Health inequalities are felt most directly by individuals and communities, but they also place a considerable burden on our health service.
This toolkit forms the major part of Sir Harry Burns' President's Project, for which he has picked the topic of how we can work together to reduce health inequalities. To inform the toolkit, we asked clinicians across the UK to tell us about initiatives they have seen or taken part in in their local areas, which have helped tackle such inequalities.
This toolkit is intended to support clinicians and medical students working across the UK, not to lay the responsibility for reducing health inequalities at their feet. Neither is it intended as a replacement for our campaigning at the BMA to ensure UK governments meet their responsibilities to reduce health inequalities.
Doctors are close to the problem of health inequalities and see it in their work every day. The stories of projects we have collected in this toolkit are to give colleagues ideas to try should they wish to act themselves.
We are keen to keep the toolkit as relevant and as useful as possible. If you are involved in a project that seeks to address health inequalities that you would like to share with colleagues, please email [email protected] to request a submission form.
It is incredibly difficult for clinicians like me to see in our patients the human cost of worsening health inequalities. The government must provide the resources to allow the health service the time and space to observe and intervene. Meanwhile, this toolkit will make it easier for doctors to take action. Together, we can make a difference.Dr Krishna Kasaraneni, NHS GP in Sheffield
How to use this toolkit
This toolkit follows a tiered approach:
- projects in Tier 1 will require action that is the least time or resource intensive
- projects in Tier 2 will require action that is somewhat time or resource intensive
- projects in Tier 3 will require action that is the most time or resource intensive.
Please note, the tier system does not denote quality or value. We believe that all the projects outlined in this toolkit are of enormous value and are tiered only because we recognise every clinician will have varying levels of time, resources, and energy to devote to the collective goal of reducing health inequalities.
Some of the determinants of inequality this toolkit might help you address first are:
- health education
- substance abuse
- income insecurity
- experience of the criminal justice system
- access to healthcare.
Wherever you work and whatever your specialty, I hope this toolkit will help support you in any work looking to address health inequalities affecting your patients and communities.Sir Harry Burns, BMA President 2020-21
Tier 1 projects
The following projects require the least amount of time and/or resources. Where possible, we have included case studies to illustrate how others are carrying out this type of work.
Campaigning on health inequalities
Advocating on behalf of those patients whose lives have been blighted by health inequalities is an important part of what the BMA does. Our efforts, and the efforts of all those organisations campaigning for the reduction of health inequity, are strengthened by the voices of the clinicians we represent. The personal stories of doctors and their patients provide the much-needed human side of what can sometimes feel like an abstract issue.
How to campaign
Writing to your MP/assembly representative on the issue of health inequalities in your local area can be an impactful tool to raise this key issue of importance to you with your representative in the UK Parliament or devolved nation assembly.
Finding out who your MP or assembly representative is, and their details, is simple.
- For your UK Parliament representative, enter your postcode into this website.
- For your Welsh Senedd representative, enter your postcode into this website.
- For your Scottish Parliament representative, enter your postcode into this website.
- For your Northern Ireland Assembly representative, enter your postcode into this website.
In your letter be sure to explain the problem, evidence it with stats or stories and include key asks you would like your member of parliament/assembly to do – this could be raising the issue with their respective Health Minister or asking a question in Parliament. Additionally, ensure that you specify in your email that you are getting in touch in your personal capacity, rather than on behalf of the BMA.
Another way to get in touch with your elected representative can be via Twitter.
If you have an account, simply type their name into the twitter search bar to find their handle.
Once on their profile, click the blue ‘compose tweet’ button, type what you would like to say, and press send.
Don’t forget to let them know you’re contacting them as their constituent.
If you’d like to raise an issue with the press, you can write a letter to the editor of your local newspaper. These are often read by local decision makers.
Be sure to keep the letters short and snappy.
Share infographics and posters you've created across social media or print and put them up around the workplace.
Twitter, Instagram and Facebook are the key channels to share these, alongside any WhatsApp groups you’re in.
