Jagtar Singh, Asian Fire Service Association National Advisor and Chair of the Coventry and Warwickshire Partnership NHS Trust, reports on the impact Coronavirus has had on NHS BAME workers and how lessons can be learnt from the Fire Service’s approach to prevention
I have watched with great interest and noted the fantastic positive pace of change we have all witnessed over the lockdown period in my Trust locally, nationally and wider. The superhuman efforts of the NHS, government and our amazing NHS staff have excelled in meeting the fast change and innovation required for the new ways of working under Covid-19. We have removed many restrictions and challenges to meeting the needs of our community that have been threatened by Covid-19.
All this has to be admired and in time recognised and rewarded. We have made change faster than ever before. We have built several large capacity units such as the Nightingale Hospital in London and others in the regions in less than three weeks and we have risen to many challenges of PPE, staff testing and reducing hospital admission. Not always perfectly but in a way and at a pace we could not have predicated.
We have also carried out HR practices and procedures of redeployment of staff from traditional support roles to frontline roles in clinical care in a way undreamed of in the past, with the full support of our trade unions and staff .
As the impact of Covid-19 spread across the NHS my attention was drawn to Exercise Cygnus, a simulation of a major flu pandemic, that was carried out in 2016. Having worked in the Fire Service as a Gold Commander and in the role of emergency planning officer, I am well aware of the value of simulations and drills in providing an opportunity to learn and practice in controlled environments. So, when we have to put into play the strategies and policy applicable to the Covid-19 pandemic we can ensure we have mitigated the mistakes made in simulation.
I am not sure that the simulation or the real planning for this event ever considered the impact on the most vulnerable in society during such a pandemic. Sometimes I feel we forget the NHS is about people and not just about strategies, policy and processes.
However, one thing has constantly troubled me during the fast and positive pace of change: the lack of reference to equality analysis. On some of the rapid change of policies, procedures and practices, we know that we have witnessed some unintended negative impact on equality for some staff and patients, as the media is now reporting.
“I am not sure that the simulation or the real planning for this event ever considered the impact on the most vulnerable in society during such a pandemic”
Equality Impact Analysis
The NHS has had a long tradition of undertaking equality impact analysis (EIA) or as it is now known, the duty of due regard. This is a way of systematically and thoroughly assessing, and consulting on, the effects that a service or policy is likely to have on people from different characteristic groups. The main purpose of an EIA has always been pre-empting the possibility of unintended consequences that any proposed policy could have on some groups. This allows boards and policy makers to take steps to mitigate and avoid or reduce the inequality of policy change.
The obvious question I asked myself from a risk analysis perspective was whether an EIA had been undertaken as part of Exercise Cygnus in 2016 and subsequently as policy and practice in relation to Covid-19 were being implemented? Has it been a feature of any government and Public Health England responses to Covid-19? If the answer is ‘yes’, why are the EIAs not publicly shown and used in evidence at press statements?
As the evidence of the impact of the pandemic spread, data soon started to emerge that Black, Asian and Minority Ethnic (BAME) communities were being disproportionately affected. Despite making up only 14 per cent of the population, one study has shown that BAME people account for 30 per cent of critically ill Coronavirus patients in our hospitals. This now is accepted by most media pundits and is a constant focus of debate.
My personal view is that the above example of disproportionate impact that have emerged could have been foreseen. The reasons behind the disproportionate impact of BAME communities as a result of the Coronavirus are recognised by all as complex and varied. Some of the reasons suggested include socio-economic factors such as: deprivation; obesity; underlying health conditions and cultural differences, like inter-generational households that are more common in ethnic minority communities.
My view is that a lack of targeted campaigns, the delay in the translation of government guidelines from English to other languages and not using the power of community groups, the voluntary sector and other key stakeholders in a targeted prevention campaign has contributed to an adverse effect on some people from ethnic minority backgrounds. This view is supported by the Runnymede’s State of the Nation report that shows just how disadvantaged ethnic minorities were at the outset of the pandemic. Furthermore, within the NHS for example, about 40 per cent of doctors and 20 per cent of nurses are from BAME backgrounds. In London alone, 67 per cent of the adult social care workforce are from BAME backgrounds. This exposure puts BAME people at greater risk of catching the Coronavirus in frontline roles and then subsequently needing hospital admissions.
Despite this data, I am informed that some leaders have shouted down voices asking for EIA, and when matters such as the issue of disproportionate deaths of NHS BAME staff and disproportionate BAME patients within intensive care units (ICUs) have been raised. The same leaders have been quick to dismiss the data or try to explain it away by deflecting the debate as if it is the BAME staff and patients who are to blame for the contributing factors as detailed earlier in this article. Similarly, I have, along with others, raised the issues of the first ten doctors who died of Covid-19 being from BAME backgrounds, male and mainly Muslim. The issue was quickly dismissed and only when the number reached 19 deaths did we hear of an acknowledgement from Number 10 Downing Street and the media started to take the issue up.
Other leaders and I also made a simple request that the new hospitals coming online be given names reflecting the diversity of the NHS and value placed in that diversity by the NHS. I also cannot understand why the idea or suggestion was so quickly dismissed.
