Are local public expenditure reductions associated with increases in inequality in emergency hospitalisation? Time-series analysis of English local authorities from 2010 to 2017.

BACKGROUND: Reductions in local government funding implemented in 2010 due to austerity policies have been associated with worsening socioeconomic inequalities in mortality. Less is known about the relationship of these reductions with healthcare inequalities; therefore, we investigated whether areas with greater reductions in local government funding had greater increases in socioeconomic inequalities in emergency admissions. METHODS: We examined inequalities between English local authority districts (LADs) using a fixed-effects linear regression to estimate the association between LAD expenditure reductions, their level of deprivation using the Index of Multiple Deprivation (IMD) and average rates of (all and avoidable) emergency admissions for the years 2010-2017. We also examined changes in inequalities in emergency admissions using the Absolute Gradient Index (AGI), which is the modelled gap between the most and least deprived neighbourhoods in an area. RESULTS: LADs within the most deprived IMD quintile had larger pounds per capita expenditure reductions, higher rates of all and avoidable emergency admissions, and greater between-neighbourhood inequalities in admissions. However, expenditure reductions were only associated with increasing average rates of all and avoidable emergency admissions and inequalities between neighbourhoods in local authorities in England's three least deprived IMD quintiles. For a LAD in the least deprived IMD quintile, a yearly reduction of £100 per capita in total expenditure was associated with a yearly increase of 47 (95% CI 22 to 73) avoidable admissions, 142 (95% CI 70 to 213) all-cause emergency admissions and a yearly increase in inequalities between neighbourhoods of 48 (95% CI 14 to 81) avoidable and 140 (95% CI 60 to 220) all-cause emergency admissions. In 2017, a LAD average population was ~170 000. CONCLUSION: Austerity policies implemented in 2010 impacted less deprived local authorities, where emergency admissions and inequalities between neighbourhoods increased, while in the most deprived areas, emergency admissions were unchanged, remaining high and persistent.

Reducing health inequalities through general practice: a realist review and action framework.

Background: Socio-economic inequalities in health have been in the public agenda for decades. General practice has an influential role to play in mitigating the impact of inequalities especially regarding chronic conditions. At the moment, general practice is dealing with serious challenges in relation to workforce shortages, increasing workload and the impact of the COVID-19 pandemic. It is important to identify effective ways so that general practice can play its role in reducing health inequalities. Objectives: We explored what types of interventions and aspects of routine care in general practice decrease or increase inequalities in health and care-related outcomes. We focused on cardiovascular disease, cancer, diabetes and/or chronic obstructive pulmonary disease. We explored for whom these interventions and aspects of care work best, why, and in what circumstances. Our main objective was to synthesise this evidence into specific guidance for healthcare professionals and decision-makers about how best to achieve equitable general practice. Design: Realist review. Main outcome measures: Clinical or care-related outcomes by socio-economic group, or other PROGRESS-Plus criteria. Review methods: Realist review based on Pawson's five steps: (1) locating existing theories, (2) searching for evidence, (3) selecting articles, (4) extracting and organising data and (5) synthesising the evidence. Results: Three hundred and twenty-five studies met the inclusion criteria and 159 of them were selected for the evidence synthesis. Evidence about the impact of general practice interventions on health inequalities is limited. To reduce health inequalities, general practice needs to be: • connected so that interventions are linked and coordinated across the sector; • intersectional to account for the fact that people's experience is affected by many of their characteristics; • flexible to meet patients' different needs and preferences; • inclusive so that it does not exclude people because of who they are; • community-centred so that people who receive care engage with its design and delivery. These qualities should inform action across four domains: structures like funding and workforce distribution, organisational culture, everyday regulated procedures involved in care delivery, interpersonal and community relationships. Limitations: The reviewed evidence offers limited detail about the ways and the extent to which specific interventions increase or decrease inequalities in general practice. Therefore, we focused on the underpinning principles that were common across interventions to produce higher-level, transferrable conclusions about ways to achieve equitable care. Conclusions: Inequalities in general practice result from complex processes across four different domains that include structures, ideas, regulated everyday procedures, and relationships among individuals and communities. To achieve equity, general practice needs to be connected, intersectional, flexible, inclusive and community-centred. Future work: Future work should focus on how these five essential qualities can be better used to shape the organisational development of future general practice. Study registration: This trial is registered as PROSPERO CRD42020217871. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130694) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 7. See the NIHR Funding and Awards website for further award information.

