Globalisation poses challenges for the NHS as it copes with rising demands and the needs of a diverse community, writes David Stout

Serving a population that is increasingly diverse and subject to global influences poses real challenges for NHS leaders. A recent NHS Confederation debate paper, How Will Globalisation Affect the NHS?, explored these challenges in depth. Chiefly, the paper considered the impact of rising public expectations as information on global healthcare systems becomes increasingly accessible, as well as the effect of ethnic and cultural diversity in the UK and what it means for commissioners and providers.

As chief executive of Newham primary care trust from 2001-07, I experienced first hand the challenges of serving a diverse community. Newham, in inner city east London, is one of the most ethnically diverse PCTs in the country, with 61 per cent of the population drawn from mixed, Asian or Asian British, black or black British, Chinese or other ethnic groups. The black and minority ethnic population in Newham is itself very diverse, with people from all over the world - aggregating and averaging does not work with this level of diversity.

In this situation, ascertaining the make-up and varying needs of the local population is essential in order to design services that meet patients' differing needs and expectations.

Recent evidence suggests the NHS could do more to overcome the challenges brought about by diversity. The national GP patient survey conducted in January 2007 found that satisfaction with access to primary care services was lower for certain minority ethnic groups than for white British patients. For example, while 88 per cent of white British patients surveyed were satisfied with access to their practice by telephone, only 67 per cent of Bangladeshi patients felt the same.

A review team, set up to investigate the survey findings and led by former Royal College of GPs chair Mayur Lakhani, concluded last month that dissatisfaction stems from the mismatch between the health needs and requirements of BME people and the services on offer. Other patient surveys by the Healthcare Commission show a similar pattern, with lower satisfaction in BME communities with other parts of the healthcare system.

Language barrier

Part of the problem lies in barriers to access. The most obvious of these is language, but harder to define and overcome are cultural barriers. An NHS Confederation report on health inequalities, In Sickness and in Health, highlighted these issues through a case study on accessing GP surgeries in Tower Hamlets.

Research into high levels of inappropriate hospital visits found that the largest ethnic group misusing accident and emergency departments was Bangladeshis aged 20-30. For some of these patients, the problem was language because they could not understand where to go and when. For others there were specific cultural issues: some patients believed they would get better treatment at the hospital.

One option is to provide extra or different kinds of services to ensure all parts of the population have equal access to services. With historically high levels of migration in Newham, this was something that could be planned for. In rural areas experiencing high increases in BME population for the first time, this is perhaps more difficult. Without prior investment in advocacy and translation, for example, commissioners must work hard to minimise cultural misunderstanding and dissatisfaction.

By removing some of the most tangible barriers to access, interpreters and patient advocates can help patients make informed choices about their care. In my experience, however, the process of translation often goes beyond the linguistic into the cultural. For instance, the smoking cessation campaign in Newham focused on finding a point of assimilation. With the highest rates of smoking in the area among Pakistani and Bangladeshi men, the PCT worked to provide an Islamic perspective on both tobacco and abstention by linking the cessation campaign with Ramadan. This saw local NHS services becoming more culturally relevant. The challenge is not how to engage hard-to-reach groups; it is how to make it easier for patients with diverse needs and expectations to access the NHS.

Not only do different communities have different expectations of the NHS, but they also have different health needs. There are consistent findings of a higher incidence of some conditions in some BME groups. Both health services and promotion need to be suitably targeted. For example, Leicester City PCT has employed peer educators to promote awareness of heart disease among the local South Asian population, to help address the high rates of heart disease in this group.

Personalised care

As the NHS becomes a more personalised service, it should be increasingly equipped to cater to different sections of society. Many of the challenges the service faces in meeting the needs and expectations of diverse groups are the same as those faced more generally by the NHS in delivering personalised care. In Newham, tailoring services to the local community means not only accounting for ethnic diversity, but also a very young age structure and high deprivation levels.

Primary care trusts will need to rise to the challenge of assessing and meeting local need in increasingly sophisticated ways. The competencies of world class commissioning summarise what is needed. PCTs are expected to work with community partners, to engage patients and the public and to manage knowledge and assess needs. They also need to proactively seek the views of patients least able to act as advocates for themselves. As leaders of health in their communities, PCTs should have the information available to be culturally competent and responsive.

Ethnic diversity is a microcosm of diversity in a broader sense. Commissioning and providing healthcare that is appropriate to an individual's ethnic and cultural background is part of an overarching drive to provide flexible, personalised health services, which patients are able to influence and understand.