked worsening of mental health conditions. There are several resources on the management of mental health and well-being during social isolation measures, but these mostly focus on the effects on the previously well population and not on those with pre-existing mental health conditions.
Whilst prioritisation of urgent cases is important, space must be made for reviewing the mental health of those at risk of deterioration, before any crisis presentation. Some practices are creating a greater number of shorter counselling slots, delivered by phone or video, to cater for the predicted increased demand for advice. Other practices are making short videos with anxiety management techniques that patients can watch on the practice`s website.
Where, previously, the offer of online CBT or the use of an App might have seemed like we weren’t taking the problem seriously, with other options reduced, this now has more credibility and a better chance of acceptance. Try it. Not everyone has the internet or can use it but our patients remain resourceful – ask them what they are doing to keep their mind healthy and encourage and support it. Gather support around them – consider how their family and friends may be able to help. Plan for both crisis aversion and for the crisis.
Caution will be needed when prescribing medication for anxiety, panic attacks and insomnia during the pandemic. It may be tempting to think of lockdown as a short interval of identifiable stress that will pass and this may result in overprescribing of dependency-forming medications. We need to be mindful of the harmful consequences of these down the line and consider alternative ways of supporting people.
The following link provides some guidance on mental health and wellbeing during the pandemic: https://www.gov.uk/government/publications/covid-19-guidance-for-the-public-on-mental-health-and-wellbeing
COVID-19 is already affecting the availability of illicit drugs because of border and travel restrictions which are limiting the import of supplies and because of the inability of distributors to travel and dealers to dispense drugs. This means that the availability of drugs to substance users will be increasingly limited.
Past drug famines give us some clues as to what to expect. When drugs are in short supply, quality tends to reduce with increased cutting, sometimes with other dangerous psychoactive substances. This can markedly increase harm and emergency presentations. When the amount of substance in a quantity reduces people may increase the amount they take to compensate, and this can increase the risk of overdose. We may also see increasing numbers of people presenting to GPs and specialist services for support coming off drugs or looking for opioid substitution therapy (OST).
Substance-users are at high risk from respiratory infections (although we do not have specific data on COVID-19 yet). The risk is higher for those who smoke cigarettes and/or smoke drugs.
Due to a driving necessity to secure drugs and the means to pay for them substance users are also identified as high risk for spreading the virus. Third sector drug and alcohol services may lack capacity to respond to increases in demand during the COVID-19 crisis. Shortfalls in services, including wider services like needle exchange programmes, will present a risk to individuals and to society.
As part of working together, GPs are encouraged to communicate and coordinate with their local substance use services to meet the needs of this highly vulnerable population. You could also consider about getting skilled up in substance misuse so that you can prescribe under the guidance of community drug services.
Scottish Drugs Forum Guidance on contingency planning for people who use drugs and COVID-19 http://www.sdf.org.uk/covid-19-guidance/
As social-distancing and isolation measures become more stringent, the number of reports of domestic violence and calls to Childline can rise.
The by-product of social-distancing outdoors is social proximity indoors, which can increase pressure on all relationships but especially those which are already compromised or fragile. Increased anxiety, outright fear and, for many, inadequate and unhealthy housing can create a high-risk environment for anger and violence to break out. For some children, school is the safe place away from what happens at home and this safety netting has been withdrawn for most children now (apart from those already identified as vulnerable who receive support from social care). For victims of domestic abuse, the loss of social contact can mean the loss of support and the safety of witnesses.
In primary care, we remain a first point of contact for many of our patients. When talking about other issues, we need to be aware of the above. It may be worth enquiring about the situation at home under the pressures of isolation measures and exploring the reasons for anxiety, depression, injuries or unusual behaviour in people of all ages, in order to minimise the indirect harms of the pandemic.
We need to work closely with social services and for those households that don’t meet the criteria for referral or intervention but are still generating concern, we could consider creating a watchlist and remain in supportive contact with patients until the concern has passed.
Family Lives – coping practically and emotionally during the COVID outbreak (managing conflict, working from home, structuring the day, advice for people with SEN or disability, bereavement): https://www.familylives.org.uk/advice/your-family/family-life/coping-practically-and-emotionally-during-the-covid-19-outbreak/
As part of working together, GPs are encouraged to communicate and coordinate with their local substance use services to meet the needs of this highly vulnerable population.
Gypsies and Travellers, as a group, have the worst health outcomes in the nation after street homeless people. They also shoulder a huge burden of stigma and prejudice associated with their lifestyle. Research has unveiled that this prejudice is widespread in many settings and primary care is not excluded as barriers to GP registration have been reported.
This is another group of people who frequently have a high burden of (often undiagnosed) chronic health conditions, at high risk of COVID-19, with limited ability to self-isolate due to the proximity and social support structure of their families and communities.
