For over a year now, the UK has collectively faced the effects of Covid-19 and experienced life under lockdown. Although on the surface everyone has been dealing with the same situation, underlying health inequalities in society have been exposed, replicated and in many cases amplified.
As data continues to be analysed and lockdown begins to lift once more, there is increasing evidence that certain population groups and communities have been more affected by the virus because of inequalities they already face.
As such, health organisations, charities and other bodies are calling on the Government to boost investment in preventing ill health to protect and enhance the health of the nation, to which the response has been broadly encouraging. And there’s an important role for community pharmacy.
Underlying health issues. Age. Ethnicity. Gender. Socioeconomics. These are all factors highlighted by the International Longevity Centre UK (ILC) at its Future of Ageing conference in December 2020, as some of the reasons why the Covid-19 pandemic has disproportionately affected certain groups of people.
“As people pore over the data relating to the pandemic, it’s impossible not to notice the different outcomes for different groups of people,” says Professor Andrew Goddard, president of the Royal College of Physicians (RCP). “But another, larger, part is that there are disparities in Covid-19 outcomes in the UK because there are long-standing disparities in health outcomes in the UK. That is, it’s unsurprising that when a pandemic added extra pressure to our health system, the people who suffered the most were those who were already suffering the most.”
Throughout the pandemic, the elderly and clinically vulnerable have been spotlighted as groups most at risk of contracting the virus and experiencing poor health outcomes and death as a result. And, in fact, age was found to have the largest disparity. According to the Office for National Statistics, around 73 per cent of all Covid-19 deaths have occurred among people aged 75 years and over. What’s more, among those diagnosed with Covid-19, people who were aged 80 or over were 70 times more likely to die than those aged under 40, according to a Public Health England (PHE) report entitled ‘Disparities in the risk and outcomes of Covid-19’.
But it doesn’t stop at age. Risk of death was higher in males than females; in those living in deprived areas compared to the least deprived areas; and in black, Asian and minority ethnic (BAME) groups than in white ethnic groups. The PHE report highlighted that these inequalities largely replicated existing inequalities in mortality rates, apart from BAME communities who were shown to be increasingly affected as mortality was previously higher in white ethnic groups.
“For BAME populations, black people were four times more likely to die from Covid [than white people],” says Arunima Himawan, research fellow at the ILC. “What puts these people at risk is these geographical, socioeconomic factors, whether they work in frontline services, which for BAME populations is often true, and deprived populations are more likely to work in the service industry. All these different factors are at play here.”
All these population groups are likely to have been dealing with poorer health outcomes prior to the pandemic, making them even more susceptible to the effects of Covid-19, especially when comorbidities are considered too, which are strongly associated with a risk of death from the virus.
“Rates of obesity, respiratory diseases, heart disease and more were already higher among people in lower socioeconomic groups, and they generally live in larger households, have poorer housing and were more likely to have to keep going to work. So of course, they were more likely to be harder hit by the disease,” adds Professor Goddard.
People who were aged 80 or older were 70 times more likely to die than those under 40
The immediate impact of the pandemic can be seen from higher death rates, but there is widespread concern that a longer-term impact will be felt for years to come.
This stems from the nature of the multiple lockdowns in the UK, which have meant there has been a stark reduction in the proactive management of pre-existing health conditions and, notably, the diagnosis of new conditions. The closing of, or limited access to, GP surgeries, dentists, foodbanks, charities and even schools and workplaces, are all thought to have had a knock-on effect in different ways, especially for those groups already in disadvantaged positions.
“Non-urgent care, people going to visit their doctors, getting regular check-ups, attending screenings for cancer and cardiovascular disease – all of these things have been put on hold,” explains Arunima. “What we are going to see is that people aren’t going to get the treatment when they need it the most and when it’s the most effective for them and that’s going to have an impact.”
For example, there were 50,000 fewer people diagnosed with cancer across the UK by October 2020, compared to a similar timeframe in 2019, according to a report by Macmillan Cancer Support in October 2020 entitled, ‘The forgotten ‘C’? The impact of Covid-19 on cancer care’.
In addition, more than 650,000 people with cancer in the UK (22 per cent) have experienced disruption to their cancer treatment or care because of Covid-19, with delays, changes or cancellations to treatment causing backlogs that Macmillan Cancer Support says will take months and years to work through.
“If cancer is diagnosed in stages one or two, there is an 80 per cent chance of surviving five years or more. But if they are diagnosed when they reach stages three and four then the survival rate drops down to 40 per cent,” says Arunima. “It’s really crucial that people get these checks early on. Prevention is really important, but if people aren’t going to get checked then we are losing crucial time. All these age-related chronic illnesses are going undetected because all of our resources are now on Covid.”