- Organise a small petition amongst colleagues and friends.
- Collate first-hand stories to share with local decision makers. Make sure you’ve asked permission from people to be able to use their experiences in your campaigning work.
- Team up with other local groups campaigning on the same issue.
Use of educational resources for health professionals
When patients who have been historically marginalised from health services feel their unique life experiences are listened to by health professionals, they are more likely to engage, and their chances of a healthy life improved. LGBTQ+ groups, homeless people, and immigrant communities are all examples of populations for whom mainstream health services have not always served well enough. It is vital to provide staff with the knowledge, skills, and confidence to understand vulnerable patients, and how health inequalities can manifest differently in patients.
Information available to us about population health and how people relate to health services is constantly improving. However, training is time consuming and may not always be realistic for understaffed practices and overworked teams of health professionals and support staff. The promotion of educational materials amongst staff can be a less time intensive alternative to ensuring the experiences of those patients whose background or circumstances are affecting their health are understood. Such resources can support health professionals to understand better how a patient’s background and circumstances may have led to poor health, and how they can respond better to the specific needs of a distinct, and perhaps vulnerable, patient group.
Fairhealth is an educational charity which produces free materials for healthcare professionals to support their education in health inequalities. From its inception it has been developed and maintained by front line primary care professionals, whose experience in practice has shaped the educational material.
Some of the charity’s courses include, 'a brief introduction to health inclusion', 'Adverse Childhood Experiences', and 'Women’s health equity.' Fairhealth also offers bespoke education and training packages to organisations.
Fairhealth was established as a charity in December 2020 but had been operating as an informal organisation since 2017 with start-up funding from Health Education England (HEE).
Tier 2 projects
The following projects require a moderate amount of time and/or resources. Where possible, we have included case studies to illustrate how others are carrying out this type of work.
Creation of a peer support group
We know that poor health can be a lonely experience. Meanwhile, loneliness itself is increasingly recognised as a health problem, with one large study suggesting social connections could be a risk factor in early death.
The experience of being socially disadvantaged can create or increase such feelings of isolation, and so addressing loneliness must be taken as part of addressing health inequalities.
A peer support group can provide a sense of community to those who may feel socially marginalised and can decrease the loneliness associated with poor health.
An approach which seeks to harness the strengths, capacity, and knowledge of the patients involved in the group can empower individuals to help other patients as well as themselves.
As well as the practical benefit of information sharing, a patient’s feeling of empowerment in supporting a fellow patient can also bring enormous benefits. Self-care is an important element of maintaining and improving health, and where that works, reduces attendance to health services.
The regular and informal contact that a support group may offer can also build the confidence a patient needs to proactively engage with other areas of their health for long-term benefits.
Networks between patients fostered in a peer support group can further develop outside the group and can lead to increased community participation and sustainable long-term support beyond the group itself.
The SOAR community regeneration project in North Sheffield has developed a chronic pain support group led by a local health coach. Chronic pain health issues can be more prevalent in disadvantaged communities where individuals are more likely to undertake manual work.
This group serves a multi-cultural population, many of whom do not speak English and have low levels of health literacy. Through fortnightly drop-in sessions for women, it aims to communicate the theories of chronic pain management through regular contact and interpreted conversations. It offers emotional support as well as practical demonstrations of techniques that can be used at home.
Positive feedback has been received by participants who reported feeling better-educated and empowered to manage their symptoms. The SOAR group is expanding their remit to include chronic pain services for the local Roma Slovak community via a Video Group Consultation clinic.
Whilst this specific example is not led by a clinician, a GP surgery can refer a patient to the group, and the SOAR group works in partnership with over 20 GP practices. The way the group operates may also act as a useful template to base something similar on under the direction of the GP practice or Trust.
Investing in the health education of the local population
Those suffering from economic and social inequality may not always have the education and knowledge to support their own and their family’s health. This is a key driver of health inequity, and it can be tackled through health education.
