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 fourth 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.
In 2018, Eric Muhammad became the first barber to feature as an author in the New England Journal of Medicine. The study, colloquially referred to as ‘the Los Angeles barbershop study’, is a beautiful illustration of how innovative and collaborative leadership can help to tackle entrenched health inequalities within a population.
The Los Angeles barbershop study, trimmed down:
- In the US, black men rank among the lowest in health, including heart disease; little progress has been made to reverse this inequality.
- 319 black male patrons with hypertension from 52 black-owned barbershops in L.A. were randomised to:
- A pharmacist-led intervention – barbers encouraged meetings with prescribing pharmacists who were based in the barbershops.
- An active control approach – barbers encouraged lifestyle modification and doctors appointments.
- At 6 months, the mean systolic blood pressure fell by 27 mmHg in the intervention group and by 9.3 mmHg in the control group; a blood pressure of less than 130/80 mmHg was achieved among 63.6% of the participants in the intervention group versus 11.7% of the participants in the control group.
The real beauty of the L.A. barbershop study was how it managed to piggyback a healthcare intervention onto an existing habit in an attempt to make the two virtually inseparable. The approach draws heavily on the behavioural psychology phenomena of:
“Nudge” – choice architecture that alters people’s behaviour in a predictable way without restricting options or significantly changing their economic incentives.
“Habit stacking” – rather than pairing your new habit with a particular time and location, you pair it with a current habit. “After I brush my teeth, I will read 10 pages of my book…”; “After I have my haircut, I will get my blood pressure checked and see the pharmacist…”
With this masterclass in co-production, the barbers and research team had created a “bright spot” of cardiovascular disease prevention.
Cardiovascular disease prevention after the pandemic…
COVID-19 is expected to have had a significant impact on the diagnosis and management of hypertension, as fewer individuals were having their blood pressure checked due to lockdown and pressures on the healthcare system. Prior to the pandemic, there were approximately 13 million people predicted to have hypertension, yet only 8 million of these were diagnosed. Hypertension is often referred to as “the silent killer”; very rarely does it have symptoms, but failure to diagnose and treat high blood pressure can lead to catastrophic outcomes including heart attacks, stroke, vascular dementia and ultimately death.
It is anticipated that the diagnosis gap is largest among the 20% most deprived (Core20 population). This Core20 population accounts for nearly a third of avoidable mortality from cardiovascular disease under the age of 75. This is why hypertension case finding has been identified as one of the five key clinical priority areas for tackling health inequalities in NHS England’s Health Inequalities Team’s Core20PLUS5 initiative.
“Learning from best practice” is not a new concept to leaders in healthcare, but the purpose of bright spot thinking is to engrain the mentality that we should, as one colleague put it to me recently, have no qualms about “pinching with pride” when it comes to good ideas. Making a concerted effort to replicate a bright spot is as much a sign of good leadership as generating the bright spot in the first place.
“See a bright spot…and clone it!”
This is the strapline of Eric Glazer’s “bright spots in healthcare” podcast, in which he interviews healthcare innovators to extract the strategies they utilise to generate positive outcomes so that they can be applied elsewhere. If the approach pioneered by the L.A. barbershop study were replicated throughout the U.S. it is predicted it could reach 800,000 men and prevent 1300 deaths from heart disease every year.
The study’s approach empowered the community to “cure itself” rather than imposing solutions from the outside in a top-down fashion. This style of approach can allow for:
- Quick progress, ideally with minimal analysis and resource requirement
- Sustainability, as the intervention is fully embedded in, and has buy-in from, the community
- Broad application – bright spots can be found in every community
Know your population and leave a legacy…
But does the success of the L.A. barbershop study mean we can export the exact same strategy here in the UK? When asked why he knew the intervention would work before the study had even got underway, Muhammad remarked, “there’s a vibe here, there’s a conversation going on…, this is the community hub”. Firstly, this might be true for some barbershops in the U.K., but is this to the same extent? Secondly, the study addressed a historical fracturing of trust between the black community and the medical establishment in the U.S., with its roots in the ethically abusive Tuskegee Syphilis Study last century. And thirdly, the study purposefully left a legacy; researchers ensured a system was in place for when the intervention ended – namely, barbers continued to monitor the blood pressure of customers who’d been diagnosed with hypertension during the study.
Nevertheless, we can apply the key learning to our efforts to improve hypertension case finding and narrow the inequalities gap here in the UK. Healthcare leaders need to be running organisations that are accessible and responsive to patient needs, and that might mean leaving the comfort of our clinics and hospitals to meet people where they are, acknowledging that, because of a whole host of cultural, societal and historical factors, we cannot expect everyone to reasonably come to us in equal degrees. If we want equity in experience and outcomes, we first need equity in access. A friend of Dr Ronald Victor, the cardiologist who led the barbershop study and who sadly died of pancreatic cancer in the same year it was published, remembered him as the person who “invented a new way of reaching out to communities and intervening there, rather than waiting for them to come to us, and that could be a major paradigm shift.”
This is also about healthcare leaders acknowledging that they may not always be the right people to lead these types of interventions. We need to empower community leaders, including those from non-healthcare backgrounds, to engage the communities who are impacted most by health inequalities.
During the pandemic, NHS teams up and down the country worked tirelessly to continue delivering care for their patients, pulling off immense feats of transformation, innovation and collaboration. Community engagement was often key to their successes, illustrated beautifully by the collaboration between local healthcare providers and faith leaders focussed on dispelling myths surrounding COVID-19 vaccination.
As we begin a difficult recovery out of the pandemic, healthcare leaders should face the challenges ahead with optimism that they are not alone. It is an underestimated trait of a good leader to look elsewhere and say “they’re doing it better than us, how can we learn from them?”. Nowhere is this more important than in tackling the stubborn issue of inequalities in cardiovascular disease. We already have a rich menu of best practice examples of tackling hypertension inequalities, of which the L.A barbershop study is just one. It’s time to adopt a “bright spot thinking” mentality to ensure the benefits can be reaped at scale.
Dr Tom Gardiner
Tom Gardiner is a junior doctor and National Medical Director’s Clinical Fellow based in the Clinical Policy Unit at NHS England and Improvement. He has a keen interest in health policy and politics and has spent time working for several leading parliamentarians, including the Shadow Secretary of State for Health and Social Care. Tom sits on the Executive Committee of the Fabian Society (a policy think-tank) and is Convenor of the Society’s Health Network. He is passionate about tackling health inequalities and has published articles on related topics in academic journals, most recently a BMJ editorial on “racial and ethnic health disparities in healthcare settings”.
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.