Annexes

Question 1

Annex A: Summary of progress against recommendations from the first quarterly report

Accepted Answer

Recommendation 1: NHS England must ensure that Trusts implement NHS plans for the next stage of the pandemic, and that these plans continue to reflect the latest evidence about ethnic disparities and risk factors.

NHSEI published Phase 3 of its COVID-19 response at the end of July. This urged all NHS Trusts to work collaboratively with local communities and partners to take urgent action to increase the scale and pace of progress of reducing health inequalities and regularly assess this progress. It recommended urgent actions, developed by an expert national advisory group including:

Protect the most vulnerable from COVID-19, with enhanced analysis and community engagement, to mitigate the risks associated with relevant protected characteristics.
Restore NHS services inclusively, so that they are used by those in greatest need, guided by new, core performance monitoring of service use and outcomes among those from the most deprived neighbourhoods and from Black and Asian groups.
Accelerate preventative programmes which proactively engage those at greatest risk of poor health outcomes.
All NHS organisations should proactively review and ensure the completeness of patient ethnicity data.

Over the last quarter, significant progress has continued to be made against these actions. All NHS systems (Integrated Care Systems) have been implementing the actions and monitoring performance. Analysis requires appropriate information, quality assurance and governance before publication and will be released in due course.

The impact of the second wave of COVID-19 will continue to be monitored on these and other indicators. Enhanced monitoring of the completeness of patient ethnicity data is also being undertaken. Executive Leads for Health Inequalities are in place in the majority of NHS organisations and the Director-Health Inequalities post in the national team is now filled. Primary care objectives have continued to emphasise the importance of addressing health inequalities despite the enormous pressures from the pandemic.

The recent letter to NHS systems from NHS England and NHS Improvement on priorities for 2021 to 2022^{[footnote 1]} reiterated the importance of addressing health inequalities. This includes auditing progress against the 8 actions, as well as reducing variation in outcomes across the major clinical specialties and making progress on reducing inequalities for people with learning disabilities or serious mental illness, including ensuring access to high-quality health checks.

Recommendation 2: Departments must put in place arrangements for the effective monitoring of the impacts their policies are having on people from ethnic minority backgrounds.

Monitoring should include:

the uptake of particular COVID-19 policies or grants of funding by ethnic minority individuals and groups
monitoring and assessing the level of infection, hospitalisation and mortality rates across ethnicities, where appropriate
assessing how effectively these policies have been understood by those people at whom they are targeted.

The RDU has been working with departments to assist them in putting effective monitoring arrangements in place. This includes preparing a technical annex setting out how to measure ethnicity impacts.

DHSC already has a strong history of monitoring impacts of health policies over time. The Chief Medical Officer (Professor Chris Whitty’s) first annual report published on 18 December 2020, presents an overview of the health of England’s population. Including discussing initial insights of COVID-19 policies including the impact of Non-Pharmaceutical Interventions on general population impacts.

Other examples include MHCLG building in monitoring structures into the Community Champions scheme to ensure that the programme delivers assistance to those groups who most need it.

Further detail on this and other similar measures can be found in section 1 and in Annex B.

Recommendation 3: there should be a rapid, light-touch review of action taken by local authorities and Directors of Public Health to support people from ethnic minority backgrounds, in order to understand what works at a local level.

This work is summarised in paragraphs 8 to 13 in section 1.

In addition, DHSC officials have engaged with Directors of Public Health to discuss the disproportionate impact of COVID-19 on certain groups, providing insights into how different local areas are responding to the virus.

This has provided valuable feedback regarding vaccine roll out plans, local concerns (particularly for certain communities such as different faith groups and health and care workers) and access/uptake of testing. Valuable feedback was also gained into the communication channels proved most effective in reaching specific communities, such as through faith groups using WhatsApp networks, video messaging and trusted community organisations (such as English Football League clubs).

Recommendation 4: Departments should continue to work at pace to develop new policy interventions to mitigate COVID-19 disparities, informed by the latest evidence.

This work is summarised in paragraphs 3 to 7 in section 1 and in Annex B.

Recommendation 5: Support should be given to the development and deployment of a risk model to understand individual risk that is being developed from research commissioned by the CMO by an expert subgroup of academic, scientific and clinical experts and the University of Oxford.

The QCOVID Predictive Risk Model has been developed and the associated research was peer-reviewed and published in the British Medical Journal in October 2020,^{[footnote 2]} approved by the MHRA in December 2020 and independently validated by the ONS in January 2021. DHSC is working at pace to apply the model in the NHS, incorporating the feedback from private testing of a clinical decision support tool. The clinical tool was made available across primary and secondary care as a secure public beta webtool from 16 February.

Recommendation 6: Ensure that new evidence uncovered during this review relating to the clinically extremely vulnerable is incorporated into health policy.

Through providing detailed data about clinical risk, the QCOVID model has enabled DHSC to incorporate the findings from the research into national policy and has used it to identify a new cohort of patients at equivalent risk to the Clinically Extremely Vulnerable. This group is being added to the Shielded Patient List as a precautionary measure, and is entitled to advice and support, including priority access to the COVID-19 vaccine if they have not already been offered it.

As more is learnt about why the threat posed by COVID-19 varies across the population, the QCOVID risk model l will be updated with the latest evidence and individuals given more nuanced advice on risk.

The Minister for Equalities wrote to the JCVI with the findings from the first quarterly report and will do so again with the findings from this report. The JCVI also reviewed the underlying data from the QCOVID model in shaping its advice on COVID-19 vaccine prioritisation.

There is excellent collaborative work underway across DHSC, PHE and NHSE linking in with the ONS and their work on core data sets. This proactive cross-system working is ensuring maximum knowledge is available in the advice given to inform policy decisions.

PHE has linked data on COVID-19 cases and deaths to more than 20 years of Hospital Episode Statistics data in order to determine presence of pre-existing conditions and ethnicity, as population registers for people with pre-existing health conditions or access to primary care data for the whole population has not been available to PHE to date.

PHE was commissioned by the RDU to prepare a report on COVID-19, ethnicity and pre-existing health conditions. This was published on 18 December 2020.^{[footnote 3]} PHE and ONS have jointly published a blog explaining these latest analyses of COVID-19 ethnic inequalities.^{[footnote 4]}

RDU facilitated conversations between ONS and OpenSAFELY about the possibility of sharing occupation data from the 2011 Population Census - although this did not proceed because of sensitivities about sharing Census data. RDU also facilitated discussions with HMRC about the possibility of sharing (with OpenSAFELY) data that might give insights into the nature of people’s occupations. However, HMRC does not hold data about tax payers’ occupations, or about (for example) whether they might work in a public-facing role. ONS analysts will publish an analysis of mortality rates by ethnicity including occupation as a risk factor in due course.

Recommendation 8: RDU should introduce and publish a new ‘Summary of evidence about COVID-19 and ethnicity’ report, working collaboratively with external experts, which would be updated every time (significant) new statistics and research are published.

RDU commissioned PHE analysis of the role of pre-existing health conditions in ethnic inequalities in diagnosis, deaths and survival from COVID-19. This was published on 18 December 2020.^{[footnote 5]}

In addition, ONS published a ‘long read’ about ethnicity and COVID-19 in an accessible form on 14 December^{[footnote 6]} and has included ethnicity in its COVID-19 “latest data” dashboard.

Links to these reports, the dashboard and other relevant information are included on a specific ‘Ethnicity and COVID-19’ page on RDU’s Ethnicity Facts and Figures website.^{[footnote 7]}

Recommendation 9: The recording of ethnicity as part of the death certification process should become mandatory, as this is the only way of establishing a complete picture of the impact of the virus on ethnic minorities. This would involve making ethnicity a mandatory question for healthcare professionals to ask of patients, and transferring that ethnicity data to a new, digitised Medical Certificate Cause of Death which can then inform ONS mortality statistics.

As the first quarterly report acknowledged, this is a longer-term objective given the need for legislation to enable this change. Recording ethnicity as part of the death certification process will also be dependent on improvements to NHS data. The DHSC has commissioned NHSEI to propose how ethnicity data can be produced and utilised using the Unified Information Standard for Protected Characteristics (UISPC). NHSEI’s report will be submitted to DHSC shortly.

In advance of this, DHSC laid a Statutory Instrument and accompanying Directions in December which made changes to the regulations governing GP contracts. When ethnicity data is provided by the patient (or someone lawfully acting on their behalf where the patient is a child or someone who lacks capacity), the GP is now mandated to record that information in general practice.

The amendment sought to improve recording of ethnicity data to enable NHS services and programmes to be more effective for patients.

Recommendation 10: Minister for Equalities to work with ministerial colleagues to establish metrics for assessing the impact of their policies to tackle COVID-19 disparities.

The Minister for Equalities wrote to colleagues in December encouraging departments to establish metrics for assessing the impact of their policies, accompanied by a technical annex setting out some of the important considerations when developing metrics based on ethnicity. She also met the Minister for COVID-19 Vaccination Deployment to consider how ethnicity data should be collected as part of the vaccination programme.

Recommendation 11: There should be a series of roundtables over the coming months involving faith leaders and other community representatives and focussing on those groups that are most at risk from COVID-19.

Over the course of the last few weeks the focus has turned to promoting uptake of COVID-19 vaccines. The Minister for Equalities, alongside the Minister for COVID-19 Vaccine Deployment and the Minister for Prevention, Public Health and Primary Care, attended a roundtable with the National Pharmacy Association in January to encourage understanding and promote uptake of vaccines.

Dr Raghib Ali, one of the government’s independent advisers on COVID-19 and ethnicity, has also participated in a number of events promoting vaccination through information and question and answer sessions with a number of communities. This included a briefing session with healthcare workers in December and events with the Sikh Council, the NHS Muslim Network and Muslim Doctors in January.

The MHCLG has led on engagement with faith groups throughout the pandemic and the Minister for COVID-19 Vaccine Deployment has also attended a number of stakeholder events in recent weeks to promote vaccine uptake among ethnic minority groups and to combat misinformation about the COVID-19 vaccines.

In February, No.10 and the RDU hosted 2 roundtables on promoting vaccine uptake amongst South Asian groups. Participants included faith leaders and other community representatives and generated a number of ideas and insights on how to improve vaccine uptake in the South Asian cohort.

Recommendation 12: work must continue on improving public health communication to enable the successful delivery of existing and new interventions to all parts of the community including hard-to-reach groups, especially those at greatest risk in areas of local lockdown and rising concern.

This should include:

Increasing and diversifying a programme of activities for ministers across government to improve engagement with people from ethnic minority backgrounds.
Continuing to improve our understanding of ethnic minority audiences and interests of each ethnic minority outlet to ensure messaging is targeted and nuanced, and build on the existing communications programme with respected third party voices to improve reach, understanding and positive health behaviours. Disaggregation of audience and channel approach will support this aim.
A more streamlined approach across government and locally to improve local translations so that those who do not have English as a first language are more likely to be able to understand and act on public health advice.
More emphasis on promotion of existing NHS guidance on minimising transmission within households, sharing these messages widely and in the range of languages and formats needed. Recent figures show that in-house transmissions have played a significant part in the increase in infections we are seeing this autumn and as we head into winter people will spend more time indoors.

A full update is included in Section 4. Highlights include:

The Minister for COVID-19 Vaccine Deployment, Nadhim Zahawi, has taken part in various media opportunities to speak directly to the public about the vaccines programme. He has also taken part in roundtable sessions to onboard community ambassadors who will improve vaccine confidence among ethnic minorities.

In his role as Business and Industry Minister, Nadhim Zahawi, ran a business support webinar with British Business leader, Yvonne Thompson. The audience included around 100 ethnic minority business owners. Additionally Minister for Small Businesses, Paul Scully, interviewed 3 ambassadors of the ‘Small Biz Sat’ campaign – one with a focus on diversity.

The government now has richer insight into reach, awareness, understanding and media consumption among ethnic minorities which has enabled improved tailoring and targeting of public health messaging. A specific effort is underway to understand beliefs, attitudes and behaviours among ethnic minority people to the vaccine, feeding into an integrated vaccines confidence campaign.

In addition to the translation of national assets, local authorities can request translations of their own assets.

A specific communications strategy has been developed to promote safe behaviours within multigenerational households and houses of multiple occupancy. The approach - which includes engagement via community, faith and business leaders to co-create and disseminate marketing materials - will be implemented through local authority partners and in the languages each area requires.

PHE has received new funding to boost the Better Health Campaign to target Black African, Black Caribbean, Indian, Bangladeshi and Pakistani groups. The work will run until March 2021 and will include out-of-home advertising, specific community media on radio and in print, targeted PR using culturally relevant health care professionals and online and social media advertising. The advertising and content will be upweighted in geographical areas with a high proportion of populations from minority ethnic backgrounds and will be multilingual where appropriate.

Recommendation 13: Further work is needed to dispel myths, reduce fear and build confidence among ethnic minority people. Over the coming months, the COVID Communications Hub in the Cabinet Office will need to keep sharpening its focus on rebuilding trust in government messaging, tackling misinformation and anti-vaccination narratives and encouraging engagement with NHS services

A full update is included in Section 4.

As part of the vaccine confidence campaign, briefing sessions are being held with community and faith leaders with an expert panel of speakers taking questions and countering misinformation. This is part of a wider, fully integrated campaign being implemented on multiple channels to improve public knowledge, perceptions and motivations to vaccines, issuing credible content which addresses identified barriers.

The campaign includes radio, television and press partnerships incorporating community radio stations and publications carrying messages in over 10 different ethnic languages using strong, credible, relevant case studies and personalities that help get important messages and guidance across.

Question 2

Annex B: Summary of government actions to address disparities

Accepted Answer

Department for Work and Pensions (DWP)

Update on actions in first quarterly report

The quarterly ethnic minority employment data published in November showed that the ethnic minority employment rate reached a record high of 67.6% for the year ending September 2020, up 0.4% from June 2020.

The ethnic minority unemployment rate was at 6.7%, up 0.4% from June 2020.

In response to this data and the broader impact of COVID-19, DWP will utilise £3.6 billion of additional funding in 2021 to 2022 to deliver labour market support.

New initiatives

The DWP’s initiatives have focussed on providing financial support, which while not directly related to addressing health disparities have helped to support those most at risk from COVID-19.

The DWP launched the Kick-start Scheme in Great Britain on 2 September 2020, which provides a £2 billion fund to create hundreds of thousands of high quality 6-month work placements for 250,000 young people, including ethnic minorities on Universal Credit who are deemed to be at risk of long term unemployment.

The UK Shared Prosperity Fund will provide £220 million bridge funding in 2021 to 2022 to help level up and create opportunity across the UK by helping vulnerable local communities respond to, and recover from, COVID-19.

As part of the government’s COVID-19 support measure, the Minimum Income Floor has been suspended until the end of April 2021, allowing self-employed people to continue to receive crucial financial support from Universal Credit based on their current actual earnings, providing additional protection for those who see a drop in earnings due to the impact of COVID-19.

DWP has expanded the Sector-based Work Academy Programme to allow unemployed people, including ethnic minorities, to pivot into priority sectors, including construction, infrastructure and social care.

Department for Business, Enterprise and Industrial Strategy (BEIS)

Update on actions in first quarterly report

BEIS continues to monitor the impact of the guidance previously updated to assist employers to identify higher risk groups and consider them in their risk assessments. Extensive industry engagement also continues.

The higher-risk groups include older men, those with a high BMI, those with health conditions such as diabetes, those from some ethnic minority backgrounds.

New initiatives

BEIS supported targeted economic support for those who need it most. For example, rolling out unprecedented levels of economic support worth over £280 billion has provided a much-needed lifeline for those working in closed sectors such as retail and hospitality, the workforces in which are disproportionately young women and from an ethnic minority background.

BEIS and ACAS are working together to establish advice on employment rights for disabled people. BEIS is aware that those from ethnic minority backgrounds often struggle to access disability services and that this group has been particularly affected by mental health issues arising from COVID-19. This will improve access to appropriate, easily-accessible information and advice for disabled people who are looking for, or already in, employment.

Department for Transport (DfT)

Update on actions in first quarterly report

DfT continues to monitor the impact of COVID-19 on the transport industry, including monitoring the impact of measures around workplace risk.

DfT has also continued with sector-specific engagement to ensure guidance is updated and disseminated efficiently. For example, DfT worked with the 3 main trade associations (Licensed Private Hire Car Association; National Private Hire and Taxi Association; Licensed Taxi Drivers Association) to refine the guidance and gain approval.

DfT is also working with other government departments to determine where mass testing would be beneficial.

Through this collaborative approach, DfT has been able to work with operators to roll out testing pilots at important transport locations during the Christmas period and use lessons learnt to feed into a future rollout of asymptomatic mass testing.

New initiatives

On 18 November DfT published sector specific Coronavirus COVID-19 Taxis and PHVs guidance^{[footnote 8]} on actions that drivers, operators and owners of taxis or PHVs can take to protect against COVID-19.

DfT has prepared and will shortly publish technical guidance to assist drivers, operators and local government licencing offices with the installation and approval of protective screens in taxis and PHVs.

DfT is working with transport operators to set up workplace test sites to help break the chain of transmission. So far, approximately 50 operators have been referred to DHSC to set up approximately 100 test sites. For more dispersed workers, such as taxi and private hire vehicle drivers, DfT continues to work to unlock barriers to provide regular testing through other means, such as community test centres or home testing. DfT is engaging with such groups to support their access to testing.

Department for Education (DfE)

Update on actions in first quarterly report

DfE continues to monitor guidance put in place for educational settings. This includes ensuring that guidance remains consistent with approaches taken for other education settings, including advice on carrying out risk assessments for staff.

New initiatives

DfE maintains regular engagement with higher education trade unions and the Universities and Colleges Employers Association to understand COVID-19 related concerns and ensure DfE guidance helps employers prioritise safety. Minority ethnic staff continue to be overrepresented in higher risk, front-line roles such as cleaning, estates, and catering.

The government has already provided £4.6 billion grant funding to support councils through the COVID-19 crisis. At the recent Spending Review, the Chancellor announced an additional £1.55 billion to support local authorities with the immediate and longer-term impacts of COVID-19 spending pressures next year, including children’s services.

The government is also putting £300 million more into the adult and children’s social care grant next year, giving councils a total of £1.7 billion in grant funding for social care in the 2021 to 2022 financial year.

DfE is working closely with DHSC to ensure children’s social care workers are prioritised for testing and vaccination. Children’s homes already have access to DHSC’s National Testing portal to order home test kits, to support stability of placements.

DfE provided £6.5 million from the Adoption Support Fund to help families under pressure during COVID-19. DfE also invested significantly in adopter recruitment to ensure children from minority ethnic backgrounds do not wait longer to be placed with families.

DfE has made £220 million available to local authorities to expand The Holiday Activity and Food Programme to cover 2021. Designed to mitigate the impact of absence from school over holidays that can disproportionately affect disadvantaged children, it will be available to Free School Meal-eligible children in every local authority in England.

The government has provided over £11 million to a consortium of national and local organisations to deliver the See Hear Respond (SHR) programme for children and young people whose usual support networks were impacted by pandemic restrictions. The programme began in June 2020 and will continue until the end of March 2021. To date, the programme has supported over 50,000 children and young people, including 6,000 children from an ethnic minority background.

Update on actions in first quarterly report

NHSEI Phase 3:

NHSEI published Phase 3 of its COVID-19 response at the end of July. This urged all NHS Trusts to work collaboratively with local communities and partners to take urgent action to increase the scale and pace of progress of reducing health inequalities and regularly assess this progress.

All NHS systems have been implementing Phase 3 actions and monitoring performance. The impact of the second wave of COVID-19 will continue to be monitored on these and other indicators. Enhanced monitoring of the completeness of patient ethnicity data is also being undertaken.

NHS-E/I’s top priorities for 2021 to 2022 are to reduce health inequalities despite added pressures of the pandemic. Progress will be evaluated against Phase 3’s 8 urgent actions (see first quarterly report). Executive Leads for Health Inequalities are in place in the majority of NHS organisations and the Director of Health Inequalities post in the national team is now filled.

Risk assessments:

The NHS is required to undertake a workplace risk assessment in all operational locations. In preparation for further increases to COVID-19 rates over the latter part of 2020, a directive was sent to healthcare leaders stating that risk assessments are a continuous process to keep staff safe.

PPE:

DHSC updates on the NHS-E/I project led by the Deputy Chief Nursing Officer state that by December 2020, a further 8 types of FFP3 mask were made available to the NHS taking the total to 16. The increased range will provide diversity of choice for ethnic minority staff. DHSC is ensuring that NHS trusts are receiving their choice of masks and ensuring staff on the frontline can access masks they have successfully fit-tested to.

Comorbidities:

DHSC Equality Matters Network held a roundtable to hear from colleagues affected by the PHE disparities report and feed into the DHSC draft Race Equality Plan.

Update: DHSC plans to expand the Better Health Campaign to target ethnic minority groups. DHSC’s focus will be on tackling obesity and other comorbidities, which are underlying risk factors associated with COVID-19.

DHSC’s particular focus will be on Black African, Black Caribbean, Indian, Bangladeshi and Pakistani ethnic groups, with the advertising and content upweighted in geographical areas with a high proportion of populations from minority ethnic communities. DHSC will measure impact and effectiveness using quantitative tracking (YouGov) and qualitative mixed method research with specialist multi-cultural research agencies.

New initiatives

COVID-19 vaccinations:

DHSC is tailoring local implementation to promote good vaccine coverage in ethnic minority groups.

The NHS, PHE and DHSC will provide advice and information at every possible opportunity, including working closely with minority ethnic communities, to support those receiving a vaccine and to anyone who has questions about the vaccination process.

DHSC is prioritising people with underlying health conditions, which will provide for greater vaccination of ethnic minority communities who are disproportionately affected by such health conditions.

NHS Test and Trace:

DHSC is working to improve, standardise and join-up its evaluations to allow for comparability, transfer of lessons learned, and drive evidence-based policy-making and intervention design. It is using performance management information and bespoke monitoring and evaluation evidence to inform future policy and interventions to address the disproportionate impact of COVID-19 on high-risk groups.

DHSC partnered with the City of Liverpool to pilot community open-access testing for people without symptoms of COVID-19. DHSC published evaluation findings from the Liverpool pilot. Overall, positivity rates were 3 times higher for the most deprived quintile compared with the least deprived. Digital exclusion was a substantial barrier to uptake, more than deprivation alone.

DHSC piloted on-site, locally-led testing in a Wolverhampton Gurdwara which was extended at the request of the local authority and the Gurdwara management due to its success. Further pilots are planned in collaboration with MHCLG’s Places of Worship Taskforce.

NHS workforce:

NHS-E/I’s operational priorities for winter and 2021 to 2022 is the delivery of the NHS People Plan and ongoing improvements on equality, diversity and inclusion of the workforce. The National People Plan Delivery Board will provide scrutiny and oversee monitoring and evaluation. Actions include:

The appointment of a named inequalities champion in every NHS organisation
Ensuring all trusts have a thriving ethnic minority network
A 5-year plan to ensure organisations reflect the communities they serve
Overhauling recruitment and promotion practices to ensure that staffing reflects the diversity of communities and labour markets
Resources training and guidance to support line managers to discuss equality diversity and including
Stretching targets to reduce the likelihood of entry into disciplinary process
Competency frameworks for every board level position that will reinforce that responsibility for leading and making progress on equality diversity and inclusion
The Care Quality Commission (CQC) placing increasing emphasis on whether organisations have made real and measurable progress on equality, diversity and inclusion
Joint training for Freedom to Speak Up Guardians and WRES leads, with more ethnic minority staff recruited to Freedom to Speak Up Guardian roles.

Adult Social Care workforce:

The Workforce Race Equality Standard (WRES) in social care will be initially implemented in 18 local authority social work departments from April 2021. WRES requires organisations to demonstrate progress against indicators of workforce race equality.

The CQC published Equality Objectives (2019-2021) to help improve equality for staff and service users across health and social care sectors.

PHE guidance for occupational settings

PHE, the Health and Safety Executive and the Faculty of Medicine issued a consensus statement in November 2020 on Mitigation of risks of COVID-19 in occupational settings with a focus on ethnic minority groups.^{[footnote 9]}

PHE is supporting the RDU and the Food Standards Agency to develop simplified resources for employers in the food industry to help reduce employee exposure and mitigate risk. PHE worked with DEFRA to develop COVID-19 guidance for food business, employers with high proportions of ethnic minority workers, which states that communication with all employees must be a high priority.

PHE is supporting the RDU to support other government departments around risk management to protect their staff from COVID-19.

Ministry of Defence (MOD)

Update on actions in first quarterly report

The Joint Medical Group released guidance in relation to the medical risk assessment for defence personnel working on tasks involving COVID-19 medical related processes or with COVID-19 patients in June 2020.

This includes advice on work process based risk assessments with the option to seek suitably qualified advice in order to better assess and mitigate risk where appropriate, as well as return to work processes post a COVID-19 infection.

Having released guidance on this, the MoD continues to monitor the situation, including COVID-19 cases by ethnicity.

COVID-19 Cases in UK Armed Forces: There have been a total of 3,291 positive cases of COVID-19 amongst the UKAF.^{[footnote 10]} Of these, 2722 (83%) were of White ethnicity and 468 (14%) were from an ethnic minority background. COVID-19 Hospitalisations UKAF: A total of 40 personnel were admitted to hospital with COVID-19. 28 (70%) were of White ethnicity, 11 (28%) were of a minority ethnicity.

New initiatives

MoD provided medical Risk Assessment Guidance for Defence Personnel working on tasks involving COVID-19 medical-related processes or with COVID-19 patients. MoD introduced a requirement for COVID-19 Risk Assessments to be carried out for every employee if required to attend the workplace.

MoD provided a reference in the Risk Assessment Policy to ethnicity, amongst other factors (such as gender, age, comorbidities), as a possible association to increased vulnerability to COVID-19; hence it informs the reader of this important link.

Ministry of Housing, Communities and Local Government (MHCLG)

Update on actions in first quarterly report

MHCLG continues to actively engage the faith community. For example, the Places of Worship Taskforce has continued to hold regular roundtables with leaders from major faiths, chaired by Faith Minister Lord Greenhalgh. Meetings have shifted focus from re-opening of places of worship to cover Test and Trace and the vaccination programme rollout.

MHCLG is also engaging with the Devolved Administrations to discuss the approach to housing and COVID-19 across the UK nations, including data on housing conditions, ethnicity and overcrowding, and steps to improve outreach and communication on public health guidance.

This seeks to strengthen prior government guidance for landlords, tenants and local authorities published on 1 June, which offers advice to tenants who are vulnerable or shielding and who are in overcrowded or shared accommodation.

New initiatives

MHCLG has responded to a SAGE report on ‘Housing, household transmission and ethnicity’ published in December by providing updated guidance for tenants, landlords and local authorities to reduce in-household transmission. This guidance advises that local authorities may be able to use their enforcement powers to require a landlord to remedy a serious overcrowding hazard.

MHCLG is using Community Champions project networks to ensure that guidance on limiting household transmission reaches disproportionately impacted groups.

MHCLG created a longlist of 65 local authority areas to support through the Community Champions Scheme using DHSC/PHE data on COVID-19 incidence.

MHCLG is monitoring the success of the Community Champions scheme by requesting returns at one, 3 and 6-month intervals and holding regular meetings with funded partners.

MHLCG invested £400,000 into education and training programmes to help Gypsy, Roma and Traveller (GRT) children catch up on lost learning during the pandemic.

MHCLG is working across government departments to gather intelligence on the impacts of local lockdowns on community tensions.

MHCLG facilitated a community-led Test and Trace pilot in a Gurdwara in Wolverhampton with excellent outcomes, and is currently in discussion with Test and Trace about holding more.

MHCLG’s Places of Worship Taskforce will assess the results of a survey on the places of worship guidance to understand how well the guidance is used and understood. MHCLG is hosting roundtables on challenges to sharing guidance with ‘fringes’ of their faiths and compliance issues.

Department for Digital, Culture, Media and Sport (DCMS)

Update on actions in first quarterly report

The Civil Society and Youth Directorate is working with the Cabinet Office and voluntary and community sector to improve engagement and disseminate effective health messages and support for people from ethnic minority communities. A particular focus has been on engaging disproportionately impacted groups with the vaccine roll out through comms (providing vaccine comms toolkits), using the VCSE sector as trusted intermediaries to drive vaccine uptake.

Engagement has continued with ethnic minority VCSE representatives and the Minister for Civil Society.

The group has focussed on 3 deep dive themes already in relation to ethnic minority communities of; financial inclusion, youth, and the ethnic minority VCSE sector. Planned future focus is on mental health in ethnic minority communities and how the VCSE sector can respond proactively.

New initiatives

Across the £750 million VCSE funding package, a total of £61.8 million has gone to 2,421 organisations who specifically target BAME people or groups.

9 organisations were awarded funding from the COVID-19 Loneliness Fund to support the main target groups at risk of loneliness. This included ethnic minority communities and refugees.

As part of the loneliness fund we are supporting The Reading Agency with £3.5 million to expand 2 of its impactful programmes. Reading Friends is a programme which tackles loneliness through reading. In addition, Reading Well Books on Prescription will deliver 3 clinically-curated mental health collections (targeted to adults, young people and children) to all public libraries (over 2,800) in England, enabling those experiencing poor mental health to access self-directed support.

£665,000 funding has been confirmed for support for small commercial radio stations and their transmission costs between now and the end March 2021 as part of a wider package agreed with Arqiva, the UK’s broadcasting transmission operator. An additional £200,000 has been made available to the Community Radio Fund to support community stations. This funding will help ensure that community stations, including those serving ethnic communities, can fully support the CO/DH led campaigns targeting these communities with new messaging - in multiple languages - about COVID-19 restrictions and influencing vaccines take up.

DCMS is working with digital inclusion and disability charities to design and deliver a £2.5 million digital inclusion programme. This will provide tablets, connectivity and digital support to around 5000 people with learning disabilities, enabling them to connect virtually with others and access online services, in a safe and secure way.

The Counter-disinformation Unit in DCMS has responsibility for monitoring and analysis of mis/disinformation narratives online, including those related to the COVID-19 vaccines, and engagement with social media platforms to tackle this issue. DCMS works closely with the Vaccine Taskforce in BEIS and DHSC, who are responsible for vaccine development and deployment, and delivering effective communications around the vaccine. DCMS is also creating new bespoke shareable assets for vulnerable audiences to misinformation, based on the principles of the SHARE checklist, which aims to increase resilience to misinformation.

A £16.5 million ‘Youth COVID-19 Support Fund’ launched on 15 January, which will protect the immediate future of grassroots and national youth organisations across the country. The Fund will help to mitigate the impact of lost income during the winter period due to the pandemic, and ensure services providing vital support can remain open. £1.7 million of the £16.5 million has been allocated to vital youth work qualifications and training. The fund closed to applications on 19 February.

Ministry of Justice (MoJ)

Update on actions in first quarterly report

HMPPS (Her Majesty’s Prisons and Probation Service) COVID emergency fund consisting of £300,000, administered by Clinks, has proactively sought applications from small ethnic minority-led organisations.

HMPPS’s strategy for the management of COVID-19 in prisons has built on PHE and Public Health Wales advice and includes the following measures:

the implementation of effective isolation
shielding vulnerable prisoners
restricting regimes to prevent social contact in custody
introduced a comprehensive testing regime

HMPPS continues to actively monitor this to ensure effectiveness in reducing COVID-19 cases amongst staff.

New initiatives

Quarterly HMPPS (Her Majesty’s Prisons and Probation Service) workforce statistics included experimental data on staff deaths, positive COVD-19 test results and numbers of staff absence due to COVID-19 broken down by business area and ethnicity. The information was included in a separate Annex to that publication.

MoJ has produced wellbeing guidance for all line managers, to inform one to one conversations with staff. The guidance covers the disproportionate COVID-19 impacts for ethnic minority staff and the potential heightened anxieties this can cause. This guidance is clear that a full individual risk assessment should be completed when underlying health conditions are disclosed or if the employee requests one, but these are not mandatory.

Question 3

Annex C: Further data and evidence

Accepted Answer

Term of Reference 3: Commission further data, research and analytical work by the Equality Hub to clarify the scale, and drivers, of the gaps in evidence highlighted by the report

Ethnicity and risk factors

Infection risk factors include a wide network of contacts a person is exposed to or a limited ability to distance from those who may pose a risk to them; both increase chances of transmission. These risk factors include geography, deprivation, overcrowding, multigenerational households, certain occupations (in particular those that are public-facing) and lifestyle factors.

Someone with COVID-19 may not be able to effectively distance within an overcrowded household, increasing transmission risk for members of their household.
Someone whose occupation requires them to work at close quarters with others outside of their household is linking the contact networks of 2 or more households, increasing transmission risk across multiple groups of people.
People living in economically deprived areas may be less equipped to remotely educate and may need to send their children into school as ‘vulnerable’ pupils, increasing contact with other households.
People living in service deprived areas may need to travel further to access services they need, increasing contact and networks between locations, particularly if they are reliant on public transport to do so.
Someone living in a dense urban area may be at increased risk of contact and limited distancing from others while conducting essential travel, shopping or exercise in public.

To verify the impact of risk factors it is necessary to conduct multivariate regression modelling using infection data and a rich set of individual level characteristics. In some cases this is not possible as the data are not collected or are based on 2011 Census data, which are ten years old. These limitations in measurement contribute to the “unexplained” proportion of the disparities, though future data linkage efforts, such as the linkage of comorbidity and occupation data from the 2021 Census, could provide further insights. Alongside the unquantifiable, there are likely further, unknown, risk factors (or combinations of factors) driving the disparities, that cannot be modelled.

It is also important to bear in mind that ethnicity is a multi-dimensional concept which includes culture, language, religion, migrant status and race, with considerable diversity within and between ethnic minority groups. Some of these dimensions of ethnicity may have contributed to higher infection rates for some ethnic minority groups, and for that reason the RDU will monitor closely new evidence and will work on improving data quality across government.

Survival analysis by ethnicity

Mortality rates from COVID-19 are based on the number of deaths involving COVID-19 in the population and these rates are determined by the combination of the risk of getting COVID-19 and the risk of dying once diagnosed with COVID-19. Survival rates isolate the 2 and are based on the number of deaths in people already diagnosed with COVID-19.

In general, a large number of cases may be explained by high exposure or risk of infection. A large number of deaths may be explained by these factors, plus factors affecting survival such as timing of seeking testing and receiving treatment in the course of illness with COVID-19.

According to Public Health England^{[footnote 11]} people belonging to the Mixed and Other ethnic (aggregate) groups, and the Black African, Black Caribbean and Asian Other (detailed) groups had similar survival rates to White people following a positive test for COVID-19 in wave 1. The high death rates reported previously by ONS for these groups are therefore likely to be largely determined by a high risk of getting COVID-19 rather than a high risk of dying once infected.

The poorest survival rates (or highest risk of dying once diagnosed), after adjusting for pre-existing health conditions and other factors, was seen in people from the Bangladeshi ethnic group who had 1.88 times the odds of dying once diagnosed than the White ethnic group. People from the Pakistani, Chinese, and Black Other ethnic groups had 1.35-1.45 times the odds of dying once diagnosed, and those from the Indian group 1.16 times the odds.

With the exception of the Chinese ethnic group, the groups with the poorest survival rates (Bangladeshi, Pakistani, Indian, Black Other) also had higher numbers of cases than expected. This means that, in these groups, both a high risk of infection and a high risk of dying once infected were contributing to high mortality.

The analysis will need to be repeated with a longer follow-up time for death, before being able to draw firm conclusions about the poor survival in ethnic minority groups amongst positive cases. It is also important to note that this analysis will not capture and control for all pre-existing conditions that could affect survival; for example obesity and those reported in primary care settings, as this analysis used hospital admission data.

Annualised age standardised mortality rates

Because wave 1 (24 January to 31 August 2020, 221 days) and wave 2 (1 September to 28 December, 119 days) are based on different lengths of time (and a longer time period will include more deaths, all things being equal), we have standardised them so that we can make valid comparisons. This process, called ‘annualisation’, involves dividing the age standardised mortality rates by the proportion of the year that each wave lasted. This allows us to calculate the percentage change between the 2 waves. Deaths from COVID-19 have dropped for most ethnic minority groups - annualised mortality rates for both Black African men and Black African women are down by over 60% compared with the first wave. However, the second wave mortality rates have risen by 124% and 97% for men and women from Pakistani backgrounds, respectively.

Examples of some of the mechanisms for risk factors increasing transmission, and consequently risk of infection, are outlined in section 2. This section provides a summary of relevant statistics for different ethnic groups.

Household composition:

When accounting for household size, the excess risk of testing positive, compared with the White British group, was reduced by 16% in Indian people, 22% in Pakistani groups and 10% in Bangladeshi groups, after also accounting for demographic characteristics, deprivation, region, and clinical comorbidities.^{[footnote 12]}
Adjusting for household size results in a reduced excess risk of COVID-19 mortality, compared with the White British group, of 12% in the Indian ethnic group, 32% in Pakistani and 39% in Bangladeshi groups, after also accounting for demographic characteristics, deprivation, region, and clinical comorbidities
Ethnic minority groups are more likely to live in multigenerational households, particularly people from Pakistani, Bangladeshi or Indian ethnic groups.^{[footnote 13]}
Depending on individual interactions and networks outside of the house, which are likely to be larger in a denser urban area - a large household may be more likely to bring the virus home, an overcrowded household may not be able to minimise transmission within the home and a multigenerational household may put more vulnerable elders at risk.^{[footnote 14]}
Viral load is associated with risk of transmission, with the risk being higher for household contacts than for other types of contact; the age of the contact also has an effect, with older individuals being more at risk of becoming infected.^{[footnote 15]}

Geography and deprivation:

50.8% of Bangladeshi people live in just 9 local authorities, predominantly London boroughs and all urban areas. 18.2% lived in Tower Hamlets alone.^{[footnote 16]}
50.5% of Pakistani people live in just 13 local authorities, predominantly metropolitan districts and all urban areas. The largest clusters were in Birmingham (12.9%) and Bradford (9.5%)
39.9% of Indian people live in just 11 local authorities, again, predominantly London boroughs and all urban but the largest clusters were in Leicester (6.6%) and Birmingham (4.6%)
The first wave was seen acutely in London and other large cities like Birmingham, while the second wave was initially predominantly seen in more Northern urban areas. The new variant, though evident nationally, was initially particularly prevalent in London and the South East/East.
Asian and Black ethnic minorities are most likely to live in urban areas, particularly Pakistani and Bangladeshi people at 99.1% and 98.7% respectively.^{[footnote 17]} Urban areas are also the most likely to have household overcrowding, 7% of households in major urban conurbations were overcrowded, compared with 2% of households in rural areas.^{[footnote 18]} Evidence at a regional level indicates that people from ethnic minorities are more likely to live in overcrowded households than White British people.^{[footnote 19]}
After adjusting for age, population density, ethnicity and socioeconomic deprivation, there are still unexplained clusters of raised COVID-19 mortality across England and Wales. The evidence of clusters spanning both urban and rural populations could be due to travel connections between communities (for work, social or shopping purposes).^{[footnote 20]}
The next quarterly report on progress to address COVID-19 disparities will provide a greater focus on the spread of COVID-19 across areas of different levels of deprivation.

Occupation:

Differences in occupation could have ramifications for the ability of different ethnic groups to work remotely or maintain safety in a workplace.
41% of employed Pakistani or Bangladeshi workers were Sales and Customer service, Process, Plant and Machine Operatives or Elementary workers, compared with 24% of workers of all ethnic groups.^{[footnote 21]}
The highest COVID-19 mortality rates for men were seen in Elementary workers^{[footnote 22]} and Caring, Leisure and other Service occupations, followed by Process, Plant and Machine Operatives.^{[footnote 23]}
Of the 17 specific occupations among men in England and Wales found to have higher rates of death involving COVID-19, 11 of these have statistically significantly higher proportions of workers from Black and Asian ethnic backgrounds.
Further analysis of the impact of occupation in COVID-19 infections is due to be published by ONS soon and will be explored in the next quarterly report.

Age:

Studies have shown that age alone is the most significant risk factor for severe illness and mortality from COVID-19,^{[footnote 24]} and generally this is the same with other coronaviruses and influenza viruses.^{[footnote 25]}

This could be because of the increased likelihood that a person will have comorbidities in older age,^{[footnote 26]} many of which are linked to poorer COVID-19 outcomes. However, it may also be due to the ageing immune system. As people age, the thymus produces fewer T cells. This in turn affects many other aspects of the immune system.^{[footnote 27]}

For these reasons, COVID-19 affects more older people. According to PHE,^{[footnote 28]} 4% of those who died with COVID-19 before mid-July were aged under 55 and 42% aged 85 and above. The age profile of COVID-19 deaths in ethnic minority groups was younger than average, we have to bear in mind that people from ethnic minorities have a younger age profile than average.^{[footnote 29]} PHE analysis shows that:

In the Black group, 12% were under 55 and 24% 85 and above. Deaths in the Black Caribbean group had an older profile than other Black groups with 6% under 55 and 34% 85 and above.
In the Asian group 10% were under 55 and 21% 85 and above. Deaths in the Bangladeshi group had a younger profile with 17% under 55 and 15% 85 and above.
In the Mixed ethnic group 14% were under 55 and 25% 85 and above.

According to ONS the number of deaths overall so far this year has been above the 5-year average for all age groups above 14 years.

By the end of 2020, three-quarters of deaths involving COVID-19 in England and Wales were of people aged 75 years and over.

Sex:

According to PHE^{[footnote 30]} laboratory-confirmed COVID-19 case rates per 100,000 are higher in women compared with men, despite men accounting for 70% of ICU admissions during the first wave of COVID-19 hospitalisations and 66% during the second wave.^{[footnote 31]}
During 2020, 55.3% of all deaths involving COVID-19 were in men. There were more deaths in women aged 85 years and over (18,333) than men aged 85 years and over (15,984).^{[footnote 32]} Higher death rates in men also occurred in other coronavirus diseases like severe acute respiratory syndrome,^{[footnote 33]} caused by SARS-CoV, and Middle East respiratory syndrome.^{[footnote 34]}
A report in ‘Nature’^{[footnote 35]} published in August 2020 found that the reason men face higher risk of severe illness or dying from COVID-19 is because of biological factors during the early immune response. Men showed higher levels of cytokines that trigger inflammation, like IL-8 and IL-18, than women. Higher quantities of these cytokines are linked to more severe disease.^{[footnote 36]}
compared with men, women had a higher number of T cells – essential for eliminating the virus – that were activated, primed and ready to respond to the SARS-CoV-2 infection. Men with lower levels of these activated T-cells were more likely to have severe disease.

Disability:

ONS^{[footnote 37]} published estimates of differences in COVID-19 mortality risk for disabled people and non-disabled people^{[footnote 38]} for the period between 24 January and 20 November 2020.
Indicative estimates suggest that compared with non-disabled people “more-disabled” women were 1.4 times more likely to die from COVID-19, “less-disabled” women 1.2 times more likely and “more-disabled” men 1.1 times more likely. Men and women with a medically diagnosed learning disability were 1.7 times more likely to die from COVID-19 than those with no learning disability. These estimates take account of factors such as underlying health conditions, socio-economic factors and geographical circumstances, but as yet no single factor can be identified to explain the increased risk.
The relative differences in the risk of COVID-19 mortality between disabled and non-disabled people remained largely unchanged between the first and second waves of the pandemic.
There is ongoing work into the impact of COVID-19 on disabled people. Future analysis from ONS will improve on the current analysis by establishing the proportion of disabled and non-disabled people testing positive for COVID-19. Research will also explore how different impairment types^{[footnote 39]} among disabled people affect the risk of COVID-19 related death.

Genetics:

According to existing research on genetics,^{[footnote 40]} health disparities among ethnic groups are largely explained by underlying social differences rather than genetic differences.
However, a gene cluster identified as a risk factor for severe coronavirus symptoms is carried by approximately 50% of people in South Asia, compared with 16% of people in Europe. This gene cluster is a risk locus for respiratory failure and may partially explain why the Bangladeshi population has the poorest survival rates (see figure 1).

Pre-existing health conditions:

According to PHE^{[footnote 41]} in the first wave of the COVID-19 pandemic in England, among people with a similar history of previous hospital admission mentioning pre-existing health conditions, there were differences between ethnic groups in the numbers of cases and deaths involving COVID-19. In addition, ethnic inequalities in survival following diagnosis with COVID-19 were not explained by differences in such patterns of admission for pre-existing health conditions between ethnic groups. Obesity is one of the main factors in determining the outcome of COVID-19 infection, a factor known to vary by ethnic group, and diabetes may also contribute to excess risk of mortality, particularly in South Asian populations.^{[footnote 42]} ^{[footnote 43]} ^{[footnote 44]}

Progress of UKRI funded projects

6 projects to improve understanding of the links between COVID-19 and ethnicity, funded by UK Research and Innovation (UKRI) and the National Institute for Health Research (NIHR), were announced in July 2020.

These projects seek to explain and mitigate the disproportionate death rate from COVID-19 among people from ethnic minority ethnic backgrounds, including health and social care workers.

The projects, which total £4.3 million worth of funding, include:

Dr Robert Aldridge, UCL: the project, Virus Watch, aims to better understand the impact of COVID-19 on minority ethnic and migrant groups and how to tackle it in community settings. As of 21 January 2021, 45,839 people across England and Wales had joined Virus Watch. A total of 4,892 people from minority ethnic backgrounds are currently taking part and the study has recently started a new phase of participant recruitment working with NHS GP practices. A total of 541,061 weekly surveys had been completed by all participants and completion and retention of participants has been high with 29,379 participants completing over 75% of surveys. In addition to weekly surveys, surveys have recently been conducted on attitudes to vaccination and contact and activity data. The main findings by ethnicity will shortly be published, accompanied by policy briefings.
Professor Thomas Yates, University of Leicester, is using the UK Biobank cohort, which has been linked to national COVID-19 data. With this dataset, he is using statistical modelling to examine whether the increased risk of developing severe COVID-19 in minority ethnic groups is explained by differences in underlying health status, lifestyle behaviours such as physical activity, and environmental factors including measures of social inequality. His analysis looking at the impact of material deprivation is in the second round of review. His analysis within the large national in-hospital ISARIC dataset has shown that obesity disproportionately increases the risk of mortality and ICU admission in Black ethnicities compared with other ethnic groups. Therefore obesity may be a particularly important risk factor for adverse COVID-19 outcomes in Black ethnic groups.
The United Kingdom Research study into Ethnicity And COVID-19 outcomes in Healthcare workers (UK-REACH) seeks to understand whether, how, and why, ethnicity affects COVID-19 clinical outcomes in healthcare workers (HCWs). It is led by the University of Leicester in partnership with other academic institutions, and with stakeholders from all the professional regulators, NHS and Healthcare Regulators. To investigate the relationship between ethnicity and COVID-19 clinical outcomes, registration data from the professional healthcare regulators and NHS HR databases are being linked with health outcome data from NHS Digital, Public Health Scotland, NHS Wales Informatics Service and NI Honest Broker service. Data sharing agreements are now in place with a number of the regulators, and data is currently being transferred to the SAIL safe haven for secure linkage and analysis. Alongside this UK-REACH is recruiting HCWs (both clinical and non-clinical) to complete surveys which aim to understand the risk of COVID-19 infection in different healthcare workers, changes in physical/mental health outcomes, social outcomes and the impact of ethnicity on this. Recruitment started in December 2020, and to date they have recruited over 13,000 HCWs, with approximately 30% being from an ethnic minority background. The survey was amended as the vaccine roll-out commenced to capture expected vaccine uptake amongst HCWs, and they will be in a position to perform an interim analysis of the data shortly. A qualitative study is underway to understand the impact of COVID-19 on HCWs from diverse ethnic backgrounds, and perceived risk factors, support and coping mechanisms, and views on emerging issues such as vaccine delivery. This is being conducted through online in-depth interviews and focus groups.
Developing and delivering targeted COVID-19 health interventions to Black, Asian and Minority Ethnic (BAME) communities living in the UK (The COBHAM Study) - The overall aim of this one-year study by Prof Alla and Dr Vandrevala is to reduce health inequalities and COVID-19 risk by delivering targeted, culturally appropriate health interventions to Black and South Asian communities. The study is being conducted in 3 phases, with Phase I now completed which consisted of qualitative interviews with the Black African, Caribbean and South Asian community. The team is currently undertaking Phase II of the study which involves co-producing a 2-minute film and informative guidance documents, delivering culturally appropriate health messages to the communities disseminated through community knowledge champions and knowledge advocates through trusted existing networks. The final phase will be used to evaluate the effectiveness of the interventions using mixed qualitative and quantitative methodology. As part of the co-production of interventions, the team has actively engaged with the community and pivotal stakeholders including representative community members, NHS professionals and community leaders across England. These interviews are currently feeding into the developing interventions (films and ‘key guidance documents’). The team is in the process of filming, with a view to finalising this by the end of February.
Professor Julia Hippisley-Cox at the University of Oxford and Dr Hajira Dambha-Miller at the University of Southampton have been working on the following 4 project themes to evaluate COVID-19 health inequalities in the UK from different angles:1) A population-based study focusing on the extent of and factors contributing to ethnic differences in COVID-19 infection rates and mortality in the UK. This is being done in comparison to a population-based study from Ontario, Canada, and a meta-analysis is planned. 2) A study exploring COVID-19 outcomes in children (0-18 years) from different ethnic groups. They identified that, compared with children from White backgrounds and adjusting for important sociodemographic factors and medical conditions, children from certain ethnic minority backgrounds were more likely to test positive for COVID-19 and require hospital, as well as intensive care admissions. 3) A study that evaluated influenza, pneumococcal and shingles vaccine uptake, offer and refusal in over 65s by ethnic group. They are currently exploring how prior receipt of these vaccinations may affect risk of COVID-19 mortality, hospitalisation and intensive care admission in the population aged 65 and over, and if this is patterned by ethnicity. 4) In parallel, they are also investigating the impact of particular comorbidities (for example, sickle cell anaemia) and concurrent medications (for example, diabetes drugs) on COVID-19 outcomes among ethnic minorities.

Emerging qualitative evidence

Policy Lab ethnographic research:

The RDU commissioned Policy Lab to research the experience of people from different ethnic minority backgrounds, with a view to utilising the insights gained in the next phase of responding to COVID-19. Using remote digital ethnographic methods, researchers interviewed and observed a small number of participants (12), from a wide range of geographical locations across England and from a variety of ethnic groups, over an 8-week period.

Ethnography is a rigorous type of social research where researchers immerse themselves in a person’s daily life. It can produce rich accounts of everyday life and reveal participants’ thoughts, perceptions, hopes and fears. However, the small number of participants means that findings should not be generalised: participants are spokespeople only for their own lives. They do not represent their ethnic minority communities or any other communities that they belong to.

With a restricted number of participants it was important to include as much diversity in ethnicity, geography, socio-economic circumstances and age as possible. Policy Lab was also mindful to contact groups such as Gypsy, Roma and Traveller communities, and people who are less digitally literate and who might otherwise be excluded from such research. 12 people were recruited aged between 22 and 65 years old; 4 people from Black backgrounds, 3 from Asian backgrounds, 3 people of Mixed or Other ethnicity, one White British person and one person from the Gypsy community. Geographically, all participants were in England, ranging from West Yorkshire to London, Cambridge to Bath.

Following the findings from the PHE ‘Beyond the data’ report,^{[footnote 45]} the research focused on gathering insights on the following areas:

Stigma, racism and discrimination especially in healthcare, social care, and frontline services
Communications around COVID-19 from the media, government, and social media, as well as community and faith groups
Intersectional experiences including housing, finances, education and employment
Future impacts of COVID-19 particularly on economic, social and political arenas

Fieldwork has now concluded and after thorough review and categorisation 6 broad themes have emerged:

Homogenising identities

Participants see their own identities as fluid and multiple, but use of the term ‘BAME’ has standardised experiences in a way ethnic minority participants viewed as unhelpful.
As a result, participants felt that narratives of a BAME identity that frame ethnic minority groups as vulnerable to COVID-19 led to stigmatisation.
9 participants, including the White British person, noted that experiences of racism were worsened by the pandemic but 3 participants cited the increasing awareness of, or engagement with, anti-racism movements as a positive development

Disruption and adaptation

The ability to adapt and adjust, along with the degree of hope and pragmatism, is largely dictated by the resources available to participants
Lack of support (or perceived lack of support), including mental health services, meant participants were self-reliant and created strategies for self-care
The pandemic intensified participants’ care networks and relationships, reducing support networks down to smaller units; for some this was a positive development but for others it created tensions within the unit.

Home, place, space

Participants experienced a diversity of home environments including homelessness and overcrowding.
The availability of space inside or outside the home impacted on participants’ well being and experiences through the pandemic
It also impacted on participants’ ability to comply with guidelines and manage risks

Risk and perception of risk

Multiple factors influenced participants’ perception of risks, including impacts of beliefs, exposure to media and existing individual experiences of COVID-19. As such, management strategies were based on each individual’s assessment and interpretation of these complex and cumulative risks.
Participants felt that associating higher risk with ethnic minorities increased existing stigma; particularly when generalised risk statements were made on this group’s risk without providing the appropriate rationale behind the statement.

Communication and compliance

Government communication has effective reach with many participants having knowledge of the rules.
Some reflected on the difficulty in navigating the advice and complying with it in everyday situations, as well as adapting to the pace of change of the guidance.
Some participants also reported feeling stigmatised for the spread of COVID-19, due to photographs, articles and information about the virus that they felt singled out ethnic minorities and implied blame on ethnic minority groups.

Histories and futures

People’s understanding, interpretation and outlook was built on their personal cultural histories and experiences. The participants’ existing social perceptions and divides along with awareness of racism have been adjusted in the context of COVID-19.
This re-evaluation of the ‘now’ and divergent ideas of the new normal has led to revised visions of the future.
The RDU is currently in the process of triangulating the research findings with further qualitative and quantitative studies, to test the coherence of these insights. Initial scoping of supporting evidence shows some ethnic minorities are likely to experience occupation related risks such as working in health and social care or in insecure employment.^{[footnote 46]} ^{[footnote 47]} ^{[footnote 48]} ^{[footnote 49]} ^{[footnote 50]} This highlights some of the potential disruption and risks faced due to COVID-19 which is also mirrored by some of the participants’ experiences.

The strengths of this research are that it:

Is a rigorous form of inductive social research^{[footnote 51]} that can often reveal things that quantitative work cannot, such as why and how patterns have emerged.
Involves observing and engaging with individuals and communities in their own environments, providing a different perspective from how participants might recall their behaviour in interviews
Provides in-depth and nuanced insights into the social realities, experiences and perspectives of people, including how they experience and respond to government policy.

These should be set against some limitations, including that:

The small sample size means findings cannot be generalised across populations; participants can only speak of their own lives and experiences.
Some important populations were not directly included in this group of participants, particularly people aged over 70.
As with all qualitative research data collection, participants may be influenced by the presence of, and relationship with, social researchers, when taking part in research.

ONS COVID-19 compliance study:

The Office for National Statistics has commissioned IFF Research to undertake a much larger scale investigation into the compliance behaviours of different population groups, including ethnic minority communities.

Research questions include:

Why do some groups comply less?
How do different social groups understand the COVID-19 guidance?
How do attitudes to compliance with COVID-19 guidance differ between social groups?
What encourages/discourages compliance with COVID-19 guidance among different social groups?
What barriers to compliance do different groups face?

The research design provides for around 180 in-depth interviews comprising 30 interviewees across 6 social groups such as people in low-income, students and ethnic minority communities. In addition, 15 respondents from each social group will be asked to complete an online diary to record encounters with people outside their bubble and how they behaved.

Fieldwork began in November 2020 and continued through January 2021. A full report of the findings is anticipated in April.

Term of reference 4: Consider where and how the collection and quality of data into the disparities highlighted can be improved on, and take action to do so, working with the Equality Hub, government departments and their agencies

Improving the recording of ethnicity in GP practices

The main report describes the Statutory Instrument and accompanying Directions laid in December which make changes to the regulations governing GP contracts.

Ethnicity data is already collected by practices for around 60% of their patients, but not systematically captured and recorded by all practices on the patient record.

Following the PHE report, NHSE has encouraged practices to ensure that, where it is available (for example, when the patient provides such information), ethnicity data should be recorded on patients’ records.

Data harmonisation

RDU has already set out its commitment to harmonisation of ethnicity across government in its Quality Improvement Plan.^{[footnote 52]} RDU continue to state the importance of harmonisation and have further outlined benefits of this recently in a published blog post.^{[footnote 53]}

The immediate harmonisation priority will be on Departments whose data collections are being used here to monitor the primary impacts of COVID-19 on different ethnic groups.

This will include harmonisation of data collection (for example, NHS data potentially via the UISPC commission described in the main report). It will also include data outputs - for example working with ONS analysts to investigate whether analyses using the Opinions and Lifestyle Survey and the COVID-19 infection survey using more detailed harmonised ethnicity classifications might be possible.

The benefits of harmonisation are increased if all Departments commit to using the harmonised standards, particularly when assessing secondary impacts in the future.

Moving to a classification similar to the 2021 Census, for example, could facilitate the capture of more data for some ethnic groups, such as the Roma group. There has been Parliamentary interest in capturing more data for the Gypsy, Roma and Traveller groups.

Harmonisation standards and guidance exist for other characteristics, such as disability^{[footnote 54]} and impairments.^{[footnote 55]} These are outlined for illustrative purposes.

There are 2 harmonisation standards and guidance publications pertaining to disability. The first is the GSS harmonised guidance on measuring disability for the Equality Act 2010. This combines the long-lasting health conditions and illness (LLHCI) harmonised standard and the activity restriction harmonised standard to determine whether a person is classified as disabled under the Equality Act 2010 in Great Britain or the Disability Discrimination Act 1995 in Northern Ireland. A person is classified as disabled if they have a physical or mental health condition or illness lasting or expected to last 12 months or more and their condition or illness reduces their ability to carry out day-to-day activities.

The second publication is the GSS impairment harmonised standard which aims to understand the functions that a person has difficulty performing, or cannot perform as a result of their condition or illness. This is designed to be consistent with the World Health Organisation International Classification of Functioning.

The quality of ethnicity data in health datasets

This report considers 3 of the main sources of health data:

Hospital Episode Statistics
The COVID-19 Infection Survey
The Opinions and Lifestyle Survey

Hospital Episode Statistics (HES):

The report outlines the work that is being undertaken to improve the allocation of ethnicity in the HES. It is critically important that ethnicity data in health records is fit-for-purpose for many reasons, including for data linkage now, and in the future to capture ethnicity in the death certification process.

The King’s Fund and UCL Institute of Health Equity paper mentioned in the main report described other ways that data collection might be improved. These included:

making it clear to NHS organisations and staff, and GPs, that ethnicity should be self-reported, using the official classifications of ethnicity
that “not stated” is a legitimate response (patients should have the option of declining to state their ethnicity)
that the “unknown” category should only be used when it wasn’t possible to ask the patient their ethnicity
that there should also be an agreed set of rules to account for situations in which the patient has a temporary or permanent lack of capacity.

COVID-19 Infection Survey (CIS):

The CIS addresses an important clinical priority: finding out how many people across the UK have a COVID-19 infection at a given point in time, or at least test positive for it, either with or without symptoms; how many new cases have occurred in a given time period; and estimating how many people have had the infection. It also enables estimates of the rate of transmission of the infection, often referred to as “R”.

There have been a number of improvements in the survey since its launch. For example, since the start of the pandemic, the sample size of the survey has increased significantly^{[footnote 56]} and the coverage has expanded to include Wales, Scotland and Northern Ireland.

The goal for the CIS was to achieve a cohort of around 150,000 individuals sampled at least once a fortnight by October 2020 in England, around 15,000 in each of Wales and Scotland, and up to 15,000 in Northern Ireland.

In total, in the 12 months from the start of the survey, ONS expects to recruit approximately 380,000 individuals from approximately 180,000 households in England, plus approximately 42,000 individuals and 20,000 households from each of Wales and Scotland, and up to 42,000 individuals and 20,000 households from Northern Ireland.

ONS recently published analysis of COVID-19 infections by ethnicity.^{[footnote 57]} In this release, because of the limitations of small sample sizes, the only breakdowns possible were White and Other than White. Analysis of other data sources has shown the differences between more detailed ethnic groups (for example between Black African and Black Caribbean people, and between people in the Indian, Chinese, Pakistani and Bangladeshi ethnic groups) and RDU encourages the use of detailed groups for analysis wherever possible.

A recent RDU quality report^{[footnote 58]} (that was more general than COVID-19 analysis) showed the extent of some differences between detailed (18+1) ethnic groups within the aggregate (5+1) groups, and demonstrated benefits and disbenefits of using aggregate groups over detailed groups.

RDU are working with analysts in the ONS to see whether further analysis by more detailed ethnic groups is possible, taking into account the size of the sample for different groups, the representativeness of the survey, and whether the geographical spread of the data means that plausible results can be obtained.

However, limitations on the sample sizes may mean that analyses for more detailed ethnic groups might not be possible.

ONS Opinions and Lifestyle Survey (OPN):

The OPN^{[footnote 59]} is an important source of data about the social impacts of COVID-19. Indicators from the OPN measure the impact of the pandemic on people, households and communities in Great Britain.

The most recent statistics release included data on compliance with government regulations including:

Handwashing
Use of face coverings
Avoiding contact and self-isolating
Working at home and location of work
Leaving home

Analyses of attitudes to vaccinations by ethnic group have also been published recently by ONS.

There have been a number of improvements to the ONS Opinions and Lifestyle Survey in recent months to improve the quality of the data:

Starting with data collected between the 14 and 17 May, the data collection period for the Opinions and Lifestyle Survey has been reduced to 4 days from 10 or 11 days in previous waves.

The time between the survey closing and results being published has also reduced to allow more timely analysis of how attitudes and experiences are changing through the pandemic.

Starting with data collected between 21 and 25 October, the sample size for the weekly OPN has approximately tripled in England, to around 3,000 people.

While the sample size has been increased, the sample sizes for the 4 aggregate ethnic minority groups (Asian, Black, Mixed and Other) remain relatively small, and there is an underrepresentation of people in ethnic minority groups (around 6% of the sample, compared with 14% in the 2011 Census).

Sample sizes can be increased by aggregating over more than one time period (more than one week) although this is dependent on the relevant questions being asked in each weekly wave of the survey.

Data publication schedule and data access

This is the publication schedule that forms part of the recommendations.

Measure title	Expected department publication	Expected publication on Ethnicity facts and figures
Detentions under the Mental Health Act	October 2020	February 2021
Patient satisfaction with hospital care	August 2020	February 2021
Prison officer workforce	November 2020	February 2021
Fire and rescue services workforce	October 2020	February 2021
Domestic abuse	November 2020	February 2021
Use of NHS mental health, learning disability and autism services	January 2021	March 2021
GCSE results (Attainment 8)	January 2021*	March 2021
GCSE English and maths results	January 2021*	March 2021
Students getting 3 A grades or better at A level	January 2021*	March 2021
Average score for students taking A levels and other qualifications	January 2021*	March 2021
Social workers for children and families	February 2021	April 2021
Confidence in the local police	February 2021	April 2021
Physical activity	April 2021	May 2021
Overweight adults	May 2021	June 2021
Sources of household income	March 2021	June 2021
Household income	March 2021	June 2021
State support	March 2021	June 2021
Persistent low income	March 2021	June 2021
People in low income households	March 2021	June 2021
Self employment	May 2021	July 2021
Average hourly pay	May 2021	July 2021
Employment	May 2021	August 2021
Unemployment	May 2021	August 2021
Economic inactivity	May 2021	August 2021
Employment by occupation	May 2021	August 2021
Employment by sector	May 2021	August 2021
Travel by distance, trips, type of transport and purpose	September 2021	October 2021
Overcrowded households	September 2021	October 2021
Housing with damp problems	September 2021	October 2021
People without decent homes	September 2021	October 2021

DfE would usually publish revised attainment statistics in January but because of the special circumstances in 2020, only provisional data is available

To enable users to have access to up to date data, ONS has made available a number of the most important micro-level datasets for the analysis of COVID-19 disparities between different ethnic groups. These are available from the ONS Secure Research Service (SRS) on application and include:

COVID-19 Infection Survey
Opinions and Lifestyle Survey
Linked 2011 Census and mortality data

Work is currently ongoing in ONS to link 2011 Census, hospital episodes and deaths data which they plan to make available to external researchers.

The ONS Business Impacts of COVID-19 survey is also available on the SRS, although this does not collect ethnicity information.

These datasets are being used to:

Identify which population groups (for example, by age, sex or ethnicity) were at higher or lower likelihood of experiencing COVID-19 related occupational risks
The data will also be used to help inform the infection fatality ratios applied to different strata of the population including ethnicity which determine the number of deaths that would be observed based on the outputs of the transmission modelling. The aim of this work is to aid the response to COVID-19 and its recovery.
Another project is assessing the extent to which excess mortality risks (COVID-19 and all causes) are due to ethnicity, residence or deprivation among health workers.

The Ministry for Housing, Communities and Local Government (MHCLG) have now provided ONS with the Energy Performance Building Certificates (EPC) data to be linked with ONS’ COVID-19 Infection Survey and the VOA data. This will also be made available to researchers through the SRS in due course.

Question 4

Annex D: Multicultural media partners and example content

Accepted Answer

Media partnership

The following titles share content with additional local titles, amounting to content featured in over 50 publications in print and online.

Content or advertorial	Language or community	Frequency	Total circulation
The Weekly Gleaner	English, Afro-Caribbean: London	Weekly	19,000
African Voice	English, African: UK	Weekly	25,000
Eastern Eye	English, South Asian: UK	Weekly	22,000
Garavi Gujarat	Gujarati: London, Midlands	Weekly	43,000
Asian Voice	English, Asian	Weekly	33,000
Gujarat Samachar	Gujarati, Asian	Weekly	33,000
Asian Standard	(3 editions: Bradford, Kirklees, North East), English, South Asian: UK	Weekly	28,000
Daily Jang	Urdu	Daily	20,000
The Bangla Post	Bengali	Weekly	10,000
Weekly Desh	Bengali	Weekly	13,000
Potrika	Bangladeshi: UK	Weekly	15,000
Surma News Weekly	Bengali: UK	Weekly	15,000
Asian Express	(3 editions: Yorkshire, Midlands, Manchester and Lancashire), English, Pakistani: whole of England	Weekly	42,000
Jewish Telegraph	(3 editions: Leeds, Manchester, Liverpool), English, Jewish	Weekly	14,000
Epoch Times	Chinese, Chinese: London	Weekly	10,000
Londra Gazete	Turkish: London	Weekly	15,000
Angliya	Russian, Belarusian, Ukrainian, and other Russian-speaking communities	Weekly	20,000
Cooltura	English, Polish: UK	Weekly	45,000
The Methodist Recorder	English, Christian: London	Weekly	4,000
Catholic Universe	English, Christian: UK	Weekly	20,00
Ziarul Românesc	Romanian	Weekly	10,000
Irish World	Irish	Weekly	22,000

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Annex A: Summary of progress against recommendations from the first quarterly report

Recommendation 1: NHS England must ensure that Trusts implement NHS plans for the next stage of the pandemic, and that these plans continue to reflect the latest evidence about ethnic disparities and risk factors.

Recommendation 2: Departments must put in place arrangements for the effective monitoring of the impacts their policies are having on people from ethnic minority backgrounds.

Recommendation 3: there should be a rapid, light-touch review of action taken by local authorities and Directors of Public Health to support people from ethnic minority backgrounds, in order to understand what works at a local level.

Recommendation 4: Departments should continue to work at pace to develop new policy interventions to mitigate COVID-19 disparities, informed by the latest evidence.

Recommendation 5: Support should be given to the development and deployment of a risk model to understand individual risk that is being developed from research commissioned by the CMO by an expert subgroup of academic, scientific and clinical experts and the University of Oxford.

Recommendation 6: Ensure that new evidence uncovered during this review relating to the clinically extremely vulnerable is incorporated into health policy.

Recommendation 7: Government departments and academics should prioritise linkage between health, social and employment data to build a complete picture of ethnic group differences in COVID-19 risk and outcomes.

Recommendation 8: RDU should introduce and publish a new ‘Summary of evidence about COVID-19 and ethnicity’ report, working collaboratively with external experts, which would be updated every time (significant) new statistics and research are published.

Recommendation 10: Minister for Equalities to work with ministerial colleagues to establish metrics for assessing the impact of their policies to tackle COVID-19 disparities.

Recommendation 11: There should be a series of roundtables over the coming months involving faith leaders and other community representatives and focussing on those groups that are most at risk from COVID-19.

Recommendation 12: work must continue on improving public health communication to enable the successful delivery of existing and new interventions to all parts of the community including hard-to-reach groups, especially those at greatest risk in areas of local lockdown and rising concern.

Annex B: Summary of government actions to address disparities

Department for Work and Pensions (DWP)

Update on actions in first quarterly report

New initiatives

Department for Business, Enterprise and Industrial Strategy (BEIS)

Update on actions in first quarterly report

New initiatives

Department for Transport (DfT)

Update on actions in first quarterly report

New initiatives

Department for Education (DfE)

Update on actions in first quarterly report

New initiatives

Department for Health and Social Scare (DHSC)

Update on actions in first quarterly report

New initiatives

Ministry of Defence (MOD)

Update on actions in first quarterly report

New initiatives

Ministry of Housing, Communities and Local Government (MHCLG)

Update on actions in first quarterly report

New initiatives

Department for Digital, Culture, Media and Sport (DCMS)

Update on actions in first quarterly report

New initiatives

Ministry of Justice (MoJ)

Update on actions in first quarterly report

New initiatives

Annex C: Further data and evidence

Term of Reference 3: Commission further data, research and analytical work by the Equality Hub to clarify the scale, and drivers, of the gaps in evidence highlighted by the report

Ethnicity and risk factors

Survival analysis by ethnicity

Annualised age standardised mortality rates

Risk factors related to higher infections for ethnic minority groups

Risk factors related to critical illness and mortality

Progress of UKRI funded projects

Emerging qualitative evidence

Term of reference 4: Consider where and how the collection and quality of data into the disparities highlighted can be improved on, and take action to do so, working with the Equality Hub, government departments and their agencies

Improving the recording of ethnicity in GP practices

Data harmonisation

The quality of ethnicity data in health datasets

Data publication schedule and data access

Annex D: Multicultural media partners and example content

Media partnership

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