The purpose of this article is not only to highlight what we already know or what the data is now showing clearly but also to highlight the continued importance of equality analysis. I hope to also share possible solutions through a variety of evidence and in particular from my experiences with the Fire and Rescue Service, which supports the effectiveness of the Service in reducing incidence of fire and wider community risks through community safety activities, projects, messages and initiatives. The key message is that prevention works if we focus our message.
The philosopher George Santayana once said that ‘those who do not learn history are doomed to repeat it’ or as Mark Twain said, ‘history does not repeat itself but it does rhyme’.
At the heart of the Fire and Rescue Service is the influence of the ‘Prevention Strategy’. The strategy recognises equality, diversity and inclusion and crucially risk from fire, and varies depending on demographics and socio-economic factors. Therefore, fire and rescue services target their prevention efforts where they are likely to have the greatest impact in reducing risk and saving lives. To do this, the service uses all sources of information at its disposal both internally and externally through partners to better inform community safety work in a targeted way. Through community profiling the risks and target groups and the specific community are identified and safety schemes and initiatives are then developed to address the inequalities and put in pace via a collaborative and partnership approach.
In the 1980s as the Fire Service embarked on a similar strategy to that of Public Health England has on Covid-19. Our message was clear and specific: it was to save more lives from fire. We needed the public to fit more smoke detectors, when cooking chips to fill the fat pan to less than half, and not to smoke in bed. Those three simple messages formed the basis of TV and poster campaigns.
The strategy worked to a point. However, for many it was not relevant to some as they either did not smoke or cook chips or could not see the need for a smoke detector. So, what worked?
The Fire Service then in the mid and late 1980s embarked on making campaigns more bespoke. It ran campaigns in different languages, and it used the BAME media to get messages out. The Fire Service used partnership collaborations as a cornerstone of the Prevention Strategy and as an example it used places of worship to promote the messages. The national government also set up a department just for fire safety and ran a branded campaign still going today called Fire Kills. It ran campaigns during faith festivals and was so successful fire deaths fell nationally by 200 every ten years from a high of 800 in the 1980s to just over 300 in recent years including the 71 multiple deaths of the Grenfell disaster.
In the 1980s the West Midlands Fire Service had over 40 deaths in the year. Via the community targeted campaign and other changes, the deaths are down to less than ten. My conclusion is prevention works but needs to be clear and targeted. It only works if you have a clear vision and you work in partnership with many stakeholders. With Covid-19 we do not need to wait to learn lessons of targeting campaigns to see significant impact on deaths. We can make changes now and impact on the tragic loss of lives and harm to those affected by Covid-19.
What we need now is not more research, nor more prevarication that BAME are more at risk, but clarity of action. I believe that we can do this together. This is not a role just for Public Health England or just for an individual Trust, it is for all of us. Can we do it? Yes we can and yes I can, meaning to me that everyone has a role in designing and delivering the message.
Yes I Can, Yes We Can
‘Yes I can’ means that I take responsibility for the information and data, it means that I can help reduce the impact of Covid-19 on my family, friends, community and in my workplace. ‘I’ also means I will bring the issue to the attention of all those who can do something to support me and my family and my staff to be safe from Covid-19. It means I will be clear the message is about how not to spread the virus and if someone has the virus to share the tools to reduce its impact. ‘I can’ means I will promote messages that are targeted at my communities and my staff. I will offer advice and support on what we can do to stop the spread of the virus and reduce the impact once someone is Covid-19 positive. I will do all I can to support and spread the public health message. I will also help to design the message to be more suitable to the audience I am presenting the message to.
‘Yes we can’ means to me what can I do as a group or organisation. It will mean that when I wear the different hats, I will take an organisational approach to what we can do in every forum I am a member of. ‘We’ means I will use all the forums I have access to promote the public health message and I will ensure these organisations that I lead and understand how they can get the messages of prevention out to all stakeholders. ‘We can’ will also mean taking the message to forums such as my staff networks in the NHS, fire and business communities. It means we all own the prevention message to promote the direct messages to our communities and ‘we’ also means we must stop the fake messages at source. ‘We’ also means that we as NHS England and Public Health England have a role to create more bespoke messages targeted at the at-risk group. If required I will support, help and advise all the groups who do not have the capacity or the knowledge of how to reach the at-risk groups.
To take things forward I would recommend the following key actions to help develop the above behaviour change I have described:
1. Focus on prevention and target the message to the most at-risk groups to have maximum impact
2. The system needs to foster better understanding and conviction between addressing prevention, health inequalities, risk and demographics
3. The system needs to integrate equality analysis to ensure processes and systems recognise risk and prevention
4. Leaders need to role model behaviour that demonstrates confidence about talking about prevention, equality, risk, and health inequalities
5. Invest in developing the skills of staff to recognise equality analysis within the context of health inequalities, risk, emergency planning and prevention
6. Fund the voluntary, faith and charity sector to take the prevention message to the community in a cost-effective way.
In summary, I hope my article will lead to the debate moving from the request for more data to what can we all do together for a common purpose of reducing infections, reducing impact of infections and, of course, reducing death.
This will also be done if we can build the right message for each community: if we use the tools we use for marketing and targeting individuals by bespoke approaches for TV or the many popular social media platforms we need to understand fast and quickly how can we reach all communities and stop the spread of this deadly virus.
My final message to the NHS and others is simple: embrace prevention through a focus on risk reduction for vulnerable people and by raising awareness about risk to the wider community.