How can lessons from covid help build a more inclusive health and care system?

The covid pandemic laid bare and exacerbated inequalities that already existed – but has also provided some lessons for the future.

That was the key message from a group of experts who took part in an HSJ webinar, held in association with Cerner, to discuss how best to build a more inclusive health and care service.

For clinical leader Karen Kirkham, covid shone a light on existing inequalities, both at a local and national level. Now a partner and chief medical officer at Deloitte UK, she spent most of the pandemic as STP clinical lead at Dorset CCG, which gave her a first-hand experience of the impact of inequalities on the ground.

“For me, it’s just highlighted that the cracks were deeper and broader,” she said. “All of these things that we’ve probably known for years but have not been able to address meaningfully either as a local system or from a national point of view.”

Although it has affluent areas, Dorset has many deprived communities, where traditionally people have had late diagnoses, less access to elective care and prevention, and tend to end up with more emergency admissions, Dr Kirkham, who is a GP, added. Rural areas, with a lack of transport, were also affected, and the impact of digital illiteracy was also highlighted as a key issue as so many services went online.

“This is something we absolutely need to address as we’re starting to work in different ways,” she continued.

One of the lessons from the pandemic is that data is absolutely essential to decision-making, said Dr Kirkham. This includes using data to make sure services reach all groups, for example, getting immunisation to homeless people, but also in prevention efforts. These lessons will be carried forward into the development of integrated care systems providing place-based care, she added. “The important thing is that it takes a population health managed approach, looking at the data to make intelligent decisions to drive care in a different way.”

The experience was much the same in the acute sector. Professor Kiran Patel, chief medical officer and consultant cardiologist at University Hospitals Coventry and Warwickshire Trust, said it was clear very quickly that covid was exposing inequalities and would potentially make them worse. “In the post-covid era, we run a real risk of inequalities widening as we speak,” he said.

His trust made a decision last year not to stop elective care, which meant that it has a less significant backlog of care than some others, but other factors have also affected current demand. “What we saw during the pandemic, very early on, was a behaviour change when we told people to protect the NHS. People did acknowledge that and stay at home. So certainly in cardiology we saw a lot of late presentation of disease.”

That’s just on the acute side, he added. “On the elective front, of course people didn’t even seek treatment, and that’s one of the reasons why we have a significant backlog of care emerging.”

The health service is “littered” with reports on health inequalities, said Prof Patel, and he has no doubt that there will be another one along soon, telling us the same things. “As well as knowing what we need to do, we need to actually start doing things to reduce inequality. And we know there is a strong evidence base that having waiting lists exacerbates inequalities.”

His trust has developed a tool that clinically prioritises people to reduce inequalities by weighting them according to factors such as deprivation, ethnicity or co-morbidities. They have also introduced a process called active waiting, where people on a waiting list are referred for treatment for issues such as hypertension, diabetes or smoking. “We don’t get paid for it, but it’s a professional obligation,” he stressed. “We know that as a provider of healthcare, if we don’t address prevention, we will actually contribute to health inequalities.”

What covid has done, he said, is accelerate digital transformation, which can be used to help tackle inequalities – although it’s also important to guard against “digital impoverishment”. “As well as providing digital access, we need to make sure we provide alternatives to those populations who are prone to inequalities.”

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