Interventions incorporating health education can be used to give individuals and their families the tools to empower them to actively participate in their own health. Interventions that involve improved communication between practitioners and individuals from disadvantaged populations can build trust in healthcare professionals and improve health outcomes where it is most needed.
Information sharing between individuals can then spread acquired knowledge amongst communities to give sustainable outcomes that relieve pressures on healthcare systems.
In 2020, Medical Aid Films created a COVID-19 animation, commissioned by the BMA, to provide valuable information for communities in the UK. Individuals living in deprived areas often have worse health outcomes and higher rates of COVID-19 infection. In response to this, bespoke video content was created in partnership with local communities where health disparity exists to provide targeted information on vaccinations, public health, and self-care measures.
The video was translated into multiple languages and disseminated via GP practices and migrant and law centres. The aim is to help communities access the support they are entitled to, specifically in communities where rates of infection and vulnerability are so distinctly high.
Since its development the educational materials have had large pick up in local communities and have received positive user testimonies from doctors, local health services, and migrant centres. The video was also showcased at the BMA’s Patient Information Awards.
The South Yorkshire and Bassetlaw Integrated Care System, with support from Yorkshire Cancer Research, developed the QUIT Programme to transform the way tobacco addiction is tackled in hospitals. The programme aims to reduce health inequalities, reduce hospital re-admissions, and save lives by tackling smoking across a region in which smoking rates are consistently higher than the national average.
The programme emphasises that smoking is an addiction that often starts in childhood, rather than a lifestyle choice. Through education and effective treatments, the programme treats tobacco addiction as a chronic, relapsing medical condition. The programme consists of four strands: patients, parents, NHS staff, and supporting a smoke free hospital. On admission, every hospital patient is asked if they have smoked in the past month. Using this information, tobacco addiction treatment and specialist support is provided for those who answer yes. Patients using A&E and outpatient services are signposted to community support or offered support from a Specialist Tobacco Treatment Advisor. Specialist advice is also offered to parents of children who smoke.
It is hoped that this approach will reduce smoking rates by 10% by 2024.
Tier 3 projects
The following projects require a high amount of time and/or resources. Where possible, we have included case studies to illustrate how others are carrying out this type of work.
New roles developed or appointed in team
Health inequalities can manifest in many ways, but at their root is economic and social disadvantage. A clinician can treat a patient’s health concerns, but the cause may lie outside the expertise of the traditional medical model of health.
For example, if someone were to come to their GP with anxiety, it may be that the anxiety comes from the stress of being unable to afford rent or meals for their family. The anxiety can be treated by the clinician, but if there were someone available to support the patient with financial advice, that would begin to tackle the root of the illness.
Broadening the expertise available to those professionals by, for example, incorporating social prescribing link workers, will increase the support that patients receive when they engage with health services.
This provides an opportunity to take a whole person approach more easily. Making every contact count is a key principle of this type of intervention where encounters with healthcare systems are optimised to encourage changes in behaviour that have a positive effect on the health and wellbeing of individuals, communities, and populations.
The addition of specialist roles in a team allows the needs of specific groups to be met with the best possible expertise available and can release time back to lead clinicians whilst allowing them to remain informed.
This approach proactively engages with patients on the causes of their ill health and can improve health outcomes and reduce future contact with healthcare services.
In 2012, the Emergency Department (ED) at University Hospital Southampton introduced a team of Vulnerable Adult Support Workers to respond better to the needs of vulnerable patients. Many patients attend ED with complex psychosocial problems including domestic abuse, substance abuse and homelessness. VAST workers have the knowledge, experience, and confidence to address these underlying causes of ill health, and work alongside other ED clinicians to do so.
Some of the aims of the project are to enable patients with troubled lives to feel heard and have their feelings validated, to improve the ED’s compliance with safeguarding protocols for adults and children at risk, to reduce repeat attendance to the ED, and to release time back to ED colleagues.
