Each day, nurses are exposed to the realities of the impact of inequalities on health outcomes. Primary care and community nurses are central to the functioning of community-based care and understand that certain patients are more susceptible to poorer health outcomes due to various factors such as socioeconomic, ethnic or sexual characteristics (Mabhala, 2015).
Healthcare inequalities describe the challenges with accessing quality care for deprived and underserved communities. They are distinguishable from health inequalities, which involve individual factors such as housing, income, ethnicity or sexual orientation (Waterall et al, 2022), whereas these are related to accessibility and equity of care provision. For example, service availability, opening times, languages spoken, literacy and fear are all drivers of healthcare inequality (NHS England, 2024a). Nurses need to be aware of the issues facing their populations and their ability to access preventative, diagnostic and curative services.
As the role of nursing in primary care continues to evolve there are opportunities for nurses to redesign their services to meet the needs of these patients with poorer health outcomes due to inequalities (McFarland and MacDonald, 2019). In primary care, nurses have taken on increased responsibilities for the care of chronic conditions such as supporting patients with self-management, social prescribing, prevention advice, advanced assessment and treatment, making them able to evaluate the service to improve attendance by patients who should be accessing these services, but are not (Griffin et al, 2017).
A national approach, led by NHS England, entitled Core20PLUS5 has been implemented to help identify those communities most at risk of experiencing healthcare inequalities (Box 1). This approach informs action to reduce healthcare inequalities at both national and system level (NHS England, 2024b). Key to the success of this campaign is innovation addressing healthcare inequalities (Inselman et al, 2020; Phillips and Evans, 2022; Norris et al, 2023). Innovation is described as novel therapeutics, diagnostics, practices, technologies and delivery methods that result in better health (Kimble and Massoud, 2017). In primary care, innovation has an impact on inequalities, such as practices in areas of high deprivation unable to implement new services or digital innovations that could potentially exclude those without digital skills, internet access or disabilities (White et al, 2009). It is important for nurses who use innovations to assess the suitability and applicability of these novel approaches for patients from Core20PLUS groups.
Box 1.Core20PLUS5Core20: The most deprived 20% of the national population identified by the national Index of Multiple Deprivation (IMD)PLUS: At-risk populations to be identified at a local level such as ethnic minority communities and those with learning disabilities5: The five key clinical priority areas: maternity, severe mental illness, chronic respiratory disease, early cancer diagnosis, hypertension case-finding and optimal management and lipids optimal managementSource: NHS England, 2024b
Innovation in Healthcare Inequalities Programme
To reduce healthcare inequalities, NHS England created the Innovation for Healthcare Inequalities Programme (InHIP). Nationally, £4.2 million was made available in 2022/2023 to integrated care systems to develop and deliver local InHIP projects to improve access for Core20PLUS communities to the latest health technologies and medicines. System-level teams have been busy working with their local communities to adopt these innovations in ways that improve their access, experience and health outcomes. They have been supported by their regional health innovation networks to support scalability of these programmes.
Asthma in Stoke-on-Trent
I spoke to Holly Minshall, Asthma Nurse Educator from University Hospital of North Midlands, who is leading on an InHIP project in Stoke-on-Trent with support from Health Innovation West Midlands. The project focuses on improving access to asthma biologics for patients in the four primary care networks with the highest levels of deprivation (at least 50%). It has been led by two nurses and one physician.
Asthma is likely to be less controlled by patients who experience some form of social or societal inequity (Asthma and Lung UK, 2023). Uncontrolled asthma results in a worsening of physical, social and mental outputs (Katsaounou et al, 2018). This is further exacerbated by factors such as being unable to communicate with your GP in your first language, social isolation and poor health literacy. As Holly explained:
‘They don't want to make themselves breathless because they don't know how to manage their disease and it just gets worse.’
The InHIP funding has been allocated to improve diagnostic testing for asthma across four primary care networks. FeNO (fractional exhaled nitric oxide) testing is an innovative medical technology used to aid in the diagnosis and monitoring of asthma. The overall aim of the project is to screen patients from deprived communities for asthma using FeNO testing and start them on asthma biologics, a proven but underutilised treatment for patients with severe asthma (Health Innovation Wessex, 2023).
Engaging communities
Relevant communities were approached through events created by the team in their locality. Community health events can reduce healthcare inequalities by bringing healthcare information, advice and specialist referrals closer to home (Fritz et al, 2023). This involved inviting patients into a community space where they can speak to a clinician about asthma and be referred for screening. These events have helped to address local inequalities by having translators on the telephone, ready to help patients and clinicians communicate with each other, translating posters into the top five most commonly spoken languages in the area, and connecting patients to community support groups.
These events have attracted over 100 local people at each event and have enabled individuals to access care in a setting more comfortable to them on a drop-in basis rather than via their GP practice. As Holly said:
‘Through these events I wanted to empower the community to support each other. It was really lovely to see these marginalised groups come together in their local spaces and talk to each other about asthma, so they wouldn't feel so alone.’
The original purpose of the events was to raise asthma awareness and improve access to specialist community asthma care. However, the team also identified opportunities to reduce the wider determinants through inviting local charities, other community health groups, and Citizens Advice to provide a holistic approach to address inequalities.
Seeing patients in the clinic
Following the community event, patients who were identified as in need of treatment optimisation or an assessment were invited into the clinic. The practice clinic was set up to best meet the needs and availability of patients following attendance at the community events and for them to have a comprehensive multidisciplinary assessment. A practice nurse from the local community was employed to facilitate these sessions as they had the local knowledge of the people, environment and communities that patients would be coming from. During these assessments, patients were reviewed for their severity of asthma and placed on biologics where appropriate.
This initiative, with support from Health Innovation West Midlands, has delivered 149 FeNO tests to patients. Holly shared an example of the impact it can have:
‘We had a husband and wife come in who'd recently emigrated and developed asthma whilst in the UK. It was uncontrolled and they were suffering quite severely and their quality of life was poor. They didn't know how to take their inhalers and why they should be taking them due to language barriers at previous appointments.
‘They came along to a community event and were booked into one of our clinics. We had a translator on the telephone and did a thorough medical assessment. We taught them how to take their inhalers and gave them medical advice on self-management.
‘They came back a month later with a normal FeNO and no symptoms. They were both able to sleep at night, which is something they struggled with before. If it wasn't for work like this, these patients would likely have continued to suffer.’
The role of a nurse leader
Holly highlighted how she has used her experience as a nurse in many different ways in leading the project:
‘I've really enjoyed working on this project, I get to use my clinical and communication expertise to promote a service to a community that has felt abandoned.’
Nurses have a depth of experience delivering holistic care while also addressing clinical needs. This enabled Holly, when reviewing the patient pathway from the community to the clinic, to focus on the patient experience and ensure that it was positive and effective.
Summary
The Stoke-on-Trent project discussed here is one example of how nurses are leading in addressing healthcare inequalities through the InHIP programme. They can use their experience of engaging with patients to design services that best meet their needs. There is more work to be done in this space and nurses have the opportunity to use their skills in communication, leadership and compassion to help those from deprived and underserved groups live longer and healthier lives.
