The COVID-19 pandemic has shone a bright light on the seriousness of health inequalities within England, exacerbating the significant discrepancy between healthy life expectancy that is known to exist between the least and most deprived areas of England. A national approach to reduce health inequalities and narrow the life expectancy inequality gap, has been developed by Dr Bola Owolabi and the Healthcare Inequalities Improvement Team at NHS England. This approach, known as ‘Core20PLUS5’, is to be implemented at both a national and system level. It defines target population cohorts – the ‘Core20PLUS’ and identifies ‘5’ focus clinical areas that require accelerated improvement as a priority due to their contribution to the life expectancy inequality gap.
This is the first in a series of five blogs, written by clinical fellows on secondment at NHS England and NHS Improvement and Healthcare Quality Improvement Partnership (HQIP), explore the ‘5’ focus areas, the links between health inequalities and the invaluable contribution of leadership to narrowing the life expectancy inequality gap. The ‘5’ focus areas are cardiovascular disease, cancer, chronic respiratory disease, maternity and mental health.
“Hi love, the docs have been on their ward round. It’s not great news, they think it is the ‘big K’.”
As third year medical student me, stood outside the side cubicle on the medical ward at a busy, inner-city hospital in Birmingham, over-hearing this private conversation, I felt conflicting emotions. I had just witnessed the consultant telling this middle-age man that his emergency presentation to hospital was due to a cancer that he did not know that he had, yet here he was describing it as the ‘Big K’. Sadness, confusion, pity and concern overwhelmed me; surely everyone knows it is cancer with a ‘C’? Doesn’t everyone know the cancer signs and symptoms to look out for? Why did this man not seek help sooner? Is he going to survive?
More than 10 years have passed since this event and the revolution in the cancer world has been like no other. We have more diagnostic tests than ever before, multiple screening programmes exist, and we have world-class treatments tailored not just to individuals but to an individual’s’ genetics. We must now be achieving better outcomes and avoiding situations like the patient in Birmingham? Well we are. According to the Long Term Plan (LTP) published in 2019, cancer survival is the highest it has ever been, with thousands more people now surviving cancer every year – for patients diagnosed in 2015, one year survival was 72% which was over 11% higher than in 2000. However, we can do better, with diagnosing cancer early (stage 1 or 2) being the ambition set by NHS England in the LTP for us to continue improving cancer survival. By 2028, we aim to increase the number of cancers diagnosed at Stage 1 or 2 from 50% to 75%.
There will be many different methods to accomplish this, including identifying the barriers that prevent early cancer diagnosis, one of which is a well-recognised problem; health inequalities. These are unfair and avoidable differences in health which occur for many reasons, including our socio-economic status, our protected characteristics, whether we are part of a vulnerable group in society and geographically where we live, as these factors impact on our opportunities for good health. My patient in Birmingham is an example of someone who faces these barriers that prevent early diagnosis, such as living in a deprived area of the city, reduced literacy levels and older age.
Unfortunately, the COVID-19 Pandemic has impeded our progress with our LTP ambition. According to Cancer Research UK, the first wave of the pandemic led to fewer people being screened, fewer urgent suspected cancer referrals, reduced numbers starting treatment, patients diagnosed at an early stage were lower and cancer waiting time targets were consistently missed. Those most impacted were men, older age groups, the two most deprived quintiles and those in Black, Asian and Minority Ethnic (BAME) groups. Whilst there has been documented recovery of many of these areas to date, the problem still exists, and is impacting more on the marginalised groups in our society. The LTP cancer ambition remains a priority within the NHS, and the Health Inequalities Improvement Team at NHS England have highlighted it as one of the five key clinical areas that needs to be addressed as a priority to narrow the life expectancy inequality gap in their approach Core20PLUS5. Sir Marmot outlined this in his review ‘Fair Society, Healthy Lives’ – while life expectancy continues to improve for the most affluent 10% of our population, it has either stalled or fallen for the most deprived 10%.
We are now in a position where the NHS is trying to recover from the pandemic whilst also preparing for the challenges that Winter 2021 will bring us. Primary care is working above and beyond maximum capacity yet is still under immense pressure. The whole NHS workforce are, to varying degrees, exhausted and burnt-out. The only way around this is to take a systems leadership approach, defined by NHS Leadership Academy as a way of working beyond organisational boundaries on issues of mutual concern that cannot be solved by any one person or institution. Individuals who take this approach will be successful by recognising the challenge, accepting that we all need to and have a part to play in solving the challenge and therefore work in a collaborative way to bring about positive outcomes. Hopefully the introduction of Integrated Care Systems (ICS), which aims to remove the traditional barriers known to exist in the NHS that has led to disjointed care, will support a system leadership approach. It must also be recognised that not only does this approach need to exist within the NHS, it should also include multi-agency support, utilising provision outside of the NHS including public, private and third sector organisations. The Faculty of Medical Leadership and Management (FMLM) have recognised the importance of System Leadership, with it being one of the four standards for Medical Professionals, highlighting the importance of interdependence of systems of care and multi-disciplinary team working. We have seen some great examples of this in practice, such as Dentists screening for oral cancers during routine checks. We must all look wider than the scope of our work, work above and beyond the norm of our day-to-day job, and join forces with our allies so that we are providing exceptional quality healthcare for all, through equitable access, excellent experience and optimal outcomes.
Dr Emma Hadley
Dr Emma Hadley is a Geriatric and General Medical Registrar, working across Kent, Surrey and Sussex Deanery. Having undertaken leadership roles within local NHS trusts and participation in local quality improvement projects, Emma applied to the Faculty of Medical Leadership and Management (FMLM) National Medical Directors Clinical Fellow Scheme to continue to develop her leadership and management skills as well as to gain a deeper understanding and appreciation of change management within the NHS at a national level. Emma has a particular interest in the wellbeing and morale of the workforce, which has been at the centre of many of her previous QI projects and Emma feels incredibly privileged to have been placed within the Health Inequalities Team at NHS England. Emma hopes that she can bring both her medical and clinical leadership skills to the team, her holistic approach to addressing tasks and her passion for contributing to positive change, now with a new health inequalities lens. Emma hopes to be an ambassador for the Health Inequalities Team, networking within NHSEI and liaising with the FMLM fellows across other organisations to align the health inequalities work being done nationally.
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.