All these age-related chronic illnesses are going undetected because all of our resources are now on Covid
So, what is being done to tackle this? In a word: prevention.
Baroness Sally Greengross, chief executive of the ILC says that “the ongoing Covid-19 pandemic has made the importance of protecting and enhancing the health of people right across the life course staggeringly clear and brought home the urgent need to reduce health inequalities through democratising access to prevention”. She also highlights the importance of governments investing in preventing ill health through interventions, such as vaccines, screenings and better management of existing conditions.
In October 2020, the Inequalities in Health Alliance was formed to help further facilitate the improvement of the UK’s health. “This new coalition of more than 170 organisations, is calling for a cross-Government strategy to address health inequalities,” says Professor Goddard. “We need to see policy changes across all Government departments in order to improve health for everyone. The announcement of a new cross-Government ministerial board on prevention, alongside the Office of Health Promotion, could be a turning point for addressing health inequalities if it is given a remit to take policy action in other departments on issues like poor housing and air pollution which we know affect health outcomes.”
Indeed, the recently formed Office of Health Promotion will build on the work of Public Health England and lead national efforts to systematically tackle the top preventable risk factors of ill health and death in the UK. It will focus on issues such as obesity and nutrition, mental health, physical activity, sexual health and alcohol and tobacco use, aiming to enable a more joined-up approach between the NHS, national and local government, and different Government departments where much of the wider determinants of health can be influenced.
It is thought that focusing on preventative care in this way will help to tackle deep-rooted inequalities, and this is where community pharmacy comes in, too. “We know that pharmacy teams already do a lot in terms of public health by providing patients with advice and delivering interventions for things like smoking and alcohol. That is important and of course needs to continue,” says Professor Goddard. “Pharmacy teams will also have a key role to play in Integrated Care Systems as they develop. Their knowledge and understanding of the community will be crucial to commissioning the right services. Pharmacy teams can also support calls for Government action to reduce health inequalities, helping to tackle the cause as well as treating the effects.”
Unlike countries such as France, Estonia, the Netherlands and Austria, the UK does not currently grant community pharmacies the access to a patient’s full medical history record.
Could this be a solution to encouraging vaccine uptake and tackling health inequalities, especially amongst those with underlying health conditions?
Arunima Himawan, research fellow at the International Longevity Centre, says that it would indeed help to have full access to people’s medical records in community pharmacy. “That needs to be part of the solution,” she says, adding that this access would mean that pharmacy teams could easily identify customers and patients who, for example, need the flu vaccination.
In 2020, some 46.8 per cent of people under the age of 65 years with a long-term health condition had the flu vaccine. While vaccine coverage in this group was higher than it had been over the last six flu seasons, coverage was still behind in comparison to other eligible groups, such as people over the age of 65, according to Public Health England. This analysis also revealed that six in 10 deaths from flu are seen in people with underlying conditions, highlighting the urgent need for them to be vaccinated.
Discussions around wider access to medical records are ongoing, but while hospital pharmacists do have full access to patient health records, laboratory results and previous treatment information, access for community pharmacies continues to lag behind.
The Royal Pharmaceutical Society (RPS) has repeatedly called for all pharmacists to have the same read and write access to patient health records with patient consent. Whether the impact of the Covid-19 pandemic on health outcomes will influence decision-making on this remains to be seen.
Community pharmacies have the potential to help tackle the growing number of health inequalities and, in most cases, already have measures implemented to do so. “If we want to improve our population health, pharmacies need to be part of that solution and there are lots of things that they can do,” says Arunima. This includes:
Vaccinations are well known as an important and impactful way to tackle health inequalities. Providing vaccine services is important, where possible, but so is raising awareness about their effectiveness and tackling vaccine hesitancy – especially among groups where uptake is low.
There are substantially lower rates of Covid-19 vaccinations among the over 80s in ethnic minority groups, with an uptake of only 20.5 per cent for black people compared to 42.5 per cent of white people, according to a recent MedRxiv report entitled ‘Trends, regional variation, and clinical characteristics of COVID-19 vaccine recipients’. It also revealed a lower rate of uptake in deprived communities in England, with the least deprived areas having a 44.7 per cent uptake and the most deprived areas 37.9 per cent. Yet deprivation and ethnicity are both risk factors for Covid-19 infection and its increased severity.
Having vital conversations about vaccines is therefore something that pharmacy teams can actively do to help in the fight against health inequalities, and Arunima Himawan, research fellow at the ILC, highlights these as “really influential in getting people to get the jabs”. And it’s not just about Covid vaccines. “Flu, pneumococcal – all these chronic illnesses are not going to go away, and the mortality rates are much higher than Covid,” explains Arunima. “Covid can spread more quickly, but the mortality rate is much higher for these illnesses and people should recognise the importance of vaccination.”