As the vaccination programme rolls out at breakneck speed and society reopens, the same groups who have suffered most in pandemic and who remain at higher risk of infection are also at greatest risk of not being vaccinated, as this sobering report and map from Bradford makes clear.
Directly standardised mortality rate per 100,000 population and proportion of total population receiving the Covid-19 vaccine with one dose in Bradford (to 11th February 2021)
Despite heroic efforts to promote vaccine uptake by local public health teams, higher levels of vaccine hesitancy among the less well off remains, particularly among people from non-white ethnic backgrounds. This hesitancy has its roots in mistrust of institutions and long standing discrimination. As the above map demonstrates, with age driving vaccine prioritisation, younger and sicker inner city populations will inevitably lag behind in terms of vaccine coverage as the programme is rolled out.
When reflecting on this subject, I immediately think of Omar *, the elderly Pakistani-British man I saw in the Covid vaccine clinic who did not believe that the tray of syringes full of vaccine that I had in front of me contained the AstraZeneca vaccine and that I was going to inject him with something ineffective or harmful. A lifetime of exposure to racism and poverty can lead to this level of skepticism. Fortunately, I was able to show him the vaccines being drawn up from the labelled vials and he agreed to go ahead.
Patients like David * are the people behind the statistics. I spoke to David a number of times in April 2020, at the height of the first wave of the pandemic. He was in his fifties, suffered from Chronic Kidney Disease, Coronary Artery Disease and COPD but did not initially make the shielding list, meaning he was having to turn up everyday to the busy, windowless and cramped warehouse where he worked. Here, there was little prospect of social distancing or good ventilation. He had to travel to work by bus because his chest and heart would not permit the 3 mile walk and he could not afford to own a car. His nervousness around the daily risk of catching covid meant he became very anxious, was not sleeping, started drinking alcohol to cope (from being a teetotaller) and, eventually, became depressed. I had no choice but to sign him off sick and we did everything we could to help him through a very difficult time financially. Clearly his risk of catching and dying of Covid was very high and the impact of the pandemic on him and his family has been significant.
I also think of Rachel *, a care worker on minimum wage at a local nursing home. I was called out to see a resident where she worked. Some masks, gloves, aprons, no face protection and some very watery alcohol gel were piled on the floor outside a Covid positive resident’s room. The landing was not ventilated and all the rooms were carpeted and full of furniture, making them impossible to disinfect. Proper hand washing facilities were only available on the floor below. It was not hard to see why carers going in and out of the room several times a day could easily be infected with Covid.
Most GPs, particularly those working in areas of socioeconomic deprivation, will have heard many similar stories of the working poor being exposed to excess covid risk solely due to social factors. There are tens of millions of Davids and Rachels in the UK. Rachel caught Covid-19 but only had mild symptoms. David managed to escape infection. Many of our patients in similar circumstances were not so lucky, caught Covid and ended up very sick or died.
The vaccine programme prioritisation categories do not include the flexibility that local areas ideally need to respond to local factors (i.e. housing conditions, infection rates, known rates of under-diagnosis of long term conditions etc). Q-Covid will help but not entirely resolve the problem and is only being introduced several months into the vaccine rollout.
It is entirely understandable that a national vaccine programme would use age to prioritise vaccination as this remains the most important driver of risk. However, what works in wealthy towns in South East England might not work so well in Bradford, Leicester and East Lancashire, parts of the country that have suffered the most, with their younger, sicker and more ethnically diverse populations.
These communities need to be able to flex their vaccine programmes according to local risk profiles and social conditions, be given the resources and scope to regulate and enforce Covid-safe work environments and support their poorer residents financially and logistically when they need to self isolate.
The number one priority must be to get as many people vaccinated as quickly as possible. Primary Care Networks have been incredibly successful in doing this so far and should remain front and centre of the vaccine programme. Vaccine hesitancy is far more likely to be overcome if vacccines continue to be delivered close to where people live, by trusted local healthcare professionals and, ideally, in a range of trusted community venues.
Omar was vaccinated at a clinic in run in his local mosque and I’m sure was mainly reassured by everyday surroundings and the presence of familiar faces when he was at his most anxious.
What does this mean for PCNs and those overseeing vaccination programmes? Ideally:
Working with grass roots community organisations, community leaders and the voluntary and charitable sector to promote vaccination, address peoples’ concerns and hesitancy about vaccination and build trust
Taking vaccination clinics out into trusted and familiar community venues, focussing on those communities where uptake and coverage is lowest
Getting the message about vaccine effectiveness and safety out there using trusted multilingual messengers and formats that will be accessible to all
Using mainstream media and social media to promote vaccination and make trusted healthcare professionals as accessible to the community as possible
Thinking about how the most vulnerable will be reached: people with serious mental illness, people with learning disabilities, people who are homeless, refugees and asylum seekers
Ensuring people with chronic disease and carers have up to date coding on their medical records that will ensure they are vaccinated as soon as they are eligible
Using good data to track progress with vaccination, including by index of multiple deprivation and ethnicity
As we emerge from the pandemic, we should remember the sense of solidarity and togetherness of March and April 2020. Until everyone is safe, none of us are safe.
We have the vaccines and we have the means to distribute them equitably, achieving high uptake in every community. Failing to do so would be grossly unfair to those who have been hardest hit by Covid-19.
Primary care teams in West Yorkshire running a vaccine clinic at Keighley Central Mosque – February 2021
The RCGP Standing Group on Health Inequalities have produced an excellent resource on increase vaccine uptake here.
*patient names and other details have been altered to preserve anonymity.
Guest blog post from Dr Kitty Worthing (@kitdempsey), GP trainee, Tower Hamlets& Dr Sophie Williams (@stw8127), Academic Clinical Fellow Oncology, Sheffield
The NHS is often spoken about as a source of pride in the UK. Pride in what is perceived to be a universal healthcare system: free and accessible to all those who need help. If only it were.
I first encountered NHS charges for migrants as a medical student, volunteering in East London with Doctors of the World, here I witnessed the far-reaching and devastating impacts of NHS charging, and its intersection with the effects of other Hostile Environment policies on health and well-being.
When I started work as a Junior Doctor, I encountered patients experiencing barriers to accessing care due to their immigration or housing status, or who were experiencing significant psychological distress secondary to being charged. I stood aghast the first time I witnessed an Overseas Visitors Manager walk unannounced into a ward to see a patient carrying a chip and pin machine to ask for payment; it felt so at odds with the principles our NHS supports. Attempts to advocate for patients on an individual basis felt inadequate in the face of the wilful implementation of a policy that clearly caused harm by NHS trusts, and this led me to my first Docs Not Cops meeting.
Whilst thankfully General Practice remains free for all, many without formal documentation struggle to register with a GP. Research I’ve been conducting has found that restrictions in secondary care and ideas around who ‘deserves’ care may in some cases inform staff’s reluctance to register this patient group. For patients, many are unaware GP is free, there are concerns about their data being shared with the home office, and they may not be able to access secondary care services when referred by a GP.
In the rest of this article, we will discuss the legal aspects of charging migrants for NHS treatment, outline the harm it causes and discuss Docs Not Cops & other campaigns active nationally to bring this practice of rationing healthcare based on immigration status to an end.
NHS charging policy
Legislation to charge patients for NHS care, based on immigration status, has existed for some time: the first attempt to charge patients not deemed ‘ordinarily resident’ was made in 1982. However, this was largely abandoned in the face of resistance led by migrant centres, trade unions, law centres and healthcare workers. With the Immigration Act of 2014, and associated immigration policy subsequently dubbed as the ‘Hostile Environment’ we saw a reintroduction of charging based on immigration status. Further regulations in 2017 expanded ‘chargeable’ services into the community, introduced ‘upfront charging’ (patients required to pay full cost of care before receiving it) and increased legal pressure on NHS trusts to check eligibility and implement charging. In brief, those deemed not ‘ordinarily resident’ (a complex legal term that in 2014 came to exclude those not deemed to be living in the UK ‘lawfully’) are charged for NHS secondary care (including in the community, but excluding care received in A&E) at 150% the actual cost of care. If the care is deemed ‘urgent’ or ‘immediately necessary’ they should receive the care regardless of their ability to pay, but will still be asked to pay upfront and charged retrospectively if they cannot do so. If the care is deemed ‘non-urgent’ it can be refused if they are not able to pay the full amount upfront.
Other important forms of immigration control outside of charging mechanisms include:
1) Data sharing – if you have a debt of over £500 to the NHS for over three months, the NHS can pass your demographic data to the Home Office, which can then be used to detain and deport you. Until recently patient data was shared with immigration officials by GP surgeries, but this is currently suspended. Many NHS trusts also employ private debt collectors to chase outstanding payments, who hound patients in their homes.
2) International Health Surcharge – an additional visa fee of £625 that must be paid annually to access the NHS, which acts as double taxation.
The harm caused by the implementation of these policies expands beyond those ‘correctly’ charged, and we have seen many racialised as ‘foreign’ who have come to harm; one notable example being those affected by the Windrush Scandal. In addition, we have seen widespread fear and reluctance to access healthcare even amongst those who would be eligible for care either because they are ordinarily resident, or meet an exemption criteria.
We have witnessed the expansion of borders into our public services beyond the NHS – many left with no recourse to public funds, unable to rent housing or access free school meals; punishing those already facing precarity by cutting off vital lifelines. This has forced healthcare workers and others to be complicit in restricting services based on immigration status, and in some cases operationalising access to care as a means by which to collect demographic information then used for immigration purposes.
It is important to be clear that this policy is racist in its intention and implementation and forms part of a Government agenda to scapegoat migrants for deliberate underfunding of public services. Furthermore, implementing and refining charging mechanisms for one group of people, inevitably lays the groundwork for the expansion of charging to others.
Docs not Cops and the Patients not Passports campaign
Dops Not Cops are a grassroots group of activists, from many different backgrounds, who believe health is a right and not a privilege. The group fights for an end to all forms of immigration control in healthcare and the Hostile Environment more broadly and for a truly universal NHS.
Docs Not Cops is an example of a campaign which works to change public perception, and political mandate, on charging for NHS treatment. Examples of the group’s work includes street protests, vigils, publications, and online videos. Docs Not Cops uses the power in everyday people to challenge those with institutional power to make change happen.
With the expansion of charging in 2017, Docs Not Cops has joined forces with groups across the country, including Migrants Organise and Medact, to form the Patients Not Passports (PnP) campaign. The work of PnP has included organising NHS staff and communities to resist charging and the creation of an online toolkit to support both individual advocacy and broader campaigning. Additionally, PnP has supported campaigns led by those directly affected by charging – one example of this is the Justice for Simba Campaign.
The Justice for Simba Campaign
In Sheffield, Simba Mujakachi’s campaign against NHS charging has brought together local MPs, health workers, students and community groups, as well as garnered support nationally.
Simba has faced the worst consequences of immigration in healthcare and has been targeted by the cruel and unjust Hostile Environment. After suffering a life threatening stroke, Simba was presented with a bill of £93,000 because he is a failed asylum seeker. He struggled with access to long term rehabilitation and appropriate housing: an example of how the Hostile Environment extends into all aspects of welfare and support. Now, he is left with a debt to the NHS of over £100,000, and ongoing health problems as a result of the stroke. His story has been covered in the national press, including on Channel 4 news.
One tragedy is that Simba had been diagnosed with a blood clotting condition prior to his stroke, but had been denied specialist, secondary care because of the upfront costs which he could not afford. We can never know whether managing Simba’s underlying condition would have prevented the catastrophic stroke, if he had been able to access treatment for the blood clotting condition. However, we do know that the associated costs prevented him from accessing the healthcare he needed. This is not the face of a universal NHS, free and accessible at the point of need, but instead another border, obstructing a right to life lived without fear and in good health.
Simba’s story is not unique – there are thousands like him, denied treatment or billed immense sums of money for care. By telling his story, Simba has sent a message to others facing similar charges, that they are not alone and that there is support and solidarity for them.
How to take action
Make use of toolkits for supporting individual advocacy and community organising:
National Trailblazer GP Session – 27th November 2020
Blog post by Dr Jayne Marston, Trailblazer GP 2020/21
This was a fantastic session led by Jonathon Tomlinson, a GP in Hackney.
It was useful to reflect on patients that GPs found challenging, I discussed this with my colleagues and we could all relate to how some consultations were more difficult than others and the themes mentioned in the presentation ran true, especially around long-term mental health problems and chronic pain.
The presentation made me reflect on why I found these cases challenging. As GPs we should be a ‘jack of all trades’ a true generalist, but it seemed some areas of medicine were consistently more challenging. As doctors we have a ‘fixer’ personality type, we strive to find solutions to problem, we all prefer ‘succinct’ consultations where the patient comes with x symptom, we give then y and they get better. In reality very few consultations are like this, patients present with a variety of symptoms and we offer them a range of treatment options with often varying degrees of success!