To support such interventions, and to signpost patients to third sector organisations that can help further, the team have a close working relationship with roughly 25 external agencies.
Whilst it took time to develop, this is now a fully commissioned service, and has been identified as an area of outstanding practice in two successive CQC inspections of the Trust. It has also won a national Nursing Times Award.
Watch their YouTube video for further information and health professional testimony.
This programme is a Scottish Government funded pilot of community link workers in 31 GP practices in very deprived areas of Glasgow. Deep End is a collaborative of the 100 general practices serving the most socioeconomically deprived populations in Scotland. The collaborative was set up to support GPs who felt that they were often unable to respond effectively to patients from these communities because of a lack of time, and because of difficulties in accessing community-led services they knew would benefit their patients.
Link workers use social prescribing approaches to support general medical practices to link people with community resources that could help them to ‘live well’ in their communities. They support patients to firstly identify goals they may have, and secondly to achieve those goals through appropriate services in the local community. They work alongside the entire primary care team, both clinical staff and non-clinical staff. They work with local community resources, supporting them to become more accessible to people accessing them via primary care.
The evaluation of the programme found differences in the secondary outcomes of anxiety symptoms, depressive symptoms, and self-reported exercise levels.
Organised collaboration with other local organisations
We know that health inequality cannot be solved within the health sector alone. To start tackling it, health services must work with other sectors, including social care, local government, the criminal justice system, and beyond. Even within health, closer working between primary and secondary care can yield positive results.
The creation of a forum in which representatives from all these sectors can meet and exchange information can be transformational. Data sharing, coordinated action, and timely referral access to appropriate third sector support is all made possible when systems and organisations come together to identify and address a specific health problem.
In England, the creation of Integrated Care Systems (ICSs) has included a strong narrative on collaboration to reduce health inequalities. By bringing together different stakeholders within a local area. ICSs should be facilitating collaboration which in turn is likely to make action to tackle health inequalities more effective.
This developing way of working aims to reduce health inequalities by picking up untreated chronic and infectious disease in groups of individuals who have been shown to have the poorest health outcomes. The Cardiff and Vale Health Inclusion Team (CAVHIT) provides an initial health assessment and public health screening to vulnerable individuals who are newly arrived in Cardiff or may live in Cardiff but are not registered with a GP practice.
The clinical team is made up of an Advanced Nurse Practitioner, health inclusion nurses, specialist homeless nurses, a health visitor, midwife, a healthcare support worker, and GPs. The CAVHIT team work closely with partners including the Infectious Diseases and Tuberculosis team, the department of Sexual Health, and local mental health services. CAVHIT also has close links with Cardiff Council, as well as housing, local, and national third sector agencies who provide vital support for the service users. CAVHIT is not a GMS service but a screening service which supports registration at a practice for the service users where needed.
Specific groups of individuals who could benefit from this service are vulnerable migrants, homeless individuals, sex workers, and the Traveller community. These groups of individuals are shown to have the poorest health outcomes and find it hardest to access healthcare. Broadly speaking, they are more at risk than the general population from conditions such as blood borne viruses, parasitic infection, and tuberculosis. The screening of these individuals is paramount to protect them from the long-term effects of untreated infection and to reduce the public health risk. Mental health problems such as traumatic stress, PTSD, depression, and anxiety are also more prevalent in these groups and early referral to allied teams and third sector organisations is beneficial.
When screening has been completed and any urgent health needs have been met, the individual will be directed to register with a GMS practice in their local area and given support from the health inclusion support worker to enable them to do this where needed.
Restore Recovery College is a case study in health care professionals coming together to address social isolation, which is both a symptom and driver of health inequalities. Social isolation and loneliness were priority issues for one of the most deprived areas of Bradford & Craven, the community in which the college is based. The Recovery College bills itself as a college like any other, providing education as a route to recovery.
The college brings together members of the Local Authority, Bradford District Care Trust, Mental Health, the Voluntary Service Sector, and GP Practices. Local people have been and continue to be consulted on the services offered and are part of the delivery of some services.
