Comment / Ethnic inequalities and the elective backlog: what needs to be done?

The elective backlog continues to grow, with the waiting list in England now exceeding seven million and still rising. Capacity was not keeping up with demand prior to the pandemic, and the direct and indirect impacts of the pandemic have accelerated the growth in waiting lists.

Against this backdrop, NHS England guidance requires organisations to consider inequalities in access to treatment as they address the backlog. This reinforces the existing legal duty to have regard to the need to reduce inequalities in access to services, and the specific duties placed on integrated care boards.

Ethnic minority groups have had worse outcomes from Covid-19, due to a combination of risk factors that disproportionately impact some ethnic minority groups, but there has been much less focus on ethnic variations in planned care, either before or during the pandemic. 

The Nuffield Trust’s new research with the NHS Race and Health Observatory explores variation in age- and sex-standardised treatment rates in England before and during the pandemic. It looks at changes in elective activity overall and specifically in relation to seven common hospital procedures across five main ethnic groups (white, mixed, Asian, black and other). The focus was primarily on ethnic variations, but we also considered variations by deprivation and region. That’s because the proportion of ethnic minority groups is higher in more deprived areas, in cities and in some regions.

We found that wide variations existed before the pandemic, and that there were also differences in how much hospital activity was ‘lost’ during the first two years of the pandemic.

• Before the pandemic, the white group had higher rates of elective procedures overall than the black, mixed and Asian groups, with the white group having almost a fifth more procedures than the Asian group per head of population. Cardiac and cataract procedure rates were highest in the Asian group and dental procedure rates were highest in the black group.
• The Asian group experienced the largest overall fall in the first year of the pandemic compared with the other groups (a fall of 49% for all procedures compared with 44% for the white and black groups). Although the gap narrowed in the second year of the pandemic, there was still a larger deficit of care among the Asian group.
• Consistent differences were not found across procedures for other ethnic minority groups, although the black group did have larger rate falls than the white group for cardiac and cataract procedures (the fall was 19% larger for cataract procedures).
• The most deprived groups in the population experienced larger rate falls overall and for most specific procedure groups. For hip and knee replacements, there was a 13% larger fall in the most deprived group compared with the national change, and a 7% lower fall in the least deprived group.

Plans to tackle the backlog need to take account of ethnic and socio-economic differences, and that requires analysis of variation in waiting lists and activity. 

There is a real risk that initiatives to reduce the backlog – including changes to patient pathways and referral routes – and making more use of remote consultations will exacerbate existing inequalities. This could be a result of the system becoming more complex for patients to navigate, and because digital solutions are more difficult for some groups to navigate than others.

As well as reporting treatment waiting times and waiting lists by ethnic group, elective recovery programmes need to be tracking the patient pathway by ethnic and socio-economic group – from referral, through outpatient appointments and attendances, to times to treatment and outcomes.

Action starts with better data. We know there are problems with the quality of ethnicity coding, and inconsistencies in recording ethnicity that affect ethnic minority groups more than the white group. These include overuse of ‘other’ ethnic group codes and ‘mixed’ ethnic group codes, where there is very poor alignment between census records and hospital data.

This results in an overestimation of rates of activity for these groups relative to their populations – and therefore an underestimation of rates for other ethnic categories. NHS organisations need to look at their data quality, not just the proportion of records with an ethnic code, but also use of not stated and ‘other’ codes.

Reviewing internal systems for collecting data and ensuring patients are identifying their ethnic group, not staff, are both important. Improving data quality will also enable more robust analysis for specific ethnic groups. This is important, as we know there are important differences, for example, between people from Bangladeshi, Pakistani and Indian origin.

But although improvements in data quality are needed, limitations with data should not be an excuse for inaction. Much more can be done now with currently available data to understand and address ethnic and other inequalities in healthcare. As integrated care systems seek to address the backlog in care, it is vital that planned action to address inequalities in access is reinforced and prioritised.