This talk about trauma informed care, almost turned the traditional model on its head. Jonathon talked about how the trauma impacted on an individuals current experience of symptoms (eg heightened anxiety, perception of pain) and very little about the traumatic event itself. It was the concept that what is left behind after an emotional trauma is important and not necessarily the event.
Given that we, as doctors, cannot treat an already experienced trauma or even the impact it’s left them with, Jonathon went on to talk about what we can do. He talked about the key concept of active listening, going back to the basics of good history taking, being kind, the validation of all symptoms (even those that are medically unexplained), vindication and building up a connection / relationship. This has helped me move away from the ‘must fix now’ model. It helps to see the consultation within the context of a longer term doctor/patient relationship and joint health goals; the integration of social security, relationships, physical and psychological well-being with the GP being central hub to other services rather than just a referrer.
I had been working as a GP in Airedale, just west of Bradford, for around 2 years when I got involved with setting up GP at the Deep End Yorkshire and Humber. Like many parts of the country, Airedale is an area of socioeconomic extremes. On one edge of our patch lies Skipton and Craven, reportedly the happiest place in the UK, and on another, Wharfedale, which hosts some of the most expensive housing in Northern England. I had completed most of my GP training in Keighley, a town closer to Bradford with a much more mixed socioeconomic outlook, and eventually took up a permanent position at Holycroft Surgery, located within one of the most deprived council wards in the UK.
As with many areas, travel across the Airedale locality and life experience, along with pretty much every other indicator of health and wellbeing, varies dramatically – an 8 mile journey can encompass a 10 year difference in like expectancy at birth for local inhabitants. However, it was not the abstract idea of health inequality and these statistical variations that got me interested in the Deep End movement. Rather, it was the shared experience of healthcare professionals working in areas of socioeconomic deprivation.
It was immediately apparent that our patients came with layers of problems and issues born out of a lifetime of disadvantage. Even something simple like a rotator cuff strain was rarely just a rotator cuff strain. How would you help get this better when the patient was working 12-14 hours a day as a carer on a zero-hours contract doing manual handling all day, did not have the money to take time off work, had the recovery rate of someone 20 years older due to a lifetime of stress and childhood trauma and struggled to remain motived to exercise due to depression and having to look after her alcoholic partner?
It was also a period when I’d watched a procession of brilliant GPs move out of my practice in Keighley to work in leafier neighbouring areas, emigrate or become unwell and retire. One GP remarked to me: “I spend a lot of my time doing social work and I just can’t carry on being here until 8 or 9pm every day trying sort peoples’ lives out. It’s making me ill”. It was around this time I read about GPs at the Deep End in Scotland. Graham Watt’s swimming pool analogy really struck a chord.
Reading through the Deep End group’s short papers, made me realise there were others out there grappling with all of the problems I was seeing and that there was this vast well of wisdom that I, a relatively newcomer, could tap into. It was also inspiring and energising to see this tough and vital work given recognition through academic and Government institutions.
From October 2015, we hosted a series of increasingly well attended meetings under the GP at the Deep End banner. We decided that the areas we needed to address were Workforce, Advocacy (for GPs and people in the communities where they worked), Education and Research.
Things developed quickly. As well as the accumulated wisdom our of colleagues in Scotland and figures such as Julian Tudor-Hart, we met amazing people like John Patterson, Laura Nielsen and the Shared Health, Focussed Care and Citadel Healthcare teams from Greater Manchester, who had set up primary care with the aim of tackling health inequalities at its heart and transformed lives across their communities in Oldham and beyond. Irish GP Austin O’Carroll inspired us all with the amazing North Dublin City Training Programme, which trains GPs to work with people living in areas of deprivation and with marginalised groups. Jonathon Tomlinson from Hackney in East London helped us learn about the role of trauma in peoples’ lives and how GPs could help through “trauma informed care”. Greg Fell, now Director of Public Health in Sheffield, has helped us focus on the role of public health in primary care and the evidence base for addressing health inequalities as GPs. Perhaps most importantly, GPs in working in Yorkshire and Humber’s major cities got to meet each other and share stories of how they’d helped patients living in communities with huge and, at times, seemingly insoluble challenges.
We set up with award-winning Fair Health website to share this collected knowledge and experience with GP trainees across the region and, now, nationally and internationally through e-learning modules, blogs and podcasts. We have “Trailblazer” training programmes specifically focussed on deprivation for GP trainees and new qualified First5 GPs. We have hosted a series of brilliant and motivated “health equity leadership” fellows in the School of Primary Care who have helped ensure every new GP in Yorkshire and Humber has received specific training around health equity and spent time out of the GP surgery in their communities.
In undergraduate education, Ben Jackson at the University of Sheffield has set up a programme of community based medical education around health inequalities. Liz Walton has set up a research network across practices in the city’s most deprived communities, increasing patient participation in designing and enrolling in medical research, and also helped write up our experiences in the BJGP and other journals.
Increasingly, our Deep End colleagues are taking on senior leadership positions or becoming involved in advocating for change across the NHS in Yorkshire and Humber. We have been lucky enough to contribute to two books: Tackling Causes and Consequences of Health Inequalities; The Exceptional Potential of General Practice, which set out approaches to workforce development and curriculum delivery.
Yorkshire and Humber GPs at the Deep End cannot and would not want to take credit for all this amazing work. But it has provided a rallying point for enthusiastic GPs. We hope it has provided some inspiration and helped us learn from each other. Perhaps most importantly, the movement has raised the profile of some the most challenging and important work in the NHS and made those people doing it feel a little less alone and a little more supported.
A summary of our work over the last 5 years can be found below.
Blog Post by Deemica Patel (Trailblazer GP 2019/20)
Write up of Trailblazer GP Education Session. This session was delivered by Suzanne Heywood-Everett, Consultant Clinical Psychologist, who has an interest in eating disorders, Autism and Chronic pain.
The session focussed on how we as GP’s can manage chronic pain and persistent physical symptoms. Frequently health professionals can feel that they are out of their depth with these issues and see patients with these problems as ‘heart sinks.’ This can create a culture where health professionals may avoid such patients, medicalise their issues, medicate the problem, and refer inappropriately for investigations and to different specialities. This in turn can make the problem worse as patients may experience further psychological issues, feel they aren’t being listened to and they may seek quick solutions.
Chronic pain is pain experienced for more than 3 months duration and is due to changes in the state of the individual’s tissues and influenced by other external factors.
Some key points around chronic pain management:
It is important to elicit cultural norms and health beliefs as these can lead to somatisation.
It is normal for health professionals to medicalise problems and they have a tendency with patients experiencing chronic pain to over investigate in case they feel that something is missed
Take ownership – patients can see lots of different professionals and sometimes this may be due to unavailability of appointments with a particular health professional, certain health professionals may not feel comfortable/ experienced seeing patients with chronic pain so do not actively encourage follow up with them.
It is important for continuity to be established.
Referrals to other services may make the problem worse.
Quick fixes can reinforce health beliefs
Admit that you don’t always have the answer
Patients should take responsibility for their pain- empower them
Role for GP to challenge a patient’s narrative around chronic pain
Points during the consultation
Try to explore the impact of the pain and pain medication on their life and the impact of medicalisationOften pentinoids/ opiates can cause multiple side effects and patients may be prescribed medications to counteract these
Explore their experience of investigations and referrals
Patients commonly feel worse as the referral and investigation culture can make them feel that something is being missed
Ask about psychological trauma- this can help you understand when and why the pain began
Be mindful of your reaction to the issue – e.g. using negative words (ouch, oh no), negative body language can reinforce a patient’s perception of the problem
Think of way you explain terms e.g. degeneration and trapped nerve are unhelpful words
Patients with chronic pain can be reluctant to change a certain behaviour
Exercise: think of a behaviour that you have found hard to give up. How would you feel if we were asked to give it up and what would the best way would be for somebody to ask you to give it up.
Most people minimise the negative aspect of the behaviour e.g. I know I shouldn’t drink more alcohol but it helps me to relax and I have had a stressful week at work, therefore I deserve a drink to help me relax
Understanding this highlighted that it would be difficult to make changes if you are not in the correct mind-set
Patients need to be self-motivated and either pre contemplating or contemplating making changes before embarking on this journey
Offer a follow up appointment when they are ready to make changes
Acknowledge pain is real and about protection e.g. twisted ankleà swollen and painful, cannot walkà restà symptoms improve
Advise management is not a quick fix and will take time
A personal reflection on racism and steps for meaningful action byDr Mariya Aziz, GP, Keighley, West Yorkshire with input from Dr Tom Ratcliffe, Fair Health
Events over the last few weeks, from the brutal killing of George Floyd to the devastating effects of COVID 19 on the BAME community, have highlighted the racial inequalities that lie deep within our institutions and the appalling impact it has on so many.
For those from a BAME background, myself included, it has churned up memories and feelings that we try and suppress and brought them to the forefront.
I cannot pretend that my experiences of racism as a British born Pakistani are the equivalent to those of my Black counterparts. However, the impact is indelible and has shaped me into the individual I am today.
The Health Services Journal reports that 44% of NHS doctors currently self-identify as BAME. At the height of the epidemic, of the number of doctors who sadly lost their lives to Covid-19, a staggering 95% were from BAME backgrounds. The same pattern is seen in other clinical staff groups (see resources).
Data from the Office of National Statistics (see resources) showed that people from Black, Bangadeshi / Pakistani and Indian ethnic groups were all at a substantially increased risk of death from Covid-19 compared with white ethnic groups, even once multiple other factors, such as age, gender and socioeconomic deprivation, were controlled for. The data standardised for age alone is even starker. This showed that Black men and women were over 4 times more likely to die from Covid-19 than their white counterparts: a shocking disparity that reveals the stark intersection of race and poverty in health inequality.
Risk of COVID-19-related death by ethnic group and sex, England and Wales, 2 March to 10 April 2020 (Age adjusted model)
Odds ratio of Death compared to White ethnicity
Source: Office for National Statistics, UK
How do we respond? What can we do better? And what we must avoid doing from now on?
First, we must all recognise and challenge the overt and more subtle forms of racism that still exist in healthcare.
Second, we must stop assuming that “not seeing colour,” means racism will go away and adopt a stance of active “anti-racism”.
Third, we must take extra steps to be more inclusive, recognising that people from BAME backgrounds will often have past experiences that can trigger difficult memories and feelings that can impact on their ability to engage with colleagues, organisations and leadership opportunities. There may also be cultural barriers, which we are not sensitive to, that could also impact their progression to senior positions.
Recognising the challenge of racism
Overtly racist comments and use of unacceptable racial terminology is becoming less common but is certainly not unheard of. I do still hear people ask questions or use language that is unacceptable and have challenged it. Sadly, I have not always felt supported in doing so. I like to think that this not because people condone what others are saying (in the majority of cases) but because people are not always clear about the forms racism can take and feel uneasy about calling it out.
I do not feel this is acceptable. Inaction and failing to challenge racism is to be complicit in racial abuse.
Most difficult to address are comments and actions that are borne from ignorance and form “micro-aggressions”. Insidious in effect, these can create self-doubt and a pervasive worry about the way in which one is perceived. This can be more harmful than the overt racism that most people would easily recognise.
Examples in healthcare include:
Patients refusing to see a BAME clinician due to their race;
Ill thought out comments such as “your/her English is surprisingly good” in clinical feedback;
Unnecessarily prefacing references to colleagues with a racial identifier that would not be used when referring to white colleague (i.e. “the Asian doctor”, “that Asian family”)
Asking questions about another person’s cultural or social life out of curiosity but posing these in a way that uses stereotypes disrespectfully (i.e. “are people in your culture allowed to have more than one wife?”)
Being actively anti-racist
Some people conclude that the answer to these issues is to remove race as an issue entirely. Co-workers have reached out to me with comments such as “I don’t see your colour”. Whilst well intentioned, I have never felt such an approach provides comfort or reassurance. For me, it minimises who I am. My race and culture are part of me, not something that can be simply ignored.
In her book, White Fragility, Robin Di Angelo, illustrates this point when reflecting on an interaction between a White woman and African-American man:
“His race meant that he had a very different experience in life than she did. If she were ever going to understand or challenge racism, she would need to acknowledge this difference. Pretending that she did not notice that he was black was not helpful to him in any way, as it denied his reality and kept hers insular and unchallenged. This pretence that she did not notice his race assumed that he was “just like her,” and in so doing, she projected her reality onto him.”
The answer to racism is not to ignore race. It is to be actively anti-racist:
“One either allows racial inequities to persevere, as a racist, or confronts racial inequities, as an antiracist. There is no in-between safe space of “not racist.” The claim of “not racist” neutrality is a mask for racism,” Ibram X. Kendi (from How to be an Anti-Racist).
For most of us, adopting a stance of anti-racism, involves painful self-examination and challenging conversations. It should not need stating, but being BAME does not exempt me from this! Sadly even within my own community, there is a racial hierarchy and there is a need to look inwards and reflect on this.
I also believe that understanding what it means to be an ally is an important first step in the road to becoming an antiracist. Being an ally is not easy. It requires us to step out of our comfort zones and challenge discrimination where we see it but to also be mindful of scenarios where it is not so evident. There is a need to acknowledge that we may have privileges not afforded to others on the basis of their skin tone and to share the benefits of this privilege.
Learning is an essential part of this process. And this means more than completing an annual mandatory e-learning module on Equality and Diversity. Whilst still worth doing, this is not even going to scratch the surface. You may find some of the resources listed at end helpful in addressing our learning gap.
Below is a chart that I have found helpful in the process of self-evaluation in my journey to becoming an antiracist.
Chart was adapted by Andrew M. Ibrahim MD, MSc from “Who Do I Want to Be During COVID-19” (original author unknown) with some ideas pulled from Ibram X. Kendi’s work.
As Scott wood, American author and poet wrote:
“Yes, racism looks like hate, but hate is just one manifestation. Privilege is another. Access is another. Ignorance is another. Apathy is another. And so on. So while I agree with people who say no one is born racist, it remains a powerful system that we’re immediately born into…It’s a set of socioeconomic traps and cultural values that are fired up every time we interact with the world. It is a thing you have to keep scooping out of the boat of your life to keep from drowning in it…”
I have no words to better this and it stresses even more that the act of being antiracist is a lifetime commitment to self-evaluation and learning.
Empowering BAME people within healthcare
Within my current role, whilst our primary care organisation (and indeed the whole medical profession), is very diverse overall, I am the only senior BAME GP working in my immediate setting. Recent events have made me reflect on the effects of this and my own empowerment.
Being placed in a group where I am in the minority as a person of colour can be paralysing. Whilst not an issue in the safety of my immediate clinical team, stepping out of this protected zone into the large business or commissioning meetings can be daunting.
At times, these experiences have rendered me acutely conscious of my race but also my culture and its variance to that of my peers. I know I speak for myself and others when I say that when placed in an ethnically homogenous environment we have all felt to some degree that we have had to compromise ourselves to blend in. In turn this leads to one feeling apologetic or the need to justify/defend certain behaviours that do not fit into the “White” norm.
I know the reasons for my response to this specific situation are rooted in my own insecurities based on past racial discriminations. The last time I was the only BAME individual in a large group was at school, which was a traumatic time due to race related bullying. Sadly, this experience was not atypical and similar feelings and experiences can be a barrier for those from a BAME background to progressing to roles of senior leadership.
Engagement with my predominantly White colleagues on this topic has not been easy. I acknowledge that race is a sensitive topic and those from a White background can feel defensive or as if they are being attacked equally those on the other side of it are perceived as “having a chip on their shoulder/always making it about race”. Hence it is imperative that we do educate ourselves and I include myself in that.
Being South Asian and Muslim does not exempt me from having my own prejudices and unconscious biases. And simply having a diverse workforce is not sufficient to resolve this issue. In fact, I am conscious that, among BAME colleagues, there is a recognised phenomenon of “pulling up the ladder” and failing to help empower colleagues or, worse still, making their progression harder than it should be.
If we are to tackle racism, there will be uncomfortable realities that need acknowledging and challenging. We must be proactive and acknowledge a need for meaningful and sustained education and training around race and its impact within all layers of the NHS. We must translate learning from this into delivery of clinical care and consider how organisation of healthcare in culturally insensitive or inappropriate ways exacerbates health inequalities.
This will take time, effort and commitment. However, there are practical steps that we can take immediately. I have listed some suggestions below:
Leaders, including Freedom to Speak Up Guardians, should use this opportunity to specifically address the issue of racism within the NHS and invite a more open discussion of this topic
Primary care organisations should organise the collection of data in primary care similar to that of the secondary care and CCG WRES reports to support and ensure that BAME colleagues are being given equal opportunities.
Healthcare employers should ensure staff surveys specifically mention discrimination relating to race and other protected characteristics
Primary care organisations and educators should promote the concept of allyship as part of wider education for all staff on antiracism and the effects of unconscious bias.
Mentoring should be provided for BAME colleagues. For example, using the reverse mentorship programme run by Health Education England. This would pair individuals from under-represented groups with healthcare leaders from non-BAME backgrounds in the hope that alliances are created and experience and knowledge shared.
Proactively encourage BAME colleagues to pursue leadership opportunities. The NHS leadership academy has courses aimed at supporting BAME individuals progressing within the work place, i.e. the “ Stepping up” and “Ready Now” programmes.
Practical steps such as recognising a wider range of religious holidays in organisational timetables, thus empowering people and making them feel valued within the organisation.
Use Health Equity Audit to look at the uptake of primary and secondary prevention and health outcomes by ethnicity, then take steps to address any inequities identified
Ensure information is provided in a range of languages and interpreters are easily accessed
Ensure that patient councils include a range of individuals and voices that reflect the demographic make up of the patient body, including by ethnicity
Ensure that the way that illness presents in different groups is recognised and that clinical staff are aware of how symptoms and signs vary across BAME and white ethnicities
Build alliances with organisations that already provide services for the most vulnerable members of the BAME community, for example inclusion health providers and the VCS
The tragic events in the USA and the Black Lives Matter movement have created huge momentum in what is most likely a once in a generation moment. I know having these conversations with our teams, calling out racism in all its forms and adopting a stance of active anti-racism will be difficult. We have to remember that this is about us coming together so that the minority can be part of the majority and receive fair and equal treatment.
There are many excellent books, films, documentaries covering the topics discussed in this blog. The list below suggests a few that may be of interest and/or provoke further reflection and debate. Please note that a number of these resources include graphic and distressing material that some will find difficult to read, hear and/or watch.
Non Fiction –
Why I’m No Longer Talking to White People About Race by Reni Eddo-Lodge. Based on Reni’s blog post of the same name that went viral back in 2014. A must read book exploring what it means to be a person of colour in the UK today.