Help available for participants includes courses on relaxation and guided meditation, increasing self-confidence, and bereavement support. Evidence suggests people are developing local friendships supporting each other away from Restore and are starting to access services in the community, which was previously less likely. Partner organisations have been contributing by leading courses on, for example, budgeting skills and how to stay safe in the community. Courses are thereby reducing social isolation at the same time as addressing the problems that arise from deprivation which can affect our chances at a healthy life.
Evaluation of the college’s success suggests huge benefits for the community and the health services which serve them. GP attendance has gone down for those people previously visiting more often, and participants reported lower pain levels, higher levels of contentment with their friendships and relationships, and a significant decrease in depression and anxiety.
Projects across the UK
Use our interactive map to read case studies about existing projects in your area.
Other resources you can use
Everybody is entitled to free general practice services at the point of need, regardless of immigration status or ability to produce documentation. This is in line with contractual requirements.
The safe surgeries toolkit developed by Doctors of the World is an accessible presentation of existing guidance and supports clinical and non-clinical NHS staff to promote inclusive care through GP registration. Notably, it aims to address specific barriers to primary care faced by vulnerable, un/under-documented migrants by ensuring that GP practices are aware of all relevant DHSC guidance and rules. This includes, for example, that patients should not be turned away if they lack proof of ID, address, or immigration status.
Integritas Healthcare – Medics and Justice
A two-week course introducing medical students to the concept of social justice and how it interfaces with medicine. This opportunity is now being offered virtually to students in all medical schools.
University of Glasgow – Medical Students LGBTQIA+ Society
This society advocates for LGBTQIA+ medical students and patients by addressing a lack of awareness of LGBTQIA+ health issues, and by tackling stigma and misconceptions about the LGBTQIA+ community.
CARE Plus study
An evaluation of a whole-system intervention to improve the quality of life of primary care patients with multimorbidity in areas of high socioeconomic deprivation in Scotland through an empathetic, patient-centred approach.
Health Education England - MECC (Making Every Contact Count)
A resource using the MECC approach which aims to use the millions of day-to-day interactions that health organisations have with individuals to support positive behaviour changes and improve the health and wellbeing of individuals and communities.
A year-long training course to encourage UK healthcare professionals to consider working with vulnerable patient groups by exploring the relationship between health and justice.
A toolkit to support practitioners encourage behaviour change to address a range of patents' health issues, such as alcohol and drug consumption, the experience of stress and trauma.
This 10-year programme addresses health inequalities in 10 deprived areas of Glasgow and involves collaboration between local people, local organisations, and local services. The programme aims to empower individuals to be pro-actively involved in the solution to health inequalities rather than a recipient of a service.
This hub provides GPs across the UK with tools to help them understand and act on health inequalities. The webpage provides e-learning tools, COVID-19 specific resources, and general advice.
Sources of support
If you are interested in starting any of the projects or initiatives outlined in this toolkit but are unsure about where to seek the funding from, the following resources may be of use.
- If you are a GP in England, the NHS England website has a useful page listing sources of funding that could be used for the purposes of reducing health inequalities.
- System transformation funding in England is another option. Integrated care systems should be doing work to reduce health inequalities so lobbying your ICS to use this funding on projects that you think would serve your local community best is another option.
- Money from The Elective Recovery Fund should in part be used to target reducing health inequalities, so this could also be cited when lobbying your ICS for funding.
- In Wales, we’ve joined with partners to call on the Welsh Government to act on health inequalities.
- Influencing the wider determinants of health is a strategic priority for Public Health Wales, working to the framework offered by the Wellbeing of Future Generations (Wales) Act.
- Public Health Scotland has more information on health inequalities in Scotland. The Scottish Government also publishes an annual update of the long-term monitoring of health inequalities.
- The Department of Health in Northern Ireland publishes an annual report on health inequalities. The PHA set out their priority areas of work.