For CCGs with traveller sites in their areas, COVID-19 response planning must include engagement with Gypsies and Travellers in order to minimise the harm of the pandemic. Good, shared decision-making rather than imposition, will be vital to the success of such planning. For GP practices, allowing and, indeed, encouraging Gypsies and Travellers to register, even if only as temporary patients can also be very helpful.
Travelling to Better Health – Welsh government guidance on working effectively with Travellers: https://gov.wales/sites/default/files/publications/2019-04/travelling-to-better-health.pdf
Coronavirus: framework to support gypsy/traveller communities – Scottish government guidance https://www.gov.scot/publications/coronavirus-covid-19-supporting-gypsy-traveller-communities/
The health and wellbeing of children during the COVID-19 crisis has received much less attention than other areas. This is probably because the experience of other countries tells us that children, if symptomatic, are likely to have mild disease, are less likely to be hospitalised and highly unlikely to die from Corona virus.
Children, however, can be vulnerable to the indirect and social consequences of COVID-19 and the pandemic response. Calls to Childline are increasing, as are reports of abuse. Social distancing and isolation measures can reduce access to protective safeguards whilst restricting children in often pressured home environments. As child poverty is growing, with an estimated 1.1 million more children expected to be living in poverty by 2022, many children are reliant on free school meals to eat. Some schools are working hard to replace this service, but others haven’t been able to do so. Food insecurity is a problem that can be worsened by COVID-19 if donations to foodbanks plummet and a coordinated effort to address the problem is needed
Primary care teams should be particularly mindful of children, who will become a less visible part of the population during social distancing and isolation. Childhood immunisations are key services for the prevention of multiple communicable disease outbreaks in the future or concurrently with COVID-19. Safeguarding is probably more important than ever, and practices could consider creating supportive watchlists of families where there are concerns if those concerns do not meet the threshold for social services referral or intervention. Coordination with local social prescribing schemes and local authority interventions and working together with community group and foodbanks can help to ensure that patients have access to food and, in particular, children are not victims to the pandemic’s socioeconomic sequelae.
Young Minds’ guidance to looking after your mental health whilst isolating: https://youngminds.org.uk/blog/looking-after-your-mental-health-while-self-isolating/
Barnardo`s How to talk to your child about Coronavirus https://www.barnardos.org.uk/blog/how-talk-your-child-about-coronavirus
Parent Club – everything you need to know about Corona virus – tailored to age groups: https://www.parentclub.scot/
Local Government advice from Scotland on speaking to children about the virus: https://www.cosla.gov.uk/covid19-advice-supporting-children-and-young-people
Refugees and asylum seekers are another group who are at risk from getting infected and spreading COVID-19. This population is likely to be in social situations which increase its vulnerability and exposure to the disease and may have chronic, often undiagnosed, health conditions which increase the risks from the disease.
Because of the barriers in accessing care, either because of the difficulties understanding and navigating a new system or because of fear of financial penalties, refugees and asylum seekers may not get the healthcare advice and treatments they need.
The work done by Doctors of the World, both through the Safe Surgeries Toolkit and by translating relevant COVID-19 information for patients in 34 languages, can help GP practices improve access to care for this population.
NRPF Network’s advice on supporting people with no recourse to public funds during COVID: http://www.nrpfnetwork.org.uk/Documents/coronavirus-factsheet.pdf
Many people turn to substances such as alcohol at a time of stress. Off-licences were added to the Government's list of UK retailers allowed to stay open during the coronavirus pandemic and there are reports that alcohol sales have increased recently.
But alcohol will not help to manage the stress of self-isolation and it can be an unhelpful coping strategy. It is important that people are aware of the risks and how to calculate alcohol units https://www.nhs.uk/live-well/alcohol-support/calculating-alcohol-units/. We need to signpost people to healthy coping strategies during the pandemic including eating healthily, exercise, and ensuring they get enough sleep and social support. https://www.mind.org.uk/information-support/coronavirus/coronavirus-and-your-wellbeing/#collapsedc006 Also, to combat feelings of anxiety, it may be helpful to stay off social media sites or limit the amount of time spent watching the news each day. Being proactive about maintaining mental health can help reduce triggers.
We should also be supporting people with pre-existing alcohol addiction as they may find the pandemic period even more challenging. Anxiety and loneliness can exacerbate problematic drinking while restricted access to alcohol, may lead to symptoms of alcohol withdrawal. Unplanned detoxes can be deadly. However, we could assist people to cut down on alcohol consumption through the local addictions services and by signposting them to online help where people can find helpful resources, access peer support and attend meetings online.
Advice from Alcohol Change: https://alcoholchange.org.uk/blog/2020/coronavirus-top-tips-on-alcohol-and-mental-health
Online resources for alcohol addiction recovery during the coronavirus https://ahauk.org/recovery-during-coronavirus/
South London and Maudsley NHS Trust’s advice on harm reduction for alcohol dependence: https://mcusercontent.com/c4876cb152fa1983ef265ad1b/files/b9b3f977-7403-4042-8cb7-d04c51b01404/Alcohol_harmminimisation_18032020.pdf?mc_cid=71866880b8&mc_eid=137e254eb9
Scottish Health Action on Alcohol Problems’ advice for heavy drinkers: file:///C:/Users/jidmm/Downloads/COVID%20Advice%20for%20heavy%20drinkers_26%2003%2020.pdf
Emerging evidence from China shows smokers with COVID-19 are 14 times more likely to develop severe respiratory disease. Smokers are more vulnerable to infectious diseases and studies have shown that smokers are twice more likely than non-smokers to contract influenza and have more severe symptoms, while smokers were also noted to have higher mortality in the previous MERS-CoV outbreak. Therefore, the current pandemic offers a good opportunity for initiating conversations on smoking cessation.
Have that conversation, use local support services if available, issue scripts and encourage people to quit. There are also many online resources and the Smokefree app which can help patients stop smoking by providing daily support and motivation. If people stay smoke free for the 4-week programme they are up to 5 times more likely to quit for good.
Loneliness was already prevalent before the social distancing rules were applied but can be made worse during the period of lockdown.
A 2017 systematic review of 40 studies from 1950 to 2016 published in the journal Public Health (https://www.researchgate.net/publication/319687009_An_overview_of_systematic_reviews_on_the_public_health_consequences_of_social_isolation_and_loneliness ) found a significant association between social isolation and loneliness and poorer mental health outcomes as well as all-cause mortality.
This is an important time to consider those that may be lonely. There are strategies that people can employ to ensure their well-being and good mental health. Most of these involve either finding ways to distract themselves (keep busy) or finding ways to connect with others (despite the circumstances). Keeping to a regular schedule as much as possible, being physically active and connecting with family and friends via online means can help.
There are useful online resources you could direct people to:
Autistic adults and people with learning disabilities are likely to find the coronavirus outbreak, the restrictions placed on daily living, and the changes to how their support is delivered, particularly confusing, worrying and in some situations distressing.
Good communication is important. GPs may need to use diﬀerent communication methods depending on patients` preferences such as emails, visual aids, and assistive and digital technologies. Communication should cover one matter at a time to avoid confusion and should be devoid of jargon.
Be aware of the increased prevalence of safeguarding issues and the increased risk of exploitation and abuse, grooming, being drawn into ‘gangs’, and neglect.
One of the ethical principles mentioned above is that everyone matters equally. The provision of care should be based on clinical need and the ability to benefit and any clinical decisions should not discriminate. GPs have an important role in communicating with and advocating for autistic people and people with learning disability during the coronavirus outbreak.
Alert card for autistic adults: https://www.basw.co.uk/media/news/2020/apr/alert-cards-autistic-adults-and-adults-health-needs
Talking Mat resource for communicating with people with SEN about Corona virus: https://www.talkingmats.com/wp-content/uploads/2013/09/20200319-coronavirus-easy-read-pdf.pdf
Learning Knows No Bounds is a Facebook page for families with special education needs: https://www.facebook.com/learningfromhomeuk/
Perhaps but, of course, it shouldn’t be. Whilst providing a service for everyone, we should always allocate the most resources towards the greatest need. The Strategic Review of Health Inequalities in England introduced the concept of ‘proportionate universalism’ (https://www.parliament.uk/documents/fair-society-healthy-lives-full-report.pdf) , suggesting that health actions must be universal, not targeted, but with a scale and intensity that is proportionate to the level of disadvantage.
General practice has a very important role to play during the COVID-19 pandemic, saving many lives by providing high quality, compassionate primary care to those who need it.
COVID-19 has already caused much suffering and hardship for our practice populations and the communities we serve, and we will be dealing with the sequelae including the consequences of the disease, trauma, bereavement and healthcare service interruption long into the future.
However, good has also come of this crisis. We are seeing governments support people in an unprecedented manner. We have seen rapid and momentous change in how vulnerable groups of people are treated. Society has recognised “key worker” roles – often the lowest paid and most insecure of jobs - as the ones which keep society going and demonstrates this publicly.
We have seen the rebirth of community. People have volunteered in staggering numbers and, throughout society, people have started looking out for and helping others. We need to encourage more to do so:
https://www.hscworkforceappeal.co.uk/ (Northern Ireland)
Important change has happened already and now we have an opportunity to ensure that this positive change endures.