The Good Immigrant. A collection of essays featuring people such as Riz Ahmed, Bim Adewunmi, Vinay Patel, Eddo-Lodge and many others exploring race and immigration.
Inglorious Empire by Shashi Tharoo. Tharoo is an Indian politician and diplomat, whose book examines the effects of British colonialism on India and challenges some of the post-colonial myths about the British Empire.
White Privilege by Kalwant Bhopal. This book explores the myth of a post-racial society.
Black and British: A Forgotten History. David Olusoga. Olusoga explores how British history has been ‘white-washed’ and sheds light on the very long (right back to the Roman empire) and interwoven history of the UK and people whose origins lie in Africa.
Between the World and Me by Ta-Nehisi Coates. A letter to his son exploring questions about race in the USA today.
Girl, Woman, Other by Bernadine Evaristo. Booker prize winning novel exploring the interconected stories of twelve characters raising questions about race and feminism.
Queenie by Candice Carty-Williams. Darkly funny and candid. Covers a huge range of topics include race, mental health.
Americanah by Chimamanda Ngozi Adichie. The novel explores the story of a Nigerian woman who moves to the USA for university, caught between the two cultures and countries.
Homegoing by Yaa Gyasi. This novel explores the story of two sisters with different destinies: one sold into slavery and one marrying becoming the wife of a slave trader.
13th, a Netflix documentary exposing racial inequality within the criminal justice system. Title comes from the 13th Amendment, (the abolition of slavery in the USA).
When They See Us, a mini-series from Ava DuVernay about the Central Park Five (uncomfortable viewing including detailed descriptions of rape and scenes of violence).
Black and British: A Forgotten History.David Olusoga. Available on BBC iplayer. Olusoga explores how British history has been ‘white-washed’ and sheds light on the very long and interwoven history of the UK and people whose origins lie in Africa. He has also presented a series exploring ‘Britain’s Forgotten Slave Owners’ which is also available on BBC iplayer.
Selma, a film that chronicles the marches of the Civil Rights Movement.
The Hate U Give, a film based on the YA novel offering an intimate portrait of race in America.
We have just finished a Trailblazer session with Susy Stirling exploring ideas around the Imposter Syndrome and how this might show up in our lives and affect our thinking and decision making. In the latter part of the session we considered how we might understand and manage these thoughts.
I have been deeply affected by the session and wanted to share my thoughts. Firstly, to reflect that I never imagined that three hours over an online platform, even with a skilled facilitator and eleven excellent colleagues, could allow for such rich thinking, self realisation and understanding. These are grandiose words, but I use them deliberately.
I have been aware of the concepts around Imposter Syndrome (‘the self perception of intellectual phoniness despite consistent external validation’) for some time. I knew I experienced it to some extent but I have previously been reluctant to be labeled with it. I certainly experience thoughts and behaviours related to imposter syndrome such as; ‘one day they will discover I am not as good as they think I am’ and, ‘other people make better decisions that I do’ and I do have a tendency to ‘overwork or ‘polish’ something beyond requirements’ (which may mean this blog never gets finished!). Today gave me the opportunity to unpack and understand these thoughts, and recognise that it probably plays a greater role in my thinking that I had previously wanted to acknowledge.
One thing I found particularly interesting was to understand what experiences might have contributed to this ‘imposter’ thinking. For me, though it may already have been part of me, I think my insecurities increased at medical school. Medical school was a very impersonal environment where there were lots of very bright individuals who I felt all seemed to know more and understand more than I did. External validation such as passing exams and getting good grades did little to challenge this narrative in me which persisted through early years as a doctor. I wonder if my current narrative would be different if there had been more opportunities during medical school and early career years for personal reflection and development, helping me understand my strengths and value. Medical school was also the time that I had few or no persistent mentoring relationships (which I am lucky to have had in the latter part of my career), and, though I had good friends I did not have a significant other to challenge my narrative or my sense of self.
During the second half of the session we discussed ways to challenge any unhelpful narratives that we carry. We considered some of the techniques from ACT (Acceptance and Commitment Therapy) about how to distance ourselves from unhelpful and negative thoughts, moving from fixed ideas to fleeting thoughts. One lovely analogy that I will take forward was thinking about our thoughts as moving clouds in a sky, they are constant, they pass over and we can let go of them.
Finally we considered the importance of self awareness and purpose. ‘When we know and understand what we are here for we can better manage our feeling of being an imposter’. We considered how our core values might align with our current roles. In my case more recently my sense of being an imposter has diminished by working with a friendly, skilled, committed team in a place with a vibrant multicultural population with significant health and life challenges. A place I feel fits with my core values.
On the 17th April the Trailblazers attended a Zoom meeting led by Jaimee Wylam, a Public Health doctor and Martin Billington, a GP. The seminar couldn’t have come at a better time whilst we are all in lock down as the emphasis was placed on how, as doctors, we can take better care of ourselves.
I found that the openness of Martin and Jaimee really helped facilitate how we are all feeling during the COVID pandemic. Initial discussions unfolded the general feeling that we all felt quite restricted, anxious and caged in. As GP’s we are doing mainly telephone consultations and when needed will see the patient face to face. This is an unprecedented working environment and with that brings it’s own stressors, the main one being managing more uncertainty. We discussed how stress impacts on us both physically and emotionally and whether we had good awareness of when we were stressed.
Martin took us through a lovely breathing exercise “square breathing” as collectively we were starting to feel a little stressed just by the very nature of discussing the impact of it.
Something that had a positive impact on me personally was the category setting in light of the pandemic. Martin asked us to categorise things that we enjoyed doing into 3 groups. Group 1-things that we could do now without restrictions, for example gardening or going for a walk. Group 2-things that we could do with some modifications, for instance swap the swimming pool and go open water swimming -this is something I have enjoyed so much and I intend to keep it up even when the pools are open. Group 3-things that we couldn’t currently do such as eat in a restaurant or go on holiday
I found this a particularly beneficial exercise as it displayed still so many things I could still do and also how many new things I had placed in the first category. Prior to this pandemic I rarely stayed at home doing arts and crafts with my 2 young boys, instead we would be out in parks, spending money on lunches or expensive days out. Our life now was slower and more simple and in some ways less stressful. I enjoyed just being at home with them not feeling like we “had” to go out. I am also one of the fortunate ones-we have garden. I have never felt more grateful for this
To continue with the positive theme we talked about things we were grateful for. For me, it was again, having a garden and my health, to still be able to go running, enjoy my children. Having a support network we all felt was quite fundamental in how we dealt with stress. We reflected on how we could improve our support networks-some of us were leaving jobs to hopefully move into a more supportive environment. We were helpfully given links to the NHS and BMA sites available to NHS workers who may need additional forms of support for their mental health. Zoom has also provided us with a form of support, through this technology, which was new to most of us, we are able to stay in contact and keep the trail blazer program going. Up and down the country family and friends are taking part in quizzes, chatting to their grandchildren, work colleagues, taking part in exercise challenges. The NHS has also become more tech savvy, video consults were alien to me prior to this pandemic but now it is the new normal.
We agreed that self care and being kind to ourselves during the pandemic was vital. Yes the majority of us are going to gain a little “Corona weight” but is now really the time to place pressure on ourselves or to start restricting our treats? Well done to those who are perfectly home schooling their children, or have learned how to play a new instrument, my sense of achievement is getting through each day, perhaps with the help of Disney Channel (best £5.99 I’ve ever spent) or if feeling inspired, some arts and crafts. I have learned to stay away from baking, it rarely ends well.
This discussion on well being made me feel less alone and very much part of a strong connected group of individuals who were honest about how they were feeling and managing during this really difficult time both personally and professionally. I ended the meeting feeling more confident due to the new techniques and exercises that we were shown that we could utilise when felt stressed or anxious. Thank you Martin and Jaimee for your time it was a truly valuable experience.
To find out more about wellbeing sessions like these check out Jaimee or Martin’s website
Blog post by Dr Esme Lawy (Trailblazer GP 2019/20)
I work in a large two-site inner-city practice serving an extremely diverse population of patients many of whom live with deprivation, many of whom are migrants to Sheffield, many very recent arrivals. It is a population of patients who are not necessarily brilliantly served by the wider health service. We have adapted to some of the challenges we face in terms of sheer workload by moving in the past year to entirely clinician first triage with patients greatly encouraged to use our online consultation system AskmyGP. The (sometimes enormous) list of patient contacts and queries is then shared around the available clinicians with a great emphasis being placed on continuity, if it can go to the doc who knows that patient then it will. We then decide whether to engage with the patient online using the messaging system, phone them, bring them straight down for a face-to-face appointment or triage it elsewhere eg. Straight to a physio assessment or another service. They can send photos easily as long as they have a smartphone with a camera (I have found through asking my patients that most but clearly not all do have one in the household).
I have been at this surgery for a year and throughout this time we have been adapting and getting used to the system and, more to the point so have our patients. Some are instant converts. One 80 yr old woman who chuckled when I asked if she had a smartphone and said ‘yeah, but I can only use messenger’ was pretty impressed when I explained that it was pretty much the same thing but she could speak to her doctor, within a few hours, without having to be on hold on the phone at all.
There are drawbacks, I have had questions in my mind throughout the process along the lines of does this make things better for our patients? Does it makes things better for our staff? Does it make things better in terms of reducing health inequity? I don’t think the answers here are simple. The first thing to say is that we have always actively been intending to improve and not to create a barrier to access, people can still also reach us in exactly the same way as they always did before, via the phone line from 8:30-10am and they will be prioritised in exactly the same way (ie clinically), reception just create an AskmyGP query on their behalf.
There have been some serious questions raised and discussed in our meetings about how this system impacts our patient’s who have low literacy or little English. Our feeling is that the requirement for English is no greater than that required to speak to a receptionist and ask for an appointment. If anything I have probably found many patients are happier this way. They can use Google translate, they can ask a family member who can create the query for them as a proxy, and they always have the option to just fall back on the old system and phone to speak to reception or pitch up at the desk (well, in simpler, pre-COVID-19 times they could anyway). The literacy side of things is interesting, since learning recently that the average reading age of adults in the UK is somewhere in the region of an 11 yr old I have adapted the way I use the system. It’s the same old com-skills that we all know and use automatically but you just have to remember them as an absolute priority. Keep it simple, don’t use jargon, keep it brief and wait for confirmation that you have been understood. If we don’t get that indication using the online messaging we would almost always phone them or bring them down to ensure things have been understood and their issues fully tackled. And one strength with online communication is that the information is there for them to go back to later, with a phone call or face to face appointment it is gone unless you also gave them some written information or they had the where with all to take notes.
A big concern is the use of the system by perpetrators of coercive control to further distance their victims from a professional who might be able to spot something amiss and offer help. Other concerns would be for those who don’t speak or write English or possibly vulnerable older people who might find that some of their communication with their doctor is taken over by a very ‘helpful’ partner or family member or friend who is more fluent in English or more computer literate. Again there is something about the system that has the potential to distance the individual from their clinician. I answer to this I can only vouch for the fact that everyone I work with has their radar switched on when it comes to spotting these problems. I’m not saying it is perfect but I do think that used judiciously and by highly trained clinicians who are not out to turn a blind eye to these scenarios I think it can work. At least as well a telephone based doctor first system. And the idea really is to free up time, if you have been able to deal with a simple UTI in a 23 yr old with a quick back and forth message you have time and, more importantly the thinking and emotional capacity to take something potentially bigger on and ask the uncomfortable question, use a professional interpreter instead of a family member even though it will take much longer, ask to see the patient alone, start to build a bridge.
And then I come finally to the current situation we find ourselves in. I do worry immensely about the disproportionate effect of the current COVID-19 crisis on patients like ours whose lives and health are not always as secure as they would like. I am alarmed by the emerging figures showing the disproportionate number of deaths amongst health professionals from a BAME background. Ten of the first eleven doctors who have died from COVID-19 in the UK were of a BAME background. It would appear that this virus does discriminate in the same way that so much ill health does. Even the experience of self-isolation/lockdown/being shielded clearly is very different for those who live in inadequate or overcrowded housing or those who live with serious long term mental illnesses. This has all been spoken about very informatively by Tom Ratcliffe in his recent blog entry below.
Very understandably coronavirus has our patient’s stressed and scared. So suddenly there is a different feel to all these online and telephone triage conversations, people are very onboard with anything that avoids them coming down to the surgery, we are now having to negotiate with people who really do need to be seen to get them in. Clearly this a frightening time for all but do think that out of this could come some positive behaviour change. More of our patients are using the online system, many many more are happy to engage with online consulting using messaging, photos or video. And we as doctors are suddenly more motivated to use it to its full potential and iron out any glitches which might have been holding us back slightly. Most of this move to online and telephone consulting is entirely appropriate. There will be non-coronavirus related fall-out from this crisis; worsening of people’s mental health, delays in diagnosis of serious disease and increased risk to those living in precarious or abusive situations. But I think used judiciously and by those who have already developed skills around it I think our system is a force for good through this time. A piece in this months edition of The Doctor cautions against a rushed move to the use of online systems. And I think there is a crucial distinction to be drawn between systems like ours and those that are designed, perhaps with AI capabilities to divert patients away. I feel fortunate to work in a practice where using this technology is an embedded part of how we work. I think that out of this appalling crisis will come a further positive shift in how we and our patients use and value the system. I think that together we are using it to build better and closer relationships.
It has shone a light on the great divides in our society. Everyone can catch it, everyone can die from it but the impact of the virus and the necessary measures to control its spread is not shared equally across society.
Our response will require kindness, caring and compassion. The current upsurge in these values should give us cause for hope during an otherwise very difficult time for many people. And they will be most needed where suffering is greatest.
What is interesting about the risk of death or hospital admission from the virus is that it almost perfectly tracks your current risk of death. So, if you are already sick, from a BAME background, grew up in poverty or already older you are more likely to develop serious symptoms and/or die.
The economic impacts will be most acutely felt by those with the fewest resources: people in low paid jobs, people who have chronic mental or physical illness, people on temporary or “zero hours” contracts and those who are living from pay check to pay check. It is also likely that those in low paid manual jobs (e.g. supermarket, social care, construction workers etc) will be less able to socially distance by working from home and, hence, less able to minimise the risk of Covid-19 infection. Those who are now confined to home in poor quality or cramped housing will have the most miserable experience and those living in the least affluent, vibrant and green surroundings will suffer the biggest fall in wellbeing.
These individuals are all part of the same group: the poorest in society.
Michael Marmot recently reminded us that, in the UK, the poorest 10% of households have less than 30% of their income remaining after deducting housing costs and the cost of healthy food. They also have very little wealth to fall back on in times of economic crisis. The implications are clear: loss of income due to Covid-19-related unemployment or illness will cause destitution among those who are already struggling to get by.
Health inequalities were already widening before Covid and these divides are now likely to be accelerated by another economic crisis, massively compounded by a virus that kills those already suffering from chronic illness and multimorbidity, the rates of which already follow a sharp social gradient.
Covid has taken the social determinants of health, which have insidiously been working away behind the scenes, slowly eroding peoples’ health and wellbeing, and exploded their impact into full view. Our civic, community and healthcare resources have been degraded by a decade of austerity, as have many aspects of the welfare safety net. Covid has triggered substantial reinvestment but we must not let these issues disappear back into the shadows as the crisis recedes.
The response to Covid has been to put the whole NHS on an acute footing, aimed at treating a single disease, whilst trying to also provide care to the non-Covid acutely unwell. This means that planned primary care, which can narrow the health gap by 10-20% if access is good and quality high, has been temporarily suspended (or at least deprioritised). Because the system was already at capacity, and because capacity was already inadequate in the most socioeconomically deprived communities, it will take a long time to catch up after this crisis. After Covid we will discover a massive pool of morbidity, mortality and unmet demand. Mental illness that existed before this crisis will also sharply deteriorate due to increased stress and isolation plus a temporary withdrawal of face to face primary care.
GPs also know that the aftermath of social trauma can last years or even decades and blight peoples’ whole lives. GPs have spent years trying to help people traumatised by war, tragic events, childhood neglect or mistreatment, crime or domestic abuse. Covid will leave thousands, perhaps hundreds of thousands, of people traumatised by its direct effects or as a result of vulnerable people being left isolated in toxic social situations, where the abuse or mistreatment they have suffered becomes temporarily inescapable.
The long tail of this crisis are neatly summarised here:
So how can we respond?
If there is a positive thing to take away from the Covid crisis it is the outpouring of kindness, the renewed recognition of the contribution of people with jobs whose value may have been forgotten or overlooked, a huge injection of investment into healthcare and social welfare and a revived willingness to think about the needs of others.
We might reflect on J.B. Priestley’s words:
“We don’t live alone. We are members of one body. We are responsible for each other.”
An Inspector Calls, 1945
So how should we respond in primary care?
As our colleagues at Citadel Healthcare in Greater Manchester remind us, for general practice, we should go back to basics: “find the sickest, and give them the best care”. And we must double down on our efforts to do this during and after Covid-19.
We will have to catch up peoples’ chronic disease management – prioritise the poorest, who can be identified by integrating the available databases on socioeconomic deprivation with primary care records and by examining chronic disease data (time to collaborate with our wonderful colleagues in public health – at Fair Health we are also trying to create some resources to make this easier for practices, watch this space!). Also prioritise those things that have the biggest impact on health outcomes – start with cardiovascular disease prevention. Perhaps revise where to focus your efforts by working through our learning modules.
Now will be the time to adopt an approach based on “Trauma Informed Care”. You can read more about this in our learning modules on this site and on the “A Better NHS” blog (see resources below).
Use the Primary Care Network DES to invest in social prescribing to try and deal with some of the acute social issues that Covid will exacerbate and use this to build better links with your local Voluntary and Charitable Sector, who may need your support and advocacy more than ever
Collaborate with the “social determinants of health workforce” more than ever:
The social workers, teachers, school nurses and health visitors who will be helping safeguarded children during and after the crisis
The Citizens Advice Bureau, debt advisors and Department for Work and Pensions operatives who will be needed more than ever to help people through the multiple domestic financial crisis that Covid will create
Organisations providing care for people who are homeless, refugees and other vulnerable groups to ensure they can access very strained services in the post Covid world
Drug and alcohol services, whose users won’t have been able to socially distance and access support as easily during this crisis
The nurses and carers out in the community supporting our most vulnerable
Remember that primary care organisations are anchor institutions for many communities – just being there is so important: you can hold onto the memories of how Covid impacted your community and you can hold the NHS leadership and politicians to account for their decisions, their efforts to address health inequalities and future readiness for a pandemic or the slower health “emergency” represented by growing health inequalities
Try and ensure that information about Covid and the social safety net that is being created is accessible to all by providing information in multiple languages and formats (see resources for free translations of material provided by Doctors of the World)
As illustrated above, the Covid crisis will have a long tail, perhaps stretching out over many years, this is where health equity focussed primary care will be needed most