Health inequalities are unfair differences in health across different groups of the population. In the United Kingdom, the health inequality gap in life expectancy between the richest and poorest is increasing and is caused mostly by differences in long-term conditions like cancer and cardiovascular disease and respiratory conditions, such as chronic obstructive pulmonary disease. Partly National Health Service inequalities arise in delays in seeing a doctor and care provided through doctors' surgery, such as delays in getting tests. This study explored how general practice services can increase or decrease inequalities in cancer, cardiovascular disease, diabetes and chronic obstructive pulmonary disease, under what circumstances and for whom. It also produced guidance for general practice, both local general practices and the wider general practice system, to reduce inequalities. We reviewed existing studies using a realist methodology. This methodology helps us understand the different contexts in which interventions work or not. We found that inequalities in general practice result from complex processes across different areas. These include funding and workforce, perceptions about health and disease among patients and healthcare staff, everyday procedures involved in care delivery, and relationships among individuals and communities. To reduce inequalities in general practice, action should be taken in all these areas and services need to be connected (i.e. linked and coordinated across the sector), intersectional (i.e. accounting for the fact that people's experience is affected by many of their characteristics like their gender and socio-economic position), flexible (i.e. meeting patients' different needs and preferences), inclusive (i.e. not excluding people because of who they are) and community-centred (i.e. working with the people who will receive care when designing and providing it). There is no one single intervention that will make general practice more equitable, rather it requires long-term organisational change based on these principles.

Developing an online knowledge sharing platform and community of practice for health professionals: Experiences from C-WorKS developed in North East England and Yorkshire during COVID-19.

BACKGROUND: Although knowledge sharing online has been recognised as an important strategy for health professionals to apply research findings to their practice, limited research exists on how to develop and implement these platforms to help facilitate collaboration and knowledge sharing. OBJECTIVES: This study evaluated an online knowledge sharing platform and community of practice developed in the North East of England and Yorkshire during COVID-19 to support UK health and care professionals to reduce the impact of the wider consequences of COVID-19. METHODS: Semi-structured interviews with stakeholders (n = 8) and users of C-WorKS (n = 13), followed by an online survey (n = 19) among a wider group of users to analyse knowledge use. RESULTS: Interview and survey findings highlighted several strengths, weaknesses, opportunities and threats to support future development of online knowledge sharing platforms. DISCUSSION: Online knowledge sharing supports six 'pillars' of successful research and innovation partnerships. This requires distributed forms of leadership and linking of different knowledge sharing strategies, and careful combination of platforms with communities of practice. CONCLUSION: Online knowledge sharing provides pragmatic and timely strategies for health professionals in the UK to apply research evidence to their practice. Our study provides generalisable, practical insights in how to develop and implement a knowledge sharing platform.

How to address the inverse care law and increase GP recruitment in areas of socioeconomic deprivation: a qualitative study of GP trainees' views and experiences in the UK.

BACKGROUND: The Deep End network in the North East and North Cumbria (NENC) was set up to tackle health inequalities in general practice. One aim is to address the inverse care law and improve recruitment of GPs, which is known to be especially challenging in areas of socioeconomic deprivation. AIM: To explore GP trainees' experiences and perceptions of working in Deep End or Deprived Area Practices (DE/DAPs) to identify how GP recruitment can be improved. DESIGN & SETTING: Qualitative study recruiting 13 doctors training to be GPs from the Northumbria training programme. METHOD: Audio-recorded, online, semi-structured interviews and discussion groups were undertaken, transcribed verbatim, and analysed with a grounded theory approach, using a process of thematic analysis. RESULTS: Overall, seven interviews and two discussion groups (13 participants in total) were conducted. Three themes were identified. The first theme was working in areas of socioeconomic deprivation is challenging but has many advantages. The challenges of working in DE/DAPs were not deterring factors for GP trainees wanting to work in areas of socioeconomic deprivation. The second theme was trainees are willing to work in areas of socioeconomic deprivation but clinical experience is important. Training in DE/DAPs gives trainees the confidence to work in areas of deprivation. Familiarity with a practice also makes them more likely to stay post-training. The third theme was financial incentives are not an important attracting factor but support and development opportunities are. Non-pecuniary measures, such as clinical support and protected time for continuing professional development (CPD), were found to be important. CONCLUSION: To improve recruitment to DE/DAPs, investments should be made to increase the opportunities to train in these environments. This can be achieved by supporting more DE/DAPs to become training practices, and providing clinical support and protected time for CPD.

