Challenges and policy implications of ethnic diversity and health
Background Britain is a m ulticultural and dem ocratic society. While significant strides have been made in term s of acceptance of its diversity, there are still unm et challenges. H ealth and social care agencies face the challenge of providing a service tha t is equitable to all regardless of colour or creed. In this chapter some of the weaknesses in the system are examined. It is argued that providing a service tha t is inclusive to all communities and responds to changing needs does not require vast expenditure but p ractical and innovative ways of redistributing resources. As the recently published W hite Paper highlights, this requires a close partnership between health authorities, local authorities and the local communities. While such a tripartite partnership has not been conspicuously successful, with sufficient support it could be developed into a thriving strategy. Knowing the people It is part of the C itizen’s C harter in the U nited Kingdom that purchasers and providers of care should know their client base in some considerable detail. O ften the organisational culture in the National H ealth Service (NHS) has supported ‘business as usual’, irrespective of evidence to support particular interventions or levels of perform ance. The subject of ethnicity and health has had a high profile. In recent years, with a com m itm ent to m eeting the health needs of ethnic groups coming from the G overnm ent, the C hief M edical O fficer (CM O) and the NHS Executive, lack of aw areness or com peting priorities can no longer be advanced as justification for inaction by senior m anagem ent or professionals responsible for health services. Social and economic circumstances Social, economic and cu ltu ra l profiles vary betw een and w ith in ethnic populations. A notable example of this heterogeneity is that of housing among those who m ig ra te d or w hose an ce sto rs m ig ra te d from th e In d ian subcontinent. The proportion of Indians living in owner-occupied housing
(82 per cent) is higher than the average among all people in England and Wales (68 per cent). In contrast, the proportion for Bangladeshis is 44 per cent, with almost 40 per cent living in council housing. Extended families in South Asian households are common. This has its advantages, but it can lead to significant overcrowding, especially among Bangladeshi households. The Fourth N ational Survey showed th a t the quality of housing also differs significantly. W hereas the quality of housing among owners is generally better than th a t of ren ters for Indians and African Asians, high proportions of Pakistani and Bangladeshi owner-occupied households lack sole access to am enities such as an inside to ile t and cen tra l heating . S ing le-paren t households are more common among African Garibbeans (16-20 per cent of all households compared with 3-4 per cent among those from the Indian subcontinent and 11 per cent overall), with about 40 per cent of live births occurring ‘outside m arriage’. This compares with 30 per cent for all women in England and Wales and 1 per cent in women from the Indian subcontinent. Unemployment is unacceptably high among ethnic m inority populations - 25 per cent among economically active African Caribbean men aged 16 + compared with 11 per cent for men in England and Wales. The proportion rises to over one-third in African C aribbean men under 25 years of age compared with 18 per cent in their W hite counterparts. Again, about one-third of Bangladeshi and Pakistani women are unemployed compared with 6 per cent among women nationally. Ethnic groups are more likely to be in lower occupational grades, to have poorer job security and to work unsociable hours. Ethnic populations tend to reside in deprived, congested, violence-prone inner-city areas, which gives a further twist to produce a situation of ‘m ultiple jeopardy’. W hereas concentration in these areas enhances ethnic identity and increases access to political power, in urban areas they are also more likely to face poorer employment opportunities and poorer access to health services. Cultural context It is im portant to be aware of the culture and health beliefs of the different communities. It could be argued that the service should address m ainstream issues but rem ain sensitive to ethnic issues. This may be a pragm atic model for the future but it is not defacto an appropriate model to address the existing situation. Linguistic difficulties Difficulties in communication among some groups within the South Asian community require a positive approach. The ageing of the first-generation cohorts of these populations means that they will make increasingly greater use of the services th an has h ith e rto been experienced. M any second-generation m igrants communicate with their GP in a language other than
