Independent report

Health

Updated 28 April 2021

Summary

Good health is necessary for all citizens to flourish. In the last year, the COVID-19 pandemic has reminded the UK public of the vital role of the health service, but it has also shone a light on disparities in the health and wellbeing of people in the UK.

In examining this theme, the Commission has carefully considered the available evidence, and engaged widely with relevant experts and frontline workers.

An analysis of available evidence into health disparities has shown again just how inappropriate it is to consider these issues under the term ‘BAME’ as there are such deep differences in the prevalence and outcome of some health conditions both between and within ethnic groups in the UK.

The Commission rejects the common view that ethnic minorities have universally worse health outcomes compared with White people, the picture is much more variable. From the evidence reviewed the following conclusions have been drawn:

• For many key health outcomes, including life expectancy, overall mortality and many of the leading causes of mortality in the UK, ethnic minority groups have better outcomes than the White population. This evidence clearly suggests that ethnicity is not the major driver of health inequalities in the UK but deprivation, geography and differential exposure to key risk factors.

• Given that most ethnic minorities have higher levels of deprivation, compared with the White majority population, these health outcomes clearly suggest that deprivation is not destiny. More needs to be done to investigate why some ethnic minority groups are doing better than others, exploring whether it is due to differences in important risk factors, family structures, better social networks, or health behaviours such as drinking alcohol and smoking

• For some health conditions there is variation within the broader ethnic group. For example, the risk for many cancers had significant differences for Indian, Pakistani and Bangladeshi ethnic groups.

• For COVID-19 and many other health conditions there is a complex interplay of socio-economic, behavioural, cultural and, in some cases, genetic risk factors, which lead to disparities.

• The Commission heard evidence which, in contrast to the narrative of other reports, suggests there is no overwhelming evidence of racism in the treatment and diagnosis of mental health conditions. In this area in particular, far more research is needed to understand the interplay of different causes, and to understand the impact of issues such as mistrust of the health services among some groups.

The Commission would like to see more in-depth research on the root causes of health disparities in physical and mental health, as well as a more systematic approach to how campaigns and communications are used in an ethnically diverse country.

Understanding disparities in health

The quality of data on health disparities is mixed and there are challenges in obtaining consistent ethnicity data across different health conditions. But the Commission was able to consider the evidence that does exist, looking at the 25 leading causes of premature mortality in the UK, as well as the key risk factors for these conditions, including obesity, smoking and alcohol use. The findings show significant variations between different ethnic minority groups, including between South Asian groups and between Black African and Black Caribbean people.

In considering disparities in health, the analysis considered both ethnicity and deprivation because there are strong associations between them. A summary of the key findings is outlined below and the full analysis supplementary paper, with accompanying charts, is available in the supporting documents published alongside this report.^{[footnote 1]}

Life expectancy and healthy life expectancy

Life expectancy reflects the impact of the key determinants of health (socio-economic, education, income, housing, employment) over the whole life course and so is the best measure of overall health. Deprivation is often considered to be the main factor associated with lower life expectancy however some ethnic minorities have longer life expectancies despite being poorer than White people (overall).

Data for Scotland has shown that life expectancy is generally higher in the larger ethnic minority populations than the majority White Scottish group, particularly for people from Indian, Pakistani and Chinese ethnic groups.^{[footnote 2]} This is despite higher levels of deprivation. A review of ethnicity and poverty by the Joseph Rowntree Foundation found that all ethnic minority groups in Scotland were disadvantaged on one or more poverty indicators, with Pakistani and Bangladeshi, and Black households experiencing higher rates of poverty than others.^{[footnote 3]}

Life expectancy data for England (where 97% of ethnic minorities in the UK lives) is not yet published, but overall age-standardised mortality rates – which are closely correlated with life expectancy – in 2019 were 26% lower in Black and South Asian people than for White people , again despite higher levels of deprivation.^{[footnote 4]}

The figures for White people overall also hide very significant ‘intra-White’ differences with those who live in the 10% most deprived areas of England (predominantly in the North and coastal towns) living on average 10 years less compared with the 10% least deprived (the gap between Blackpool and Westminster).^{[footnote 5]} There is limited data on healthy life expectancy (the average number of years that an individual is expected to live in a state of self-assessed good or very good health) by ethnicity. One paper from Scotland using linked 2011 Census data showed that despite having longer life expectancy than White people, women in the Pakistani and Indian ethnic groups had shorter healthy life expectancy.^{[footnote 6]}

Of the 25 leading causes of premature mortality, as measured by years of life lost, people from South Asian and Chinese ethnic groups have better outcomes than White people in more than half of these. Black people have better outcomes than White people in over a third.

Figure 17: Causes of premature mortality measured by years of life lost (YLL), compared with the population average, by ethnicity and cause of death (England, 2016)^{[footnote 7]}

Note: All cancers combined is not included in the Public Health England analysis but it is the leading cause of death in the UK. This does not include COVID-19 as data is for years prior to 2020. The following footnotes are to the data sources used for Figure 17: ^{[footnote 8]}, ^{[footnote 9]}, ^{[footnote 10]}, ^{[footnote 11]}, ^{[footnote 12]}, ^{[footnote 13]}, ^{[footnote 14]}, ^{[footnote 15]}, ^{[footnote 16]}, ^{[footnote 17]}, ^{[footnote 18]}, ^{[footnote 19]}, ^{[footnote 20]}, ^{[footnote 21]}, ^{[footnote 22]}, ^{[footnote 23]}, ^{[footnote 24]}, ^{[footnote 25]}, ^{[footnote 26]}, ^{[footnote 27]}, ^{[footnote 28]}, ^{[footnote 29]}, ^{[footnote 30]}, ^{[footnote 31]}, ^{[footnote 32]}, ^{[footnote 33]}, ^{[footnote 34]}, ^{[footnote 35]}, ^{[footnote 36]}, ^{[footnote 37]}, ^{[footnote 38]}, ^{[footnote 39]}, ^{[footnote 40]}, ^{[footnote 41]}, ^{[footnote 42]}, ^{[footnote 43]}, ^{[footnote 44]}, ^{[footnote 45]}, ^{[footnote 46]}, ^{[footnote 47]}, ^{[footnote 48]}, ^{[footnote 49]}, ^{[footnote 50]}, ^{[footnote 51]}.

Cancer

Cancer is the leading cause of death in the UK overall accounting for 28% of all deaths.^{[footnote 52]} For all cancers, and 9 out of 11 leading causes of cancer death, it is the White population that have the highest incidence and, in some cases, poorer survival.^{[footnote 53]} The breakdown of incidence and survival rates from different cancers is, by itself, enough evidence of why ethnic minority groups should be disaggregated in health data and research if health providers want to effectively target healthcare interventions.

Compared with White ethnic groups, South Asian people have a much lower incidence of every one of the 11 leading causes of cancer deaths.^{[footnote 54]} The Black population generally has a slightly lower incidence for all cancers and most of the leading cancers, but significantly increased risk of stomach and prostate cancer.^{[footnote 55]}

People from the Chinese ethnic group also generally have a slightly lower incidence for all of the leading cancers except stomach cancer.^{[footnote 56]}

Among South Asian people, there was a significant difference in risk for many cancers between the Indian, Pakistani and Bangladeshi ethnic groups, highlighting the importance of analysing them separately.^{[footnote 57][footnote 58]} For Black African and Black Caribbean people, this difference in risk was also apparent for some cancers.^{[footnote 59][footnote 60]} This is to be expected for the majority of cancers given the differences between diets, habits and socio-cultural practices in the 3 main South Asian groups and between Black African and Black Caribbean people.

For certain cancers, however, the incidence was unusually high or low in all 3 main South Asian groups or both Black groups which is suggestive of genetic predisposition (for example, prostate, myeloma, pituitary in Black people, gallbladder and thyroid in South Asian people) or protection (malignant melanoma in Black and South Asian people).^{[footnote 61][footnote 62][footnote 63]}

The lower incidence of many cancers in South Asian people, even when the majority have spent most of their lives in the UK or were born here, is striking. This contrasts with, for example, the experience of Japanese migrants to the USA who were found to have similar rates of a number of cancers (for example, colorectal) to White Americans within one generation.^{[footnote 64]} This could be due to dietary factors, with most South Asian people still maintaining a fairly typical South Asian diet, or there may be genetic differences which provide some protection against certain cancers. There may be potential for cancer prevention here if, for example, aspects of the diet are found to be protective.^{[footnote 65]}

In general, cancer incidence in South Asian people tends to be closer to that of White people among those aged under 50 (50% of whom were born in the UK, with many more migrating as children)^{[footnote 66][footnote 67][footnote 68]} than among those older than 50 years (virtually all born outside the UK).^{[footnote 69]}

This is consistent with environmental exposures, particularly at younger ages, being important in the study of the causes of these cancers and it is unlikely that ethnicity itself (or genetic factors) are responsible for most of the observed differences in incidence with ethnicity instead acting as a proxy for environmental and lifestyle factors (including smoking, alcohol and diet).

The pattern in Black people was more mixed which may reflect the different patterns of migration for Black African and Black Caribbean people, and so is harder to interpret. In general, as would be expected for most cancers (where the environment is the most important risk factor), the incidence of cancer in the immigrant population is related to the gradual adoption of Western habits and lifestyles.^{[footnote 70]}

However, there were some notable exceptions with the somewhat unusual finding that the incidence in an ethnic group was higher than both country (or region) of origin and than in White ethnic groups in the UK. For example, cancers of the thyroid, prostate, stomach, gallbladder, myeloma, non-Hodgkin lymphoma in Black people, and of the thyroid, liver, gallbladder and Hodgkin lymphoma in South Asian people. This is likely to be due to under-diagnosis or under-reporting in many of the countries of origin due to the limited access to healthcare facilities and lack of comprehensive cancer registration.^{[footnote 71]} Also, there may be genetic predisposition to developing these conditions in these ethnic groups, which means they could still likely maintain high incidence after migration.

For other cancers, mainly in South Asian people, incidence in the ethnic group was lower than both country or region of origin and White people (for example, stomach, cervix, malignant melanoma) reflecting a reduction in exposure to the harmful risk factor after migration (for example, reduced exposure to H. Pylori, HPV, ultraviolet B radiation).^{[footnote 72]}

For the cancers where data is available, survival is generally better or the same for lung, prostate and colorectal in ethnic minority (not including White minority) groups, with mixed evidence for breast cancer.^{[footnote 73]}

This may reflect decreased uptake of screening for breast cancer^{[footnote 74][footnote 75]} where South Asian people and Black people generally have lower uptake of screening – which is also the case for colorectal^{[footnote 76][footnote 77]} and cervical cancer.^{[footnote 78]}

Cardiometabolic diseases (CVD, stroke and diabetes)

Cardiovascular diseases (CVD) causes 27% of all deaths in the UK (in 2019). There is striking variation in CVD risk between South Asian and Black ethnic groups.^{[footnote 79]} CVD prevalence is higher in South Asian people. For CVD incidence, the highest risk is in women from the Pakistani ethnic group and men from the Bangladeshi ethnic group. In contrast CVD prevalence and incidence are lower among Black African and Black Caribbean people. Men and women from the Chinese ethnic group also have lower CVD incidence than the White group.^{[footnote 80]}

South Asian people had more ischaemic heart disease (IHD – the commonest type of CVD), hypertension and diabetes, and the Black group had more hypertension and diabetes but lower IHD than the White group.^{[footnote 81]}

Stroke is more common in Black people, who are at 1.5 to 2.5 times greater risk of having a stroke than White people. South Asian people also have a risk for stroke about 1.5 times greater than White people, particularly in Pakistani and Bangladeshi ethic groups.^{[footnote 82][footnote 83]} In contrast, people from the Chinese ethnic group have a lower risk of stroke than the White population.^{[footnote 84]} Data from the Stroke Register in London shows that while stroke incidence has decreased by 40% for White people in the past years, it has not decreased for Black people.^{[footnote 85]}

There are few studies that have investigated ethnic and social disparities for CVD procedures. Amid the limited evidence, there was none for systematic differences by ethnicity. The Whitehall Study on the relationship between health and social status found no evidence that a low social status or South Asian ethnicity was associated with lower use of cardiac procedures or drugs, independently of clinical need, and differences in medical care were unlikely to contribute to social or ethnic differences in coronary heart disease in this cohort.^{[footnote 86]}

Type 2 diabetes

Compared with the majority White European UK population, the prevalence of type 2 diabetes is higher for ethnic minority groups. When diagnosed biochemically, type 2 diabetes prevalence is up to 3 to 6-fold higher in South Asian and Black ethnic groups compared with White people. Self-reported diabetes prevalence is 3 to 5-fold higher among Bangladeshi, Pakistani, Indian and Black Caribbean ethnic groups compared with the general population.^{[footnote 87]}

The higher diabetes risk among South Asian, Black African and Black Caribbean immigrants is shared by people in their countries of origin.^{[footnote 88]}

For ethnic minority groups, diabetes develops at a younger age and at lower body mass index (BMI) than in the White population. The mean average age of onset of type 2 diabetes is approximately 5 to 10 years younger in migrant South Asian than White European adults. This may be due to the younger age profile of these groups (the South Asian median age is 10 years less than the White population. Age specific incidence and prevalence rates would need to be calculated to see if there is a genuine difference by age).^{[footnote 89]}

There are also differences in complications of diabetes by ethnic group. The reasons for the high risk of type 2 diabetes, IHD and stroke in South Asian people, and of high diabetes and stroke risk (but not IHD) in Black groups are not completely clear, but may be explained in part by differences in risk factors. Age, sex, genetics and ethnicity are fixed factors, but potentially modifiable factors are critical to understand and manage. Socio-economic factors are also relevant.

Outcomes, risk factors and causes of the causes

The table below shows the relationships between risk factors and outcomes for the 5 main causes of death and disability in the UK, across one’s life course. It shows how proximal and intermediate risk factors (which are often behavioural and in theory modifiable by individuals) are in turn affected by distal risk factors or the ‘causes of the causes.’ Some of these are fixed (for example, genetics) whereas others can be changed (for example, socio-economic factors) but often require government or societal action to facilitate that change. Although interventions can be implemented at all ‘distances’ of risk factors, the earlier they are applied in the life course, the greater the impact on prevention of the outcome.

Table: The relationship between the causes and outcomes of the five main causes of death and disability

Distal risk factors (‘Causes of the causes’)	Intermediate risk factors (modifiable or behavioural)	Proximal risk factors (also outcomes)	Outcomes (5 main causes of death and disability)
Socio-economic factors Genetics Epigenetics Exposures in the womb and early life	Tobacco Alcohol Unhealthy diet Physical inactivity Air pollution	High blood pressure High cholesterol High glucose Obesity	Heart disease Cancer Chronic lung diseases Diabetes Mental health disorders

Obesity

Black adults had consistently higher risk of obesity than White adults. Adults and children from the Chinese ethnic group had consistently lower risk of obesity than White people. There were no consistent patterns in South Asian adults or children relative to White people.^{[footnote 90]}

There are significant limitations in the data on this topic. Few studies explore, and statistically adjust for, potential predictors of obesity among ethnic minority groups, particularly the known risk factors for obesity such as socio-economic status, maternal BMI, physical activity and diet. This makes it difficult to know why any ethnic differences arise.

Use of aggregated ethnicity categories, such as South Asian, can mask important differences between smaller groups such as the Indian, Pakistani and Bangladeshi ethnic groups.

Figure 18: Percentage of children who were obese, by ethnicity and school year (reception year, and year 6) (England, April 2019 to March 2020)

Interventions to reduce obesity across the population may still need to be sensitive to ethnic, socio-economic and cultural factors that may make some interventions less likely to be engaged with by some population sub-groups.

Behavioural risk factors

Diet, physical activity, tobacco use and alcohol use are the key risk factors for cardiometabolic diseases and cancer.

In 2019 13.9% of adults in England were current smokers. Prevalence of smoking was highest in individuals with Mixed ethnicity (19.5%) and lowest in people from the Chinese ethnic group (6.7%). Compared with the benchmark of 13.9% in the population as a whole, White and Mixed ethnicity adults have higher smoking rates. Asian, Black and Chinese adults have lower smoking rates.^{[footnote 91]}

Figure 19: Percentage of adults who smoked cigarettes (England, 2019)

Ethnic differences in smoking in children are different from those in adults. Boys and girls of Black and Asian ethnicity were most likely to have never smoked. Whereas boys and girls in the White and Mixed ethnic groups are most likely to be regular smokers. This may indicate evolving changes in ethnic differences in smoking that will be reflected in adults in due course.^{[footnote 92]}

South Asian people are more likely to use non-cigarette forms of tobacco such as smokeless tobacco and shisha and this may mean that overall exposure to tobacco is underestimated in some ethnic groups in national surveys that focus exclusively on cigarette smoking.^{[footnote 93]}

Young South Asian people are least likely to have ever drunk alcohol and those of White ethnicity most likely to have drunk alcohol). The difference between groups is more than 5 times (10% and 52%). The prevalence of recent alcohol consumption is also highest in White young people and lowest in Asian young people . In this case the ratio is more than ten-fold (13% and 1%).^{[footnote 94]}

Table. Percentage of boys and girls in years 7 to 11 who have ever drunk alcohol, by ethnicity, 2018

Ethnicity (aggregated)	White	Mixed	Asian	Black	Other
Ever drunk alcohol	%	%	%	%	%
Boys	51	36	10	21	30
Girls	52	43	10	24	17
Total	52	40	10	23	25

White British men and women are most likely to be drinking at hazardous, harmful or dependent levels, and Asian men and women least likely. White British men are more than 6 times as likely to be drinking at hazardous, harmful or dependent levels than Asian men (22.6% and 3.7%) and White British women are more than 5 times as likely to be drinking at this level than Asian women (14.8% and 2.6%).^{[footnote 95]}

The Active Lives Survey collects self-reported physical activity and has shown that White adults are most likely to be active, and people of Asian ethnicity are least likely to be active. Men are consistently as or more likely to be active than women in all ethnic groups. However, gender differences are more pronounced in some groups, for example in Black people (64.6% for men and 51.3% for women).^{[footnote 96][footnote 97]}

Figure 20: Percentage of people aged 16 and over who were physically active, by ethnicity (England, 2018 to 2019)

Possible reasons for the differences described in figure 20 have been explored. Two reviews focused on South Asian people found that this population group tend to understand the link between physical activity and chronic disease, but underestimate recommended levels of activity; perceive higher body weights to be healthier than people of White ethnicity; fear racial harassment when exercising; and lack culturally appropriate opportunities for group-based activities such as mixed-gender classes or classes delivered in English.^{[footnote 98]}

Socio-economic disparities

The analysis of health disparities considered the interplay of socio-economic factors and ethnicity. The Commissioners considered the Marmot Review as part of their investigations into this area, as this report is a seminal examination of the so-called social gradient in health, which links levels of health to social class and status (originally in a Whitehall Study of civil servants).^{[footnote 99]} The Marmot Review did find variations by ethnic minorities, however, it did not answer why the social determinants of health are unequally distributed between different racial and ethnic groups. This question was beyond the remit of the review but was also affected by the lack of consistent data collection on ethnicity in health.

There is a well-established link between socio-economic disparities and risk of obesity, type 2 diabetes, cardiovascular disease; many cancers and life expectancy.^{[footnote 100]} Disentangling the effects of socio-economic status and ethnic background is complex. Within each ethnic group there is a social or deprivation gradient, but this may not explain the greater risk seen for some diseases in some ethnic groups (for example, diabetes in South Asian people).^{[footnote 101]}

For example, in the Whitehall Study, there was a strong social gradient with 67% of Black Caribbean people, 50% of South Asian people and 19% of White European people in the lower end of the grade structure (clerical and support staff). After adjustment for socio-economic factors there remained, however, 2 to 4 times greater risk of type 2 diabetes and hypertension in both Black Caribbean and South Asian ethnic groups compared with White ethnic groups.^{[footnote 102]} Those from Black ethnic groups had a more favourable lipid profile which may explain their lower risk of ischaemic heart disease, showing that differences in risk factors cannot be explained by socio-economic status alone.

Lower socio-economic status leads to some of the risk factors observed for overall mortality including obesity, diabetes and hypertension. People from South Asian groups have a greater prevalence of elevated blood pressure, blood sugar levels, obesity, and abnormal HDL-cholesterol. Together with insulin resistance these factors can increase the risks of diabetes, coronary heart disease and stroke.^{[footnote 103]} People from Black ethnic groups have a lower risk for ischaemic heart disease but an increased risk for diabetes and stroke.^{[footnote 104][footnote 105]}

However, as has already been shown in this report, some ethnic minority groups have higher life expectancies and lower risks of many cancers than the White majority population, despite higher levels of deprivation. These factors are complex but this is no way an overall negative picture for ethnic minority groups, and the Commission believes that more should be done to learn from those ethnic minorities that have better health outcomes despite being more deprived to improve health for all ethnic groups, including White ethnic groups.

Role of genetics and epigenetics in explaining differences between ethnic groups

Ethnicity consists of a combination of genetic, cultural and geographical factors, and individuals’ self-reported ethnicity is not necessarily consistent with their genetic ancestry.^{[footnote 106][footnote 107]} Furthermore, governmental Census categories may be combinations of races, ethnicities, national groupings and aggregations of smaller ethnic groups.^{[footnote 108]} For example, the West African contribution to individual African-American ancestry averages about 80%, but ranges from approximately 20% to 100%.^{[footnote 109]}

Approximately 85% of genetic variation between human beings exists within members of the same ethnic group^{[footnote 110]} with only 10% to 15% being explained by differences between ethnic groups^{[footnote 111][footnote 112]} – that is, there is usually more genetic variation between members of the same group than between groups (especially for those of African origin).

There are some rare diseases which are markedly more common in certain ethnic groups. These are often related to selective advantages of such mutations or historical genetic bottlenecks within populations (when populations reduce in size and their genetic variation decreases). For example, the presence of sickle cell disease confers protection against malaria, making it more common in African populations where malaria is endemic.^{[footnote 113]}

Non-disease related genetic variants have also been identified across ethnic groups. For example, East Asian populations are more likely to be alcohol intolerant than European populations due to an inactive variant of an alcohol processing gene^{[footnote 114]}, and European populations are more likely to be able to drink milk into adulthood due to the presence of a variant of the enzyme lactase.^{[footnote 115]}

The contribution of genetics to common chronic diseases (such as cancer, diabetes and obesity) is modest. Although there are clear ethnic differences in risk for many of these disorders, genetic variation does not, in general, explain much of those differences.^{[footnote 116]} There are, however, some exceptions – for example the higher incidence of prostate cancer in Black populations.^{[footnote 117]}

Data on genetic variations in common disease across ethnic groups are limited. This may reflect a bias within current research, as genetic studies investigating the role of disease tend to predominantly use European or European origin cohorts.^{[footnote 118]}

New drugs, vaccines and therapies undergo vigorous clinical trials to determine their efficacy and safety before being approved for use. Different sub-groups of patients may respond differently to different therapies depending on their age^{[footnote 119]}, gender^{[footnote 120]} and ethnicity.^{[footnote 121]} With advances in medical research, therapies are increasingly targeted making it crucial for clinical trials to recruit a diverse range of participants. Diversity of participants in clinical trials investigating standards of care is necessary to minimise disparities in outcomes and ensure equity in healthcare.^{[footnote 122]} Historically, ethnic minorities have been under-represented in clinical trials^{[footnote 123]} and this disparity has continued. The Commission heard evidence from academics leading a number of large cohort studies and research programmes that there remains a significant challenge in recruiting enough ethnic minority participants into these trials and studies. The Commission’s view is that much more needs to be done in this area, both in terms of research into the barriers and causes of these low numbers of ethnic minority trial participants, and in campaigns and communications to improve these numbers.

Case study: Adolescent cohort study

UK Research and Innovation is developing plans for an Adolescent Health Study (AHS), a major new place-based longitudinal cohort and data platform that will follow more than 100,000 children at different ages through their adolescent years.

Participants will be recruited primarily from schools across the UK and the study will over-sample ethnic minorities and under-represented groups in order to be able to study the origins of health disparities in this formative period of life.

Information from the study will support analyses of the rapid developmental changes that happen during adolescence are affected by puberty in the context of the rapid and unique socio-economic transitions that society is currently undergoing. This means understanding the factors behind resilience and vulnerability to a wide range of conditions, the roots of which often lie in adolescence.

There is a gap in engagement and hence data in this age group which the AHS will overcome by forming partnerships with young people, their parents, local communities and schools, for example, by involving AHS in the curriculum. Adolescents will advise on the best means of data capture which will be as unobtrusive as possible, often in real time, and include measures such as mental wellbeing, hormones, inflammation, location, social mobility, retail habits, and diet. There has never been such a large study over this life period anywhere in the world.

The AHS will enable researchers to understand adolescent health and its wider impacts in a modern societal context. It is expected to boost research on this formative period and transform knowledge and policy to improve public health, taking a holistic approach that places health disparities at centre stage.

Maternal mortality

In 2018, the stillbirth rate in England reached its lowest level on record, at 4.0 stillbirths per 1,000 births, a decrease from 5.1 stillbirths in 2010.^{[footnote 124]} In 2015 to 2017, 209 women died during or up to 6 weeks after pregnancy, from causes associated with their pregnancy. This was out of the 2,280,451 women giving birth in the UK during this period. 9.2 women per 100,000 died during pregnancy or up to 6 weeks after childbirth or the end of pregnancy.^{[footnote 125]}

Maternal deaths are fortunately rare in the UK, although analysis of maternal deaths, stillbirths and neonatal deaths undertaken by ‘Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK’ (MBRRACE-UK) shows that poor outcomes are higher for mothers and babies from Black and Asian ethnic groups, particularly those born in Asia or Africa, and for women living in the most deprived areas of the country.^{[footnote 126]}

The emotions quite rightly attached to this topic means it is prominent in any conversation about health disparities. It was brought up as a key example of health disparities by a number of respondents in the Commission’s call for evidence.

It is important that all involved in these conversations understand that highlighting this disparity without emphasising the low numbers overall, is unfair to expectant mothers everywhere. As the MBRRACE-UK states, “many women have found these figures very worrying and it is important always to qualify such stark statistics with absolute numbers – in 2016 to 2018 in the UK, 34 Black women died among every 100,000 giving birth, 15 Asian women died among every 100,000 giving birth, and 8 White women died among every 100,000 giving birth.”^{[footnote 127]}

Although incidence of maternal mortality is rare, the increased rates seen in ethnic minority groups need to be better understood and explained. The Commission is aware that work is being done in this area both in government and as part of the NHS Long Term Plan.^{[footnote 128]} The Commissioners believe that more research into causes in the disparities of maternal mortality should be one of the highest priorities for the new Office for Health Disparities outlined in the recommendation below.

Access to healthcare and attitudes towards the NHS

The key health outcome inequalities addressed above, such as life expectancy differences, have arisen over decades and even centuries and are driven by an unequal distribution of the wider determinants of health, such as employment, income, housing, social networks, education and access to green space.^{[footnote 129]}

However, health care inequalities (for example, different groups receiving differential access to services, diagnosis and treatment)^{[footnote 130]} are also important and can contribute to differences in health outcomes although they have a minor role.^{[footnote 131]}

There are differences in attitudes to different forms of healthcare across ethnic groups. South Asian groups in Scotland had higher avoidable hospital admissions than the White Scottish group, with the highest rate in Pakistani men and women. There may be issues of access to and quality of primary care to prevent avoidable hospital admissions, especially for South Asian people. There was little variation between ethnic groups in hospital length of stay or unplanned readmission.^{[footnote 132]}

There is little difference in measures of patient satisfaction with received hospital care, among ethnic groups. For example, in 2018-2019, the average satisfaction score (out of 100) for Black African people is 76.9, compared to patients from Bangladeshi (69.2), Pakistani (72.6), and White British (76.1) ethnic groups.^{[footnote 133]}

Satisfaction with GP services presents a more nuanced picture. While there are few differences between White British, Black African and Black Caribbean patients, the percentage of Asian patients reporting positive experiences tends to be lower – for example, 85.5% of White British patients, compared with 86.3% of Black African patients and 72.6% of those from the Bangladeshi ethnic group.^{[footnote 134]} Such a pattern is repeated with satisfaction with access to out of hours GP services. For example, 69.7% of White British patients report positive experiences compared with 70.1% of Black Caribbean patients and 59.1% of those from the Bangladeshi ethnic group.^{[footnote 135]}

It is important to note that majorities of all groups report positive experiences and that while the relative lack of satisfaction with GP services among some British Asian people is of concern, the overall picture suggests that racism and discrimination are not widespread in the health system, as is sometimes claimed, as Black groups are more or less equal in their satisfaction to White groups.

COVID-19

In light of the events of 2020, the Commission also analysed the emerging data relating to COVID-19, and has met with experts and frontline staff to discuss the pandemic. Due to the extensive work being carried out elsewhere, including the quarterly reports published by the Minister for Equalities, the Commission has not focused in detail on COVID-19 in this report, but we have examined evidence on the rates and causes of the disparities in infection and deaths among ethnic minorities.

The evidence shows that the raw data on deaths reflects the ethnic balance of the country with the White British group accounting for 82% of deaths in hospitals in England up to 24 March 2021 (the White British population share was 80.5% of the population in 2011).^{[footnote 136]} But once adjustment for the age profile of a group is made the numbers look very different and in the first wave Black African men were almost 3.4 times more likely to die than White British men, with Black Caribbean and South Asian people also being at higher risk of death.^{[footnote 137]}

This is mainly due to increased risk of infection – for example, geographical factors such as living in a densely populated inner-city area, socio-demographic characteristics (deprivation and occupation) living in larger and multi-generational households. It is also partly due to poorer outcomes once infected due to comorbidities such as obesity, diabetes and chronic kidney disease.^{[footnote 138]}

After adjustment for these risk factors, the difference with the White British death rate reduces significantly for all ethnic groups.

Figure 21: COVID-19 age-standardised mortality rates in the first and second waves of the pandemic, by ethnicity and gender

The second report of the COVID-19 review of disparities, looking at the disproportionate impact the pandemic has had on ethnic minorities, also describes how the impact on certain ethnic minority groups has changed between the first and second waves. It asserts that changes within this period suggest inequalities in outcomes for different ethnic groups are driven by risk of infection, as opposed to ethnicity alone being a risk factor. The report also highlights insights into some ethnic minority people’s experiences of COVID-19; particularly that messaging was felt to be aimed at a single homogenous ethnic minority group who were vulnerable to COVID-19. Participants reported that they felt this was stigmatising. Participants also reported that they felt public health messages were sometimes difficult to apply to their everyday lives.^{[footnote 139]}

COVID-19 as an infectious disease is a specific case with risk factors operating differently to the other common causes of death. Indeed, some of the risk factors that would protect against other diseases (for example, living in a multi-generational household) have increased the risk of infection and death from COVID-19.

Continued data and evidence is needed in order to understand further the causes of the COVID-19 risk factor disparities, the relative importance of different factors to each other and their interactions, and the reasons why different people who are infected experience different outcomes. The government has given Professor Thomas Yates (University of Leicester) funding to examine whether the increased risk of developing severe COVID-19 in ethnic minority groups is explained by differences in underlying health status, lifestyle behaviours such as physical activity, and environmental factors including measures of social inequality.

The study will help to build a picture of how the increased risk in ethnic minority communities may be prevented or managed and help to tailor public health policy in the future.

During its engagements with stakeholders, the Commission heard a sense of frustration about the amount of time taken for these differing factors to be understood.

The Commission welcomes the recommendations made in the government’s first ‘Quarterly report on progress to address COVID-19 health inequalities’, particularly “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.”^{[footnote 140]} The key to reducing these disparities is reducing risk of infection and vaccination enables that. It is therefore essential to continue making every effort to increase vaccine confidence and uptake in ethnic minorities (particularly amongst the younger cohorts) to protect themselves, their elderly relatives, and the wider community.

Mental health

One area of particular interest for the Commission was mental health. There has been some significant work in this area recently, specifically the Wessely Review^{[footnote 141]} and the 2020 government response to the review.

The Wessely Review found Black people were 8 times more likely to be subjected to community treatment orders than White people, and 4 times more likely to be detained. Figures from the Race Disparity Unit show there were 306.8 detentions per 100,000 for Black people compared with 72.9 per 100,000 White people (not adjusted for age and deprivation).^{[footnote 142]}

The disparity is most pronounced for the Black Other group (however, it should be noted that these rates are a potential overestimate, as the ‘Other’ categories may be used for people whose specific ethnicity isn’t known, as also seen with the ‘Any other’ group). Rates are much lower for the Black African and Black Caribbean groups. Rates for Asian groups tend to be lower than for Black but higher than White groups, with the exception of the Indian and Chinese ethnic groups for whom there is near-parity.

Such disparity is often taken as evidence of racism. However, it must be benchmarked against disparity in the prevalence of mental illness. A meta-analysis conducted by Halvorsrud et al (2019) of 28 studies concluded there were significantly higher risks of diagnosed schizophrenia among ethnic minority groups, and that they were most pronounced among Black groups.

For instance, the relative risk for the Black African group was 5.72 (compared with White British), for Black Caribbean 5.2. Elevated risks were also found for South Asian (2.27), White Other (2.24) and Mixed (2.24) ethnic groups.^{[footnote 143]}

Experts advise that mental ill health has little to do with genetic predisposition but rather is to do with adverse social circumstances, including racism and hardship. In 2018 the Synergi Collaborative Centre, a national initiative to consider ethnic inequality in mental health and deprivation led by Professor Kamaldeep Bhui from Queen Mary University of London, published a briefing on the relationship between racism and mental ill health suggesting that the fear of racism and racist attacks among people from ethnic minority groups can lead to chronic stress.^{[footnote 144]} As well as being harmful in itself it can also weaken resilience and in parents can affect the mental health of their children. The authors conclude that “there is a growing and convincing body of evidence that psychosis and depression, substance misuse and anger are more likely in those exposed to racism”.^{[footnote 145]}

Minority and immigrant groups are more likely to experience mental health difficulties in many countries all over the world, including White minorities in majority White countries. For example in Northern Ireland the suicide rate among male Irish Travellers in 2010 was over 6.5 times greater than that for men in the general population.^{[footnote 146]} Other studies have shown similar disparities for migrants to Denmark from Greenland^{[footnote 147]} as well as White men from non-English speaking backgrounds emigrating to Australia.^{[footnote 148]}

A number of interconnected factors are associated with the onset, progression and relapse of mental health problems. These are genetic and epigenetic, childhood environment (such as early family relationships, social learning and childhood experiences), and adolescent and adult environment (such as stressful life events including divorce, unemployment and poor living conditions).^{[footnote 149]}. The Commission notes that many ethnic minority individuals will be more exposed to these factors, contributing to their elevated risk.

Also there is evidence that Black and Asian people with mental health needs are less likely to be receiving treatment. A study by Cooper et al (2012) concluded Black people were less likely to be taking antidepressants (odds ratio 0.4) after controlling for symptom severity.^{[footnote 150]}

The same paper found Black groups (odds ratio 0.7) and South Asian (0.5) groups were less likely to have contacted a GP about their mental health within the last year, after controlling for socio-economic status and symptom severity.

Ethnicity facts and figures shows that Black people were just 1.3 times more likely than White British people to be receiving mental health care, with the Black African group actually less likely (0.9 times).^{[footnote 151]}

The Commission is concerned that a lack of uptake of treatment may stem from fears that mental health provision is discriminatory, manifesting itself in people of an ethnic minority seeking help elsewhere, or putting off getting help, so that the problem manifests itself later, in some cases, in the criminal justice system. There is evidence to suggest that Black Caribbean and Black African patients have been found to be more likely to come into contact with mental health services through more negative routes (such as referral by a criminal justice agency) than White British patients.^{[footnote 152]}

In the Commission’s call for evidence, this view was apparent with individuals and organisations referencing mistrust with the mental health system as a barrier and cause of disparity among ethnic minority groups: “We’re also reluctant to admit mental health issues, because we lack confidence in the system, which can lead to incarceration instead of mental healthcare, or being classed and treated on the basis of a stereotype.”

The Commission does not believe that the evidence it reviewed offers support to claims of discrimination within psychiatry. The Commission views the challenge therefore as being partly one of convincing vulnerable people in ethnic minorities that mental healthcare provision is neither a threat nor a punishment, but something genuinely helpful to people in real need.

Targeted public awareness programmes aimed at ethnic minority communities, with models of collaboration between NHS, voluntary sector and faith organisations can reduce stigma, facilitate early and appropriate access to care, and reduce the risk of coercive entry into services (for example, detention under the Mental Health Act). Evidence from Norway shows that an early detection programme with targeted educational packages reduces treatment delays both in the short and long term.^{[footnote 153]}

The Joint Commissioning Panel for Mental Health is a collaboration co-chaired by the Royal College of General Practitioners and the Royal College of Psychiatrists, which brings together organisations with an interest in commissioning mental health services. They have produced a guide which describes what ‘good’ mental health services for people from ethnic minority groups look like. Among its 10 key messages for commissioners are: commissioners should identify and address any ethnic inequalities, and services should be “culturally capable” and meet the needs of a multicultural population through effective interventions.^{[footnote 154]}

The government has published its Mental Health White Paper which takes forward recommendations from the Wessely Review, including reform of the Mental Health Act to enable greater patient choice and support in the care system, and supporting community-based mental health support that can prevent avoidable detentions.^{[footnote 155]} This should help towards reducing high detention rates and building trust amongst all patients, and particularly those from Black ethnic minority groups.

Improving the data

There are numerous places where limitations in the available data need to be addressed. Future research needs to see the investigation of differences between risk in ethnic groups as central to the research and not a spin-off.

The UK is very well placed for this type of research given the strength of it’s health data and cohort studies such as the UK Biobank, which contains in-depth genetic and health information from half a million UK participants. However, the low representation of ethnic groups in these studies^{[footnote 156]} means it is challenging to run analysis into sub-group differences and particularly the interaction between genetics and environment in causation of disease.

The Commission has had conversations with the leaders of 2 very large-scale research programmes, due to start in the coming years - the Adolescent Cohort study which plans to recruit 100,000 adolescents and the ‘Our Future Health’ study of 5 million adults. There was agreement with both about the need to ensure that ethnic minorities are recruited in proportion to their future share of the population reflecting demographic changes , and so allow for more in-depth studies in these areas. Other generally under-represented groups (based on geography and deprivation) will also be oversampled so as to better understand the underlying drivers of poorer health in these groups.

One of the challenges raised in these conversations was that of recruiting people from ethnic minorities for genetic studies (and clinical research in general). There was a question of whether this was due to mistrust of biomedical research in minority communities due to historical abuses in other countries, logistical barriers to recruitment, and a lack of diversity in researchers designing and leading these studies.

Case study: Our Future Health

Our Future Health will be the UK’s largest ever health research programme, designed to help people live healthier lives for longer through the discovery and testing of more effective approaches to prevention, earlier detection and improved treatment of diseases such as dementia, cancer, diabetes, heart disease and stroke.

It will collect and link multiple sources of health and health-relevant information, including genetic data, across a diverse and inclusive cohort of 5 million people that reflects the UK population.

Our Future Health is committed to building a resource that truly reflects the UK population, so it can identify differences in how diseases begin and progress in men and women from different backgrounds.

It is vital that a diverse range of people join the study so discoveries that are made benefit everyone. In the past, some groups have not had enough representation in health research. This includes people from Black communities, Asian communities and people from other minority ethnic groups. It also includes people living in less wealthy parts of the country. This means that the medical advances made from past research may not benefit everyone equally.

This would be the most diverse cohort ever recruited in the UK with up to 1 million participants from ethnic minorities and the largest such multi-ethnic cohort in the world. Our Future Health plans to focus particular effort on recruiting and retaining 3 key groups: South Asian people, Black people and people of low socio-economic status and high deprivation.

Recognising the challenges faced by research studies in recruiting participants from these groups, additional efforts are being made to ensure good representation of these groups that have previously been under-served or under-represented in health research.^{[footnote 157]}

To that end, there is a comprehensive and lasting programme of public engagement and involvement with numerous focus groups, meetings and interviews already having been held with the public and relevant stakeholders to inform the development of the protocol and participant materials.

The UK is uniquely well-placed to deliver this project with an exceptional track record in population research; a diverse (ethnically and socio-economically) population willing to take part in research and a government that is committed to levelling up the major inequalities in health outcomes seen across the population.

Targeting campaigns

The Commission heard from representatives from frontline services, health sector charities, local authority health departments and regional representatives of Public Health England on the topic of best practice providing health care support and messages to different groups. Some of these organisations provided examples of health campaigns and programmes they run which target specific ethnicities or specific postcodes or socially deprived areas.

Representatives also expressed frustration that lessons learnt from such campaigns weren’t being effectively shared across different locations or organisations and more coordination was required. One contributor articulated the “need for one place to go and find out how other organisations or initiatives had successfully landed health messages to enable scaling up and spending funding properly.”

Case study: Sussex Health and Care Partnership

The project took the form of a locally commissioned service to primary care, whereby GPs were empowered to support patients in at-risk groups for COVID-19. All practices in Sussex were offered access to the locally commissioned service.

95% to 98% of GP practices took up the service. The local authority public health team complemented this work by producing benchmarking for practices to highlight their population demographics. GPs identified the patients they needed to target – those from areas of high deprivation and people from high-risk ethnicities. They were also asked to focus on equity of access.

There were 2 components to the locally commissioned service – parts A and B.

Part A had 3 proactive elements:

1. Messaging around risk to ethnic minority groups – 37 languages translated available to GP for their use – centrally designed and then GPs could add nuances – also highlighted proactive measures such as usefulness of vitamin D, shielding advice and ‘hand, face and space’, re-enforcing public health messaging on how to stay safe.
2. Holistic reviews for ethnic minority patients who have additional modifiable risk factors – one-to-one telephone appointments – to offer support in tackling smoking, obesity, CVD, diabetes, respiratory illness, mental health and social needs.
3. Encourage practices to reflect on equality of access – including ethnicity recording, and representation of ethnic minority patients on patient participation groups.

Part B focused on acute and reactive care in at-risk patients diagnosed with COVID-19:

• Once patients had a positive COVID-19 diagnosis, additional remote monitoring of their condition was offered based on their clinical risk profile. For example, patients living in areas of highest deprivation, patients from ethnic minority (not including White minority) backgrounds and patients with comorbidities, irrespective of ethnicity or deprivation.
• Pulse oximetry and regular welfare calls were offered at home to such patients. If suitable for home monitoring, patients are offered a pulse oximeter with instructions, a remote COVID-19 monitoring diary and regular welfare checks.

In addition to the above, community champions were deployed, to talk to GPs about what they could offer to support local communities including forums and training sessions with GPs.

The clinical commissioning group developed a detailed locally commissioned service specification, protocols for managing patients based on NHSE guidance and online resources to support practices in this work.

The main intended benefits include:

• enhancing relations between practices and communities by creating a lasting legacy of improved engagement
• populations having access to the information they need, in languages of their choice – over 27,679 letters in 36 languages sent out
• culturally appropriate monitoring of patients – over 1,750 holistic reviews and over 170 saturation probes have been provided by pulse oximetry at home, and expected outcomes will include whether this approach reduced hospital admissions and whether there was a reduction in severe illness and deaths
• positive qualitative feedback was received from both practitioners and the community

Creating agency

Although previous research has shown that policies or interventions in the UK to reduce obesity by focussing on changing individual’s behaviour (for example, diet and physical activity), have not always been successful,^{[footnote 158]} it is also true that interventions to reduce diabetes^{[footnote 159]} and cardiovascular diseases^{[footnote 160]} have been shown to be effective internationally. Limited research has been conducted in ethnic minorities in the UK to assess the effectiveness of such interventions to date – partly due to the low numbers of ethnic minority participants in trials. Novel interventions using smartphones and AI could be developed as well as culturally tailored interventions (for example, extended family-based interventions^{[footnote 161]}).

The Commission’s view is that individuals and communities of all ethnicities should be encouraged to take control of their own health. This would be both in relation to changing their own behaviours and in taking part in research studies to see what is effective. Communities can take steps to improve their own health outcomes – and be helped to do so – particularly where they are more susceptible to certain health conditions (for example, diabetes in South Asian groups, High blood pressure in Black groups and many cancers in White groups) – all of which have modifiable risk factors (for example, diet, physical inactivity, tobacco and alcohol).

The COVID-19 pandemic has also provided a stark reminder that many of these risk factors (for example, diabetes, obesity) also increased the risk of death from COVID-19 and showed the critical role that clinical research plays in providing treatments and vaccines. It is hoped this will encourage people to change their behaviour and to participate in research studies.

Case study: Office for Minority Health, USA

The Office of Minority Health is a federal agency set up in 1986 at the Department of Health and Human Services.

Their mission is to improve the health of racial and ethnic minority populations through the development of health policies and programs that will help eliminate health disparities.

The Institute has a $281 million budget to conduct and support research, training, research capacity and infrastructure development, public education, and information dissemination programs to improve minority health and reduce health disparities.

Focus areas:

• Prevention (physical activity and nutrition).

• Clinical conditions, such as substance use disorder, hypertension, HIV, maternal health, sickle cell disease and trait, diabetes (including prevention of peripheral artery and kidney disease, lupus, Alzheimer’s, and cancer prