England is becoming more ethnically diverse, with an increasing proportion of the population identifying as being from Black, Asian and Minority Ethnic Groups (BAME). For decades there has been clear evidence of health inequalities affecting different ethnic groups in England and sadly the gaps are not closing at pace.
In 1998 the Acheson Report – the independent inquiry into inequalities in health – clamed that ‘There are many indications of poorer health among the minority ethnic groups in England. For example, people in Black (Caribbean, African and other) groups and Indians have higher rates of limiting long standing illness than white people’. Twenty years later in 2018 Public Health England’s report Local action on health inequalities: Understanding and reducing ethnic inequalities in health consolidated the evidence and showed that not only do the health inequalities persist but also the wider inequalities in the determinants of health such as employment, education and criminal justice.
Lewisham is the 15th most ethnicity diverse local authority in England and Birmingham is one of the most ethnically and culturally diverse cities in the UK outside London and both face significant public health challenges. Addressing these challenges cannot be done without proactively working with communities and talking about dimensions of identity and culture such as ethnicity, sexual orientation and faith.
Both Birmingham and Lewisham public health divisions shared a joint aspiration to address this and improve ethnic inequalities, through an increased understanding, appreciation and engagement with BAME groups. This resulted in a collaboration to share knowledge and resources through a joint engagement and review process supported by strong political leadership that is willing to face up to the challenges of opening up a ‘real conversation’ about change.
By focusing on different ethnic groups and communities separately, beginning with the Black African and Black Caribbean communities, this will enable a more detailed and culturally sensitive approach to the review. The councils are building on the existing relationship established through the Childhood Obesity Trailblazer partnership and chose to focus on the African and Caribbean communities because in Lewisham this is one of the largest ethnic groups in the population and although in Birmingham the community is not the largest ethnic group, it is the largest population of African and Caribbean people in any authority in England.
The COVID-19 outbreak has further highlighted the impact of these inequalities in the context of infectious disease, with Black African and Black Caribbean people over-represented in the deaths from the virus. A national review of ethnicity and COVID was launched in May and its findings will also feed into this joint work but are not its primary focus. However the outbreak has reinforced the need for local authorities to have a much greater granular understanding of communities and the inequalities that affect them.
National evidence highlights a wide range of health inequalities affecting African and Caribbean communities, including both physical and mental health conditions. This is not just about increased prevalence of disease, it is also about access to treatment and management support, risk factors such as obesity and the wider determinants such as unemployment.
The 18-month partnership is aiming to dive deeper into these relationships and will explore a range of issues affecting this ethnic group, including for example specific health conditions, lifestyle factors, mental health and wider determinants (crime, deprivation, employment and housing).
Speaking on the partnership, Mayor of Lewisham Damien Egan has said this is not just about the impact coronavirus is having on BAME communities, but prompted by this current pandemic, we must seize the opportunity to drive an evidence-led approach on addressing health inequalities. He added that news of the coronavirus-related deaths of front line workers from these communities is heart breaking and a stark reminder that we need to urgently address these health inequalities.
An external Advisory and Academic Board will be set up, with the aim of representing a wide range of different aspects of the Black African and Black Caribbean communities in Lewisham, Birmingham and nationally, to enable regular discussions that will inform the review process. The review will draw together the evidence, available from both research and lived experience, to focus on solutions that are sustainable and will achieve sustainable change.
Too often inequalities are homogenised, and solutions are short-term initiatives based on non-recurrent funding and unstable infrastructure. There is often evidence of what works in small scale initiatives, but little evidence of this being industrialised and embedded in ways that drive down the inequalities at population level. Both councils aim to use the review to provide a space to explore how we get beyond this in a meaningful way to achieve impact at scale.
Through this detailed exploration of the experiences and evidence for action with a specific ethnic community there is potential to achieve sustainable solutions that create a fundamental step change in these outcomes and provide learning to build on for future reviews with different ethnic communities and other minorities.
Dr Justin Varney is director of public health at Birmingham City Council