English, especially women. A nother com pounding factor is the gradual retirem ent of current practitioners from ethnic communities who have held the front line for many years. Newly qualified South Asian doctors often do not speak the languages of their parents or do not practice in these relatively deprived areas. This highlights the need for in te rp re te rs and adequate translation services. Currently, these are poorly distributed and in some places members of the family, especially children, act as in terpreters. Use of alternative therapies Ethnic groups often use alternative remedies, such as acupuncture and herbal remedies, which have not been subject to rigorous scientific testing. Faith and confidence, however, play an im portant part in the healing process, and it may be necessary to provide support for interventions tha t people believe in until such time as evidence on clinical efficacy becomes available. Only 15-20 per cent of interventions are based on scientifically m easured clinical benefit, and it is clearly im portant to substitute knowledge for belief and supposition. Refusal to invest in interventions because of non-availability of evidence of a beneficial effect may, however, be harm ful and cause distress to patients. This is different from reacting to evidence that an intervention has no beneficial effect. Low uptake of screening services There is little awareness in ethnic groups of many m ajor national initiatives, such as cervical screening. This raises questions about the effectiveness and the role of the H ea lth Education Authority. U ptake of cervical cancer screening nationally is about 60 per cent. The uptake in women of Indian subcontinent origin is about half that level, with significant proportions saying that they did not know what a cervical sm ear is (one-third in Bangladeshi women), or that they had never been recom m ended to have one (one-third in Pakistani women). This reflects poorly on the outreach of preventive care among sections of ethnic m inority women, and there is clearly scope for im provement. Local studies have shown tha t poor uptake is due more to poor adm inistrative arrangem ents than to indifference to screening. Muslim women prefer to see a female GP. In fact, a substantial proportion of all women in this country would prefer to see a female GP. Randomised clinical trials or m eta-analyses are not needed to make simple pragm atic and low-cost responses to these issues. Health needs Chronic diseases such as diabetes and hypertension are excessively prevalent among some ethnic groups. M ortality from diabetes is seven times greater among Bangladeshis than among all people in England and Wales. Although
not as extrem e, higher prevalence is also a fam iliar feature among other Asians and in African Caribbeans. Furtherm ore, these ethnic groups are more susceptible than Caucasians to serious secondary com plications such as coronary heart disease, stroke and end-stage renal failure. The difficulty in coming to term s with a life-long disabling disease and the need to comply with treatm ent for life cuts across the health beliefs and health behaviour of some ethnic groups. Is this worth a trial to see whether a disease m anagem ent approach might work? Would it help if these communities were supported by ded ica ted d iabetic nurse p rac titioners? Is th e re a role for preventive practitioners focusing on such in terrelated chronic conditions as diabetes, co ronary h e a r t d isease and hypertension? As th ese re la tive ly young populations age, the burden of chronic disease in the communities as well as on the NHS is likely to grow. It is crucial that we look at models of care that will deliver effective intervention in term s of prevention and care in both prim ary and secondary sectors.Hypertension is another disease that disproportionately kills and disables people from ethnic minorities. African Caribbeans around the globe are known to suffer disproportionately from hypertensive disease and stroke. Recent research has shown that Bangladeshis in this country also experience high levels o f stroke m ortality . C onven tional m easures of socio-econom ic circum stances do not explain all of this excess. O ther factors related to the stress of m igration , d iscrim ination and the d isproportionate im pact of cumulative deprivation are likely to be implicated. Unlike the U nited States, where there are special screening program m es for hypertension, these are not readily found in areas of B rita in w ith high proportions of African Caribbeans. An opportunistic approach to screening needs to be considered. These are only some of the areas where consensus on the best approach needs to be developed. Consensus conferences m aybe one way of achieving solutions to some of these key issues.A striking inequality is the high rate of infant m ortality and congenital anomalies among Pakistani infants. There are several likely explanations, the m ost sign ifican t being high levels of consanguinity , low ra te s of participation in genetic screening and an unwillingness to accept term ination when fetal abnormalities are identified. Despite the sensitivity of these issues, w orking in pa rtn e rsh ip w ith the com m unity is essential to tackle this inequality.T here is also the issue of changing lifestyles in ethnic communities, with the a ttendant health risks. Excessive alcohol consumption among Sikh men and their increased prevalence of cirrhosis of the liver is an example. High levels of smoking among Bangladeshi men which could lead to increasing levels of lung cancer in the future is another. Strategy for ethnicity and health The approach to ethnicity and health is patchy and opportunistic. There could be a successful balance whereby within the m ainstream , issues are addressed
