Race equality monitoring and diabetes

Lifestyle is a major factor in diabetes but does not completely explain why black and minority ethnic people are five times more likely to get the condition than the general population, and usually at a much younger age than their white peers. Nor does it explain why they are 50 per cent more likely to develop heart disease and kidney failure - two of the key consequences of diabetes - as a result.

Over 2 million people in the UK suffer diabetes, with a further three-quarters of a million unaware that they have the disease. And rates of type-2 diabetes, which comprise most cases, are set to climb, fuelled by the continuing surge in obesity and physical inactivity.

The Department of Health's Health Profiles for England showed that in the five years to 2003, rates rose to almost 5 per cent for men and to over 3.5 per cent for women. Reported UK cases are expected to top 3 million by 2010.

Genetic differences are thought to have a role. But so too do poor knowledge of available services, a reluctance to access them, language barriers and social deprivation. It is a complicated mix, which challenges traditional models of service delivery.

'People from BME communities often don't have a voice, or don't know how to use it to ask for services,' contends Jenne Dixit, equality and diversity manager for Diabetes UK. 'And if PCTs are not doing much about it, they won't get people asking. But we do need ethnicity monitoring. The diabetes figures don't currently include an ethnicity question. If they did, it would give PCTs a much wider understanding of the problem. The chances of people coming through the door are very low. By the time they do, most have already had their disease for nine to 15 years, with the longer-term problems that brings.'

Dearth of data

There is particularly poor ethnicity data in primary care and the incentive offered to GPs to collect it under the quality and outcomes framework is small.

In its guidance on effective commissioning, Race for Health stresses the importance of ethnicity monitoring to build up a profile of the local health needs of diverse communities. But a Healthcare Commission audit released last week found over 90 per cent of trusts are failing to publish evidence of any race equality scheme in compliance with the requirements of the Race Relations Act, in respect of either workforce or service user interests.

And the Commission for Racial Equality's final report in September concluded it will be impossible to improve the health of BME communities and promote race equality under the act unless the NHS systematically collects and analyses ethnicity data.

Diabetes UK has worked closely with trusts on race equality, and they are aware of the need to move away from a broad brush approach and provide culturally specific services, says Ms Dixit. 'But the reality is resources. We don't think that's justifiable. But it is particularly hard work, and some say they would rather not engage with it.'

But Professor Helen Hally, director of the PCT-led Race for Health Programme, which aims to improve health outcomes for BME communities, says trusts are wrong to think they have a choice.

'It's a challenge for all PCTs to tackle health inequalities, but unless they do, the gap actually widens,' she says. 'The internal tension is whether to provide different services or come at it in a different way.'

'Dealing with race equality is the only cost-effective way of providing services. It's getting it wrong that's expensive,' she adds, citing the prevalence of healthcare-associated infections as an example.

Get serious

But there is a tendency not to take diabetes very seriously, she suggests. And in case trusts are left in any doubt about their responsibilities, she warns: 'Narrowing health inequalities is now one of the top six priorities for the NHS, and [NHS chief executive] David Nicholson is pushing hard for key performance indicators for inequalities. This isn't optional.

'We neglect these groups at our peril, because of the impact [diabetes] has on the community as well as the individual,' concurs Viki Wadd, assistant director for the Slough Locality, and patient and public involvement lead at Berkshire East PCT.

'Prevention has to be done at a very local level. Word of mouth is the best way of getting information across, with written material as a useful back-up. It's much better accepted.'

Outreach activities include a mobile service offering spot checks on glucose levels. In its first week, 486 took advantage of the facility.

'Health activists,' drawn from local BME communities, and trained to NVQ level, spread culturally appropriate health messages on diet and exercise in various local venues, and work with the diabetes nurse specialist in mosques and temples.

'The amount of confidence it has given to the activists is incredible,' says Ms Wadd, adding that some have used their experience to move on to full-time jobs. Health issues have come to light that would not have been raised with healthcare professionals, she says.

At Bradford and Airedale teaching PCT, tailored approaches include taking patients shopping to help them understand the implications of food choices, screening at community centres, and health MOTs at barber shops.

The trust has also run adverts during Ramadan on local radio on various health issues, including diabetes, and links across to its Walking for Health programme.

Trust equality and diversity deputy director Ali Jan Haider says: 'We need to make race equality everyone's business and stitch it into quality outcomes. When a chief executive simply says diabetes is important and should be part of policy, nothing happens.

'It can be difficult for staff, because this challenges the status quo, and people can feel they are not good enough. But the key is to look at what's working well and then what can be improved.'

HSJ's Achieving Race Equality in the NHS conference is in London on 6 December. Visit www.hsj-raceequality.co.uk for details