Socioeconomic inequalities in vaccine uptake: A global umbrella review.

This global umbrella review aimed to synthesise evidence of socioeconomic inequalities in the uptake of routine vaccinations and identify the mechanisms that may contribute to the association. To our knowledge, no attempt has been made to synthesise the global body of systematic reviews across a variety of vaccines, geographical locations, and measures of SES. The inclusion criteria were as follows: studies assessing vaccination uptake according to education, income, occupation/employment, and/or area-level deprivation; any country or universally recommended routine vaccination (according to the WHO); qualitative or quantitative reviews, published 2011-present. The searches were performed in eight databases. The screening process followed PRISMA-E guidelines, each stage was performed by one reviewer, and a 10% sample checked by a second for consistency. Included reviews underwent data extraction, quality appraisal (AMSTAR-2), and narrative synthesis according to country-context. After deduplication, 9,163 reports underwent title and abstract screening, leaving 119 full texts to be assessed for eligibility. Overall, 26 studies were included in the umbrella review. Evidence for lower uptake amongst disadvantaged SES individuals was found in all 26 reviews. However, 17 reviews showed mixed results, as inverse associations were also identified (lower uptake for advantaged SES, and/or higher uptake for disadvantaged SES). Those that explored high-income countries had a greater prevalence of mixed findings than those focusing on low/middle-income countries. The two most frequently cited mechanisms were vaccination knowledge, and confidence in vaccination or vaccination providers. These mechanisms were often understood by review authors as varying by level of education. We find socioeconomic differences in routine vaccination uptake, but the association did not always follow a gradient. Whilst education may be associated with uptake globally, our study indicates that its role varies by country-context. A limitation is the overlap of some primary studies across the included systematic reviews.

Coproduction of a resource sharing public views of health inequalities: An example of inclusive public and patient involvement and engagement.

BACKGROUND: UNderstanding Factors that explain Avoidable hospital admission Inequalities-Research study (UNFAIR) addresses how to reduce health inequalities, particularly for avoidable hospital admissions. Our Patient and Public Involvement and Engagement (PPIE) members broached that health inequalities are complex, challenging to understand and communicate. They identified a need to explore diverse views, including people who have a higher risk of health inequalities. With limited public-facing resources relating to the public's understanding or emotions around health inequalities, this project aimed to fill this gap using co-leadership and co-production. METHODS: Members of the public worked with researchers to co-produce and run PPIE workshops. This project was co-led by a member of the public and a researcher. One online workshop open to anyone in England accompanied by three face-to-face workshops were held. Public contributors, including people living in diverse communities, were invited. Inclusive involvement opportunities were offered including flexible ways of involvement and remuneration. To strengthen the key messages' rigour, transcriptions of the audio-recordings from each workshop, with facilitator notes, were analysed using thematic analysis. From the key messages, an animation was co-produced with public contributors with the public's voice being integral throughout. KEY MESSAGES: A total of 58 people took part capturing intersecting and multiple dimensions of marginalisation including people with a range of ages, genders, ethnicities, socioeconomic backgrounds, and members of communities who face exclusion (including people with learning difficulties and experiencing ill-health). The animation highlighted powerful lived experience, for example, some people are dying earlier than expected. Health inequalities conjured up powerful emotions, such as anger and hopelessness. Public views of how to address health inequalities included respecting, accepting and valuing everyone, regardless of, for example, where people live. The animation is publicly available for use by anyone, including decision makers across the health and care system. CONCLUSIONS: Through co-leadership and co-production, this project is an example of inclusive PPIE. This project provided a way for the public's voice to influence policy and practice to inform understanding and action to address health inequalities. The animation provides powerful insights into what health inequalities mean to people with examples of lived experience and corroborates the moral argument for action by decision makers. PATIENT AND PUBLIC CONTRIBUTION: Members of the public, including people who were affected or at higher risk of health inequalities, co-led this project and were involved as co-creators and developers from the inception of the project to completion. Their involvement was integral and documented in full throughout the project.