through special projects and program m es, evaluation of which should be part of perform ance m anagem ent reviews. Primary care Prim ary care provides the bedrock for most people’s health care and is the gateway to other specialist services. The lim ited inform ation available from studies, however, shows unequal access and dissatisfaction among patients. Most ethnic m inority communities live in inner cities where the quality of prim ary care varies widely and there is a preponderance of ‘single-handed’ GPs, who often lack the support and facilities of a group practice. People from ethnic m inorities, South Asians in particular, consult their GPs more frequently than the general population, but this is sometimes for problems or difficulties unrelated to medical needs. There is a case for developing a m ore innovative app roach w ith g re a te r involvem ent of o th e r h ea lth professionals, since such broad-based support at the prim ary care level may appropriately be provided by someone other than the GP.Comm unity clinics, such as m aternal and child health clinics, are often used by ethnic groups. They provide the opportunity to persuade m others to accept and use preventive services more widely and also to address other issues such as those related to nutrition and other lifestyle habits. Cross-sectoral work Services frequently fail to provide satisfaction because of a lack of cooperation between the various agencies involved. While continuity of care is a central feature of prim ary care, the level of communication and collaboration often falls short of what is desirable. W here such jo in t working breaks down, inevitably patien ts suffer. W ith the high prevalence of diseases such as diabetes and hypertension among ethnic minorities, it is especially im portant to achieve regular inputs from a range of sources. There is a strong argum ent for m ore m anaged care in such situa tions in p a rtn e rsh ip w ith ethnic communities. Equitable allocation of resources Inform ation detailing expenditure on ethnic m inorities is not available. H istorical spending patterns have often favoured well-endowed areas. For example, in west London, H am m ersm ith receives much more per capita than Southall or Northolt. The health needs of these two areas are so different that if a zero-based budget approach was adopted a reversal in the order of m agnitude of the allocations would be expected. It is im portant that the allocation of resources to small localities is considered. Although the use of RAWP and subsequent initiatives was m eant to achieve equity of per capita funding at the health authority level, allocations at the sub-district level have been straight-jacketed. Purchasers have tinkered at the margins with minor
services such as family planning, ra ther than introduce changes which impact on core specialities or activities.Over the 3 years of its existence, the NHS Ethnic U nit dispensed around £3 million to health authorities for developm ental projects. It was intended to build awareness within the communities because a prerequisite was the participation of community organisations. In many instances, however, the projects do not appear to have brought about changes in the service. O ften they were either not completed or adopted by the service organisation and were not evaluated. Public health strategy Strategy in certain key areas, such as hypertension, diabetes, coronary heart disease and haem oglobinopathies, should be developed with the help of consensus meetings. At a recent bilateral conference between the U nited Sates and Britain, on ethnicity and health, a document was signed expressing m inisterial in ten t to explore a range of good practices and is a good example of partnership development.Ethnicity and health should feature specifically in national initiatives such as ‘O ur H ealth ier N ation’ and the inequalities agenda. There should be a range of initiatives, key areas and targets geared specifically to the needs of the ethnic population. For exam ple, among Bangladeshis, diseases for which there are national targets (coronary heart disease, hypertension and stroke) are im portant but other targets are needed for diabetes, oropharyngeal and liver cancers, sm oking-related diseases, and m aternal and child mortality. The high level of some of these diseases in ethnic groups also means that the levels of the national targets need to be revised. Health service strategy
Purchasing strategy Issues related to ethnicity need to be considered in many processes such as resource allocation, prim ary and secondary care. Prim ary care purchasers, for exam ple, should reflect on the evidence tha t patients from ethnic groups are currently under-represented in cohorts of patients receiving secondary care and interventions such as coronary artery bypass grafting, in spite of being more prone to coronary heart disease. Provider strategy Standards are im portant for high quality of care. For example, m easures of waiting time, referrals, GP and secondary care need to be m onitored, and m ore resources in to com m unication , h ea lth education and preventive m easures should be considered. The National Service Frameworks should provide a major advance in this direction.