Addressing health inequality in a multi-ethnic population

Vinod Patel

Professor of Diabetes and Clinical Skills, Warwick Medical School, and Honorary Consultant Physician, George Eliot Hospital, Nuneaton

Cultural competence: “Ability of systems to provide care to patients with diverse values, beliefs and behaviours, including tailoring delivery to meet patients’ social, cultural and linguistic needs” (Betancourt et al, 2002).

Health inequality: “A systematic inequality in health (or in its social determinants) between more and less advantaged social groups; in other words, a health inequality that is unjust or unfair” (Braveman and Gruskin, 2003).

The significant ethnic and religious diversity in the UK is good, but some groups have higher T2DM burden and onset 10–12 years younger, resulting in more complications. Higher risk of serious consequences from COVID-19.

Deprivation and unhealthy behaviour interact  – harms and mortality higher for those with unhealthy behaviours in deprived groups, but equally, if healthy behaviours can be sustained, mortality is reduced even in the most deprived groups
(Foster et al, 2018).

Addressing health inequality requires us to identify and seek to minimise the impact of:

• Ethnicity or “Heritage” – Differences in T2DM and CVD risk. Differences in care delivery (e.g. Ramadan).
• Deprivation – when adjusted for, reduces effect of ethnicity almost completely.
• Lifestyle factors – address smoking, obesity, diet and physical activity aggressively (see Lifestyle factsheet for advice).
• Socioeconomic determinants of health – explore environment, climate, pollution, stress and access to nature.

National diabetes audits remain fit for purpose and should be pursued.

Further reading

• Healthy lifestyle and life expectancy free of cancer, CVD and T2DM: https://doi.org/10.1136/bmj.l6669
• Interaction between deprivation, healthy lifestyle and health outcomes: https://doi.org/10.1016/s2468-2667(18)30200-7

Severe mental illness and learning disability

Peter Bagshaw

GP and Mental Health Autism and Learning Disabilities Clinical Lead, Somerset CCG

Clarify definitions and check coding is used accurately:

• Learning disability – reduced intellectual ability, difficulty with everyday activities affecting someone for their whole life.
• Learning difficulty – specific difficulty learning in one area (e.g. dyslexia, dyspraxia, ADHD). Not a global intellectual impairment.
• Severe mental illness (SMI) – psychological problems which can be so debilitating that they severely impair ability to engage in functional and occupational activities (e.g. bipolar disorder, schizophrenia).

SMI and learning disability similarities and differences:

T2DM more common in both, and management more challenging:

• T2DM risk 2–5 times higher in schizophrenia; almost three times higher in bipolar disorder.
• 10% with learning disability have T2DM and 40% are obese.
• Lithium, antiepileptic medication and antipsychotic drugs all contribute to weight gain and obesity.

Two-way interaction – people with diabetes have double the risk of depression and three times higher anxiety. There may be significant genetic overlap, increasing co-existence of depression and T2DM.

Premature mortality in both conditions (up to 20 years earlier) – mainly due to CVD, T2DM, and hypertension. Often preventable.

Change in attitude is the critical factor for dealing effectively with both.

STOMP (STopping Over Medication of People with a learning disability, autism or both) – many psychotropic drugs can be stopped safely. Learn more here;  Quick guide here.

Resources

• Mencap for learning disabilities; Mind for mental illness
• Diabetes UK: EasyRead leaflets
• NHS RightCare diabetes pathway: Reasonable adjustments for people with a learning disability
• Books Beyond Words – many health topics, including Getting on with Type 2 Diabetes