Reducing health inequalities through general practice.

Although general practice can contribute to reducing health inequalities, existing evidence provides little guidance on how this reduction can be achieved. We reviewed interventions influencing health and care inequalities in general practice and developed an action framework for health professionals and decision makers. We conducted a realist review by searching MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Cochrane Library for systematic reviews of interventions into health inequality in general practice. We then screened the studies in the included systematic reviews for those that reported their outcomes by socioeconomic status or other PROGRESS-Plus (Cochrane Equity Methods Group) categories. 159 studies were included in the evidence synthesis. Robust evidence on the effect of general practice on health inequalities is scarce. Focusing on common qualities of interventions, we found that to reduce health inequalities, general practice needs to be informed by five key principles: involving coordinated services across the system (ie, connected), accounting for differences within patient groups (ie, intersectional), making allowances for different patient needs and preferences (ie, flexible), integrating patient worldviews and cultural references (ie, inclusive), and engaging communities with service design and delivery (ie, community-centred). Future work should explore how these principles can inform the organisational development of general practice.

Experiences of Non-Pharmaceutical Primary Care Interventions for Common Mental Health Disorders in Socioeconomically Disadvantaged Groups: A Systematic Review of Qualitative Studies.

Common mental health disorders (CMDs) disproportionately affect people experiencing socioeconomic disadvantage. Non-pharmaceutical interventions, such as 'social prescribing' and new models of care and clinical practice, are becoming increasingly prevalent in primary care. However, little is known about how these interventions work and their impact on socioeconomic inequalities in health. Focusing on people experiencing socioeconomic disadvantage, this systematic review aims to: (1) explore the mechanisms by which non-pharmaceutical primary care interventions impact CMD-related health outcomes and inequalities; (2) identify the barriers to, and facilitators of, their implementation in primary care. This study is a systematic review of qualitative studies. Six bibliographic databases were searched (Medline, ASSIA, CINAHL, Embase, PsycInfo and Scopus) and additional grey literature sources were screened. The included studies were thematically analysed. Twenty-two studies were included, and three themes were identified: (1) agency; (2) social connections; (3) socioeconomic environment. The interventions were experienced as being positive for mental health when people felt a sense of agency and social connection. The barriers to effectiveness and engagement included socioeconomic deprivation and underfunding of community sector organisations. If non-pharmaceutical primary care interventions for CMDs are to avoid widening health inequalities, key socioeconomic barriers to their accessibility and implementation must be addressed.

Non-pharmaceutical primary care interventions to improve mental health in deprived populations: a systematic review.

BACKGROUND: Common mental health disorders are especially prevalent among people from socioeconomically disadvantaged backgrounds. Non-pharmaceutical primary care interventions, such as social prescribing and collaborative care, provide alternatives to pharmaceutical treatments for common mental health disorders, but little is known about the impact of these interventions for patients who are socioeconomically disadvantaged. AIM: To synthesise evidence for the effects of non-pharmaceutical primary care interventions on common mental health disorders and associated socioeconomic inequalities. DESIGN AND SETTING: Systematic review of quantitative primary studies published in English and undertaken in high-income countries. METHOD: Six bibliographic databases were searched and additional grey literature sources screened. Data were extracted onto a standardised proforma and quality assessed using the Effective Public Health Practice Project tool. Data were synthesised narratively and effect direction plots were produced for each outcome. RESULTS: Thirteen studies were included. Social-prescribing interventions were evaluated in 10 studies, collaborative care in two studies, and a new model of care in one study. Positive results (based on effect direction) were reported for the impact of the interventions on wellbeing in groups that were socioeconomically deprived. Inconsistent (mainly positive) results were reported for anxiety and depression. One study reported that people from the group with least deprivation, compared with the group with greatest deprivation, benefitted most from these interventions. Overall, study quality was weak. CONCLUSION: Targeting non-pharmaceutical primary care interventions at areas of socioeconomic deprivation may help to reduce inequalities in mental health outcomes. However, only tentative conclusions can be drawn from the evidence in this review and more-robust research is required.

A Qualitative Evaluation of a Health Access Card for Refugees and Asylum Seekers in a City in Northern England.

Refugees and asylum seekers residing in the UK face multiple barriers to accessing healthcare. A Health Access Card information resource was launched in Newcastle upon Tyne in 2019 by Newcastle City Council, intended to guide refugees and asylum seekers living in the city, and the professional organisations that support them, to appropriate healthcare services provided locally. The aim of this qualitative evaluation was to explore service user and professional experiences of healthcare access and utilisation in Newcastle and perspectives on the Health Access Card. Eleven semi-structured interviews took place between February 2020 and March 2021. Participants provided diverse and compelling accounts of healthcare experiences and described cultural, financial and institutional barriers to care. Opportunities to improve healthcare access for these population groups included offering more bespoke support, additional language support, delivering training and education to healthcare professionals and reviewing the local support landscape to maximise the impact of collaboration and cross-sector working. Opportunities to improve the Health Access Card were also described, and these included providing translated versions and exploring the possibility of developing an accompanying digital resource.

Co-design to deliver service improvement: What does this mean and how can we do it? A qualitative study with upper gastrointestinal cancer patients and professionals.

BACKGROUND: There is strategic objective to incorporate the principles and practice of co-design into routine service development and improvement. AIM: The aim was to explore the concept and feasibility of service co-design with patients and health professionals with regards to the upper gastrointestinal (UGI) cancer care pathway. METHODS AND RESULTS: Qualitative telephone interviews and face-to-face focus groups in one region of England. Twenty patients completed interviews. Nine patients and ten professionals formed two focus groups. Patients were referred through the urgent (two week) GP referral route and were within six months of receiving their first treatment for an UGI cancer. Professionals were working as service planners and providers of the UGI cancer care pathway. Thematic analysis was undertaken. Six themes emerged: Responsibilities and expectations, Knowledge and understanding, Valuing patient input, Building relationships, Environment for co-design activities, Impact and effectiveness. Based on the themes a checklist has been created to provide practical suggestions for both professionals and patients on approaching co-design for service improvement. CONCLUSION: This study offers policy and practice partners a clearer understanding of co-design and factors to consider when approaching co-design in real life settings.

Levelling up health: A practical, evidence-based framework for reducing health inequalities.

There are substantial inequalities in health across society which have been exacerbated by the COVID-19 pandemic. The UK government have committed to a programme of levelling-up to address geographical inequalities. Here we undertake rapid review of the evidence base on interventions to reduce such health inequalities and developed a practical, evidence-based framework to 'level up' health across the country. This paper overviews a rapid review undertaken to develop a framework of guiding principles to guide policy. To that end and based on an initial theory, we searched one electrotonic database (MEDLINE) from 2007 to July 2021 to identify published umbrella reviews and undertook an internet search to identify relevant systematic reviews, primary studies, and grey literature. Titles and abstracts were screened according to the eligibility criteria. Key themes were extracted from the included studies and synthesised into an overarching framework of guiding principles in consultation with an expert panel. Included studies were cross checked with the initial theoretical domains and further searching undertaken to fill any gaps. We identified 16 published umbrella reviews (covering 667 individual studies), 19 grey literature publications, and 15 key systematic reviews or primary studies. Based on these studies, we develop a framework applicable at national, regional and local level which consisted of five principles - 1) healthy-by-default and easy to use initiatives; 2) long-term, multi-sector action; 3) locally designed focus; 4) targeting disadvantaged communities; and 5) matching of resources to need. Decision-makers working on policies to level up health should be guided by these five principles.

Socioeconomic Inequalities and Vaccine Uptake: An Umbrella Review Protocol.

The effectiveness of immunization is widely accepted: it can successfully improve health outcomes by reducing the morbidity and mortality associated with vaccine-preventable diseases. In the era of pandemics, there is a pressing need to identify and understand the factors associated with vaccine uptake amongst different socioeconomic groups. The knowledge generated from research in this area can be used to inform effective interventions aimed at increasing uptake. This umbrella systematic review aims to determine whether there is an association between socioeconomic inequalities and rate of vaccine uptake globally. Specifically, the study aims to determine whether an individual's socioeconomic status, level of education, occupation, (un)-employment, or place of residence affects the uptake rate of routine vaccines. The following databases will be searched from 2011 to the present day: Medline (Ovid), Embase (Ovid), CINAHL (EBSCO), Cochrane CENTRAL, Science Citation Index (Web of Science), DARE, SCOPUS (Elsevier), and ASSIA (ProQuest). Systematic reviews will be either included or excluded based on a priori established eligibility criteria. The relevant data will then be extracted, quality appraised, and narratively synthesised. The synthesis will be guided by the theoretical framework developed for this review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Equity extension (PRISMA-E) guidance will be followed. This protocol has been registered on PROSPERO, ID: CRD42022334223.

Tailoring lipid management interventions to reduce inequalities in cardiovascular disease risk management in primary care for deprived communities in Northern England: a mixed-methods intervention development protocol.

INTRODUCTION: Hyperlipidaemia contributes a significant proportion of modifiable cardiovascular disease (CVD) risk, which is a condition that disproportionally affects disadvantaged socioeconomic communities, with death rates in the most deprived areas being four times higher than those in the least deprived. With the national CVD Prevention programme being delivered to minimise risk factors, no evidence is available on what has been implemented in primary care for deprived populations. This study describes the protocol for the development of a tailored intervention aiming to optimise lipid management in primary care settings to help reduce inequalities in CVD risks and improve outcomes in deprived communities. METHODS AND ANALYSIS: A mixed-methods approach will be employed consisting of four work packages: (1) rapid review and logic model; (2) assessment and comparison of CVD risk management for deprived with non-deprived populations in Northern England to England overall; (3) interviews with health professionals; and (4) intervention development. A systematic search and narrative synthesis will be undertaken to identify evidence-based interventions and targeted outcomes in deprived areas. General practice-level data will be assessed to establish the profile of lipid management, compared with the regional and national levels. Health professionals involved in the organisation and delivery of routine lipid management to deprived populations will be interviewed to understand the implementation and delivery of current lipid management and associated challenges. The prototype intervention will be informed by the evidence generated from workpackages 1-3, which will be reviewed and assessed using the nominal group technique to reach consensus. Training and skills development materials will also be developed as needed. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the Faculty of Medical Sciences Research Ethics Committee at Newcastle University, UK. Findings will be disseminated to the participating sites, participants, commissioners, and in peer-reviewed journals and academic conferences.

Conceptualisation of health inequalities by local healthcare systems: A document analysis.

In 2019, local healthcare systems in England were asked to develop formal plans to reduce health inequalities. Here, we explore plans to understand how local healthcare systems conceptualise health inequalities and why. A broad Internet search and targeted search of NHS websites were conducted to identify all publicly accessible healthcare planning documents (National Health Service (NHS) Long-Term Plan (LTP) response documents) produced by local health partnerships in England. A thematic document analysis of the accessible plans was undertaken in NVivo by coding text relating to health inequalities. Of the 44 documents developed, 13 were publicly accessible. These 13 local plans were submitted to NHS England for review between September 2019 and January 2020 and averaged 167 pages (range: 41-273 pages). Only one document contained a chapter dedicated to health inequalities. After analysis, five themes were identified: (1) variation and (2) vagueness explained how health inequalities were conceptualised and (3) use of value judgements, (4) lack of prior conceptualisation and approach and (5) a lack of commitment to action in the documents to reduce health inequalities explained what led to the overall vagueness and variation. Local healthcare systems were found to conceptualise health inequalities in a vague and varying manner, and their conceptualisations did not reflect established health inequalities frameworks. A clear conceptual national framework for addressing health inequalities is needed to support local healthcare systems, so they can address health inequalities meaningfully and sustainably.

