Health equalities and inclusion are crucial considerations in providing digital first primary care. This topic is closely related to several other articles in this series, including those on, Digital accessibility standards and Digital skills for patients.
The UK Government has committed to addressing health equalities and promoting inclusion as part of its broader health and social care policies. This includes initiatives such as the:
- NHS Long Term Plan, which aims to improve health outcomes and reduce inequalities by targeting investment in areas of greatest need
- NHS England Equality and Health Inequalities Hub, which sets out the statutory responsibilities around equalities and health inequalities and the national NHS programmes in these areas
The UK has also implemented the National Health Service (NHS) Equality Delivery System (EDS) which is a framework to help NHS organisations improve the services they provide to their local communities, create discrimination-free working environments for NHS employees, and comply with the requirements of the Equality Act 2010.
Health inequalities explained
The World Health Organisation defines health inequalities as ‘avoidable inequalities in health between groups of people within countries and between countries‘.
As indicated by the establishment of an equalities and health inequalities hub, the NHS is committed to advance equalities, achieving equitable access and optimal outcomes for the people we serve, and the colleagues we work with. NHS England says that ensuring everyone can access services on an equal footing is a key priority for the NHS.
Nine protected characteristics are listed in the Equality Act 2010, but there is no specific list of ‘at risk’ groups in relation to reducing health inequalities.
A range of groups and communities are at risk of poorer access to health care and poorer health outcomes (see the table below, taken from the NHS Long Term Plan).
Others who face health inequalities:
Nature of equitable access
General practice organisations must ensure all patients have equitable access to care, and that decisions or policies do not unfairly disadvantage people or lead to an increase in inequalities. Moreover, all NHS organisations are legally obliged to not discriminate against patients or staff.
Equitable treatment does not necessarily mean always treating everyone the same. Instead it means treating everyone fairly, giving them equal opportunity to receive the care they need. In some cases, it may be necessary to provide different levels of service to individuals to ensure equal access to care. For example, providing interpretation services during appointments is a way to treat patients differently while still ensuring they receive the same level of care.
Equality and health impact assessments (EHIA)
Equality and health impact assessments (EHIA) are a formal mechanism for ensuring fairness when providing care and should be implemented when creating new polices or practices. In 2019, Public Health England published a Strategy for 2020 – 2025. This was followed in 2021 by the release of a health equality assessment tool called HEAT.
Equality and health inequalities assessment is a combined approach designed to avoid discrimination and reduce health inequalities. If the conclusions of an assessment are disregarded or ignored, this could be classed as unlawful discrimination. Further details are available on the NHS England website.
Example | A new policy and process on interpretation focussed on spoken language and did not address the needs of hearing-impaired people. As a result, there was a negative impact on the service that people with hearing impairments received when they attended general practice.
An equality & health impact assessment would have identified this issue at an early stage and advice from patients and disability experts could have contributed to policy. The impact could have been mitigated by including sign language in the policy and process.
Equalities and inclusion in digital primary care
Implementing digital services must be done with care, as unequal access to these services across different socio-economic groups can lead to worsening healthcare inequalities. Households with lower incomes, for example, may have limited internet access and lack the digital skills needed to make use of it. Disability may also contribute to difficulties accessing digital tools and inclusivity must be at the heart of their design.
When registering patients for general medical services and/or for online access, it is important not to discriminate, and to support people who may face health inequalities due to challenges such as not having a fixed address or having low levels of literacy or digital literacy.
Example | When registering patients for general medical services, you do not need proof of address or immigration status, ID or an NHS number.
When providing appointments, it is important to offer a mixture of in-person, face-to- face and remote (telephone, video or online) appointments. It is also important to design services with consideration towards those who may be housebound, live in remote areas, or in areas where poor internet or mobile networks can negatively impact on video calling/online appointments. This mixture of appointments is likely to mitigate inequalities in access across the patient population.
Reasonable adjustments flags
Patients who may need ‘reasonable adjustments’ should have reasonable adjustments flag attached to their clinical record. This is a national record in the NHS Spine which indicates that reasonable adjustments are required for an individual. It optionally includes details of a patient’s significant impairments and key adjustments that should be considered.
How GP practices can promote inclusive and safe access
A service manual to build consistent, usable services is available here and practices can take a range of actions in order to reduce the potential impact of online services on inclusive access. This allows the reception team to take an appropriate and consistent approach.
Staff should support patients with access needs, for example those with learning disabilities, autism, visual impairment, and hearing loss. NHS patient guides are available to assist with this.
Specific protocols should be developed for children and young people under 18 years old.
A more traditional, non-digital, solution should be available for those patients who simply cannot or will not engage digitally.
Legal requirement | The Equality Act
There is legal requirement to not discriminate against people with protected characteristics and to follow The Equality Act (2010) . The Public Sector Equality Duty (PSED) is part of the Equality Act focussed on eliminating discrimination, advancing equality of opportunity and fostering good relations between persons who share a relevant protected characteristic and persons who do not share it. Failure to do so would not only disadvantage vulnerable patients but also leave your organisation at risk of litigation.
Table 1: Prohibited conduct under the Equality Act 2010
Direct discrimination arising from disability
Gender reassignment discrimination involving absence from work
Pregnancy and maternity discrimination in both work and non- work situations
Failure to make reasonable adjustments for disabled persons
Enquiries about disability and health before the offer of a job is made
Breach of non-discrimination rule
Breach of an equality clause
Breach of an equality rule
Breach of maternity equality clause
Breach of maternity equality rule
Discrimination and harassment in relation to relationships which have ended
Unlawful acts by agents or employees
Instructing, causing, or inducing discrimination
NHS Constitution requirement
The NHS Constitution states that all staff should aim to contribute towards providing fair and equitable services for all. We must all play our part, wherever possible, in helping to reduce inequalities in experience, access or outcomes between differing groups or sections of society requiring health care.
Addressing health inequalities continues to be a core priority in the NHS Operational Planning and Contracting Guidance 2023-24. Data and analytics should be used to redesign care pathways to improving access and health equity for under-served communities.
The NHS 2021/22 priorities and operational planning guidance explicitly included the need to mitigate against digital exclusion and accelerate preventative programmes that proactively engage those at greatest risk of poor health outcomes.
Accounting for and reducing health inequalities is important to achieve digital clinical safety for all patients, carers, the public and health and care providers. NHS England has published a Digital Clinical Safety Strategy which sets out priorities, direction of travel, and a call to action for the whole NHS.
Related GPG articles
- Identity (ID) verification
- Registering patients for online services
- Primary Care Networks (PCNs)
- Digital skills for patients
- Digital accessibility standards
- Population health management
- Digital clinical safety assurance
Other helpful resources
- FutureNHS, Digital inclusion & Digital access (log-in required)
- NHS England, General practice case studies – Improving access to general practice
- NHS England, Equality, diversity and health inequalities (overarching information about NHS duties and objectives relating to equality)
- NHS England, inclusion resources
- NHS Digital, Digital inclusion for health and social care, 2019
- NHS England, Equality and health inequalities assessment
- Public Health England, The NHS Long Term Plan: Equality and Health Inequalities Impact Assessment
- FutureNHS, NHS England, Inclusive access toolkit, pilot evidence (log-in required)
- NIHR, Applied Research Collaborative East Midlands, Equality Impact Assessment (EqIA) Toolkit
- Public Health England, digital access toolkit, general practice communications toolkit, webinar and campaign materials
- British Medical Association, Reducing health inequalities in your local area: a toolkit for clinicians
- GOV.UK, Health profile for England: 2018, Chapter 5: inequalities in health
- Future NHS, Healthwatch report GP access during COVID-19 (log-in required)
- NHS England, Improving access for all: reducing inequalities in access to general practice services
- Institute of Health Equity, Fair Society Healthy Lives (The Marmot Review) 2010
- Institute of Health equity, Marmot review 10 Years On, Feb 2020
- Institute of Health Equity, Build back fairer: The COVID-19 Marmot Review, Dec 2020
- Nuffield Trust, Digital access to general practice – evidence review
- e-Learning for Healthcare, free e-learning with sessions on embedding prevention within day-to-day practice, including sessions aimed at particular groups e.g., Inclusion health, statutory and mandatory training and All our health programme
- e-Learning for Healthcare, free e-learning on use of the HEAT tool to enable professionals to systematically identify and address health inequalities and equity in their work programmes or services, Health equity assessment tool (HEAT)