Dr Melrose Stewart writes that the NHS long-term plan is far from revolutionary when it comes to addressing healthcare inequalities
When evaluating a “new” initiative such as the NHS long-term plan, it is natural to ask what is in it for the constituencies of which one is a member or have extensive direct involvement with.
As a chartered physiotherapist, past NHS employee, now university lecturer, and one of the Windrush generation resident in England since 1965, I was unsure what to expect from reading this plan. I should be heartened reading promises that will, if fulfilled, benefit black and minority ethnic communities. So why am I feeling underwhelmed?
The NHSLTP must be put in historical context. When one does that, it becomes evident that it is far from revolutionary (and risks being another exercise in unfulfilled expectations). I can illustrate this by highlighting some of its implications for BAME communities.
In the past, numerous policies and NHS plans have emphasised health inequalities disadvantaging such communities and health conditions that affect them disproportionately, such as cardiovascular disease and diabetes.
For example, the NHS Plan: a plan for investment: a plan for reform (DH, 2000) identified the need for improved integrated care for different groups, personal choice, being responsive to different needs of different populations, strengthening partnership and service integration, and for delivering on target and on time. The NHSLTP offers something similar.
In the past, numerous policies and NHS plans have emphasised health inequalities disadvantaging such communities and health conditions that affect them disproportionately, such as cardiovascular disease and diabetes
Likewise, the NHSLTP continues the standard rhetoric of better education and nutrition. It tells us that expanding the Diabetes Prevention Programme will be a key vehicle for tackling health inequalities. This programme could certainly have a significantly higher take up from BAME groups than the general population due to the disproportionate extent to which diabetes affects BAME groups.
Additionally, supporting local health systems to address inequality of access to multidisciplinary foot care teams, and providing specialist nursing support for preventing a greater number of amputations and other diabetic complications, for weight management and nutrition training, could all make a difference. I have treated numerous individuals who had lost multiple limbs through poor control of their diabetes and cardiovascular disease.
Ineffective communication across healthcare teams and health sectors has plagued effective management of individuals and community health in this and other areas. Thus, as a black healthcare professional, these areas in the plan should particularly interest me, especially when the declining health in BAME communities is well documented.
Nevertheless, I feel sceptical about the likely fulfilment of the NHSLTP aims here. Ultimately, my scepticism is due to a concern that we have been here before with NHS plans that willed ends without willing the means to achieve them.
Nearly 15 years ago, The NHS Improvement plan – Putting People at the Heart of Public Services (DH, 2004) – contained similar aspirations to the NHSLTP’s for the treatment of people with diabetes and coronary heart disease, among other long term conditions. Community and primary care providers in local settings were to be supplied with more specialist services.
What appears to be different now is that the NHSLTP has identified more fully integrated community based healthcare supported through the ongoing training and development of multidisciplinary teams in primary and community hubs.
Furthermore, implementation and development of higher intensity care models for stroke rehabilitation might mean the BAME groups that are disproportionally affected by strokes could see an upturn in the effectiveness of the service they receive.
More focus in expanding the role of allied health professionals, increasing their numbers and skill mix and making physiotherapists first contact practitioners have been promised.
Development of these hubs does have the potential to be a game changer in addressing inequalities in health and rehabilitation at a local level, but only if they are resourced and managed appropriately. Otherwise, they will suffer the fate of previous promises.
The pledge to give local community groups control over their own health is not new. Tackling Health Inequalities - A Programme for Action (DH, 2003) promised similar targets, for eg “engaging communities and individuals to ensure relevance, responsiveness and sustainability”. Buy-in from BAME communities certainly will be needed to effectuate the NHSLTP.
The extent to which hubs understand the health needs of their population and more importantly, how they share their aims, maintain dialogue and disseminate results and outcomes as they happen will be significant for its fulfilment. Over recent years, Local Health Needs Assessment for BAME communities have been put in place alongside action plans.
One of the triggers for this has been the Race Relations (Amendment) Act 2000, which placed a statutory duty on NHS organisations to promote race equality. However, the form of this “promotion of race equality”, without any objective benchmarks, offered organisations flexibility in its interpretation and rarely is evidence seen of any variations being held up to scrutiny or penalties applied for non-compliance.
Without robust ethnic monitoring, evaluation and reporting systems to demonstrate outcomes, I fear that little will change. Historically, plans and assessments have often been put in place but without transparent evaluations thereafter.
I believe that the capacity of BAME practitioners within the health and care sectors to assist in the health improvement of BAME communities has been underutilised
Dissemination of the outcomes of reviews is critical for maintaining trust and for keeping communities interested and engaged in guided action to improve and maintain local health plans. The NHSLTP promises to introduce more accurate assessment of need for community health and mental health services from April 2019. Local health systems will be expected to set these out during 2019.
But didn’t the Tackling Health Inequalities Cross Cutting Review, a long term strategy to reduce health inequalities (DH, 2002), set out to do similar? And didn’t it aspire to empower local communities to address the health inequalities in their areas, working in partnership with all agencies with a role to play locally?
And what of Tackling Health Inequalities – A Programme for Action, the first national health inequalities strategy, which set out plans to tackle health inequalities over the next three years (DH, 2003), Race for Health (2007) and The Equality Strategy – Building a Fairer Britain (DH, 2010)? Didn’t they all signal similar messages of decreasing inequalities and thereby improving BAME health? The list goes on.
I believe that the capacity of BAME practitioners within the health and care sectors to assist in the health improvement of BAME communities has been underutilised. I could not help but experience a wry smile when I read the statement that “The NHS draws on a remarkably rich diversity of people to provide care to our patients. But we fall short in valuing their contributions and ensuring fair treatment and respect.”
Roll back the clock to the days of “valuing diversity” and you might understand where I am coming from. Attempts to improve the number of BAME staff in senior roles and to improve staff retention on a significant scale are also part of the plan.
Will these continue to be historically elusive goals? I hope that I will be alive in five years’ time to experience the full effects of this promised plan, a more effective NHS, greater equity in care and improved access to healthcare for disadvantaged groups.
However, I cannot help but look back over recent decades and the promised changes announced in previous NHS plans. They continue to exist as reminders of goodwill and intent, but hope unfulfilled. Will this plan share the same fate?