COVID-19 and the role of Voluntary, Community, and Social Enterprises in northern England in responding to the needs of marginalised communities: a qualitative focus group study.

BACKGROUND: The Voluntary Community and Social Enterprise sector has a crucial role in supporting the health and wellbeing of people who are marginalised or who have multiple complex needs. We aimed to understand perceptions of those working in the sector and examine the short-term, medium-term, and long-term effects of COVID-19 on Voluntary Community and Social Enterprise organisations in northern England as they respond to the needs of marginalised communities. This research formed one component of a regional multiagency Health Inequalities Impact Assessment. METHODS: We conducted qualitative focus groups with staff and volunteers from five organisations between March and July, 2021, via a video conferencing platform. Eight of nine focus groups were audio-recorded and transcribed verbatim. One focus group was not recorded due to concerns raised over anonymity and safeguarding, but non-ascribed fieldnotes were taken. Focus group transcripts were analysed using framework analysis. FINDINGS: One organisation supported children and young people; two organisations supported vulnerable women, young people, and families; one organisation supported refugees and asylum seekers, and one organisation supported disadvantaged individuals to improve their mental and physical health and wellbeing. Three central themes were identified: the exacerbation of pre-existing inequalities, adversity, and challenges for vulnerable and marginalised populations; the cost of being flexible, innovative, and agile for Voluntary Community and Social Enterprise staff and volunteers; and the voluntary sector as a lifeline (organisational pride and resilience). INTERPRETATION: The considerable expertise, capacity, and resilience of Voluntary Community and Social Enterprise organisations and the crucial role they have in supporting marginalised communities has been clearly shown in their response to the COVID-19 pandemic. The Voluntary Community and Social Enterprise sector therefore has an essential role in the post-COVID levelling-up agenda. The implications of these findings for service provision are that the Voluntary Community and Social Enterprise sector must be recognised as an integral partner within any effectively functioning local health system and, as such, adequately resourced to safeguard sustainability and to ensure that attempts to involve the sector in addressing the social determinants of health are not jeopardised. FUNDING: National Institute for Health and Care Research (Applied Research Collaboration North East and North Cumbria (grant reference NIHR200173) and Public Health England. SSo is supported by a Health Education England and National Institute for Health and Care Research Integrated Clinical Academic Lecturer award (reference CA-CL-2018-04-ST2-010) and Research Capability Funding, National Health Service North of England Care System Support. VJM is funded by the National Institute for Health and Care Research School for Public Health Research (grant reference PD-SPH-2015).

Reducing inequality in avoidable emergency admissions: Case studies of local health care systems in England using a realist approach.

OBJECTIVE: People in disadvantaged areas are more likely to have an avoidable emergency hospital admission. Socio-economic inequality in avoidable emergency hospital admissions is monitored in England. Our aim was to inform local health care purchasing and planning by identifying recent health care system changes (or other factors), as reported by local health system leaders, that might explain narrowing or widening trends. METHODS: Case studies were undertaken in one pilot and at five geographically distinct local health care systems (Clinical Commissioning Groups, CCGs), identified as having consistently increasing or decreasing inequality. Local settings were explored through discussions with CCG officials and stakeholders to identify potential local determinants. Data were analysed using a realist evaluation approach to generate context-mechanism-outcome (CMO) configurations. RESULTS: Of the five geographically distinct CCGs, two had narrowing inequality, two widening, and one narrowing inequality, which widened during the project. None of the CCGs had designed a large-scale package of service changes with the explicit aim of reducing socio-economic inequality in avoidable emergency admissions, and local decision makers were unfamiliar with their own trends. Potential primary and community care determinants included: workforce, case finding and exclusion, proactive care co-ordination for patients with complex needs, and access and quality. Potential commissioning determinants included: data use and incentives, and targeting of services. Other potential determinants included changes in care home services, national A&E targets, and wider issues - such as public services financial constraints, residential gentrification, and health care expectations. CONCLUSIONS: We did not find any bespoke initiatives that explained the inequality trends. The trends were more likely due to an interplay of multiple health care and wider system factors. Local decision makers need greater awareness, understanding and support to interpret, use and act upon inequality indicators. They are unlikely to find simple, cheap interventions to reduce inequalities in avoidable emergency admissions. Rather, long-term multifaceted interventions are required that embed inequality considerations into mainstream decision making.

Which Non-Pharmaceutical Primary Care Interventions Reduce Inequalities in Common Mental Health Disorders? A Protocol for a Systematic Review of Quantitative and Qualitative Studies.

Common mental health disorders (CMDs) represent a major public health concern and are particularly prevalent in people experiencing disadvantage or marginalisation. Primary care is the first point of contact for people with CMDs. Pharmaceutical interventions, such as antidepressants, are commonly used in the treatment of CMDs; however, there is concern that these treatments are over-prescribed and ineffective for treating mental distress related to social conditions. Non-pharmaceutical primary care interventions, such as psychological therapies and "social prescribing", provide alternatives for CMDs. Little is known, however, about which such interventions reduce social inequalities in CMD-related outcomes, and which may, unintentionally, increase them. The aim of this protocol (PROSPERO registration number CRD42021281166) is to describe how we will undertake a systematic review to assess the effects of non-pharmaceutical primary care interventions on CMD-related outcomes and social inequalities. A systematic review of quantitative, qualitative and mixed-methods primary studies will be undertaken and reported according to the PRISMA-Equity guidance. The following databases will be searched: Assia, CINAHL, Embase, Medline, PsycInfo and Scopus. Retrieved records will be screened according to pre-defined eligibility criteria and synthesised using a narrative approach, with meta-analysis if feasible. The findings of this review will guide efforts to commission more equitable mental health services.

COVID-19 at the Deep End: A Qualitative Interview Study of Primary Care Staff Working in the Most Deprived Areas of England during the COVID-19 Pandemic.

COVID-19 is disproportionately impacting people in low-income communities. Primary care staff in deprived areas have unique insights into the challenges posed by the pandemic. This study explores the impact of COVID-19 from the perspective of primary care practitioners in the most deprived region of England. Deep End general practices serve communities in the region's most socioeconomically disadvantaged areas. This study used semi-structured interviews followed by thematic analysis. In total, 15 participants were interviewed (11 General Practitioners (GPs), 2 social prescribing link workers and 2 nurses) with Deep End careers ranging from 3 months to 31 years. Participants were recruited via purposive and snowball sampling. Interviews were conducted using video-conferencing software. Data were analysed using thematic content analysis through a social determinants of health lens. Our results are categorised into four themes: the immediate health risks of COVID-19 on patients and practices; factors likely to exacerbate existing deprivation; the role of social prescribing during COVID-19; wider implications for remote consulting. We add qualitative understanding to existing quantitative data, showing patients from low socioeconomic backgrounds have worse outcomes from COVID-19. Deep End practitioners have valuable insights into the impact of social distancing restrictions and remote consulting on patients' health and wellbeing. Their experiences should guide future pandemic response measures and any move to "digital first" primary care to ensure that existing inequalities are not worsened.

Transforming health systems to reduce health inequalities.

Never before in history have we had the data to track such a rapid increase in inequalities. With changes imminent in healthcare and public health organisational landscape in England and health inequalities high on the policy agenda, we have an opportunity to redouble efforts to reduce inequalities. In this article, we argue that health inequalities need re-framing to encompass the breadth of disadvantage and difference between healthcare and health outcome inequalities. Second, there needs to be a focus on long-term organisational change to ensure equity is considered in all decisions. Third, actions need to prioritise the fundamental redistribution of resources, funding, workforce, services and power. Reducing inequalities can involve unpopular and difficult decisions. Physicians have a particular role in society and can support evidenced-based change across practice and the system at large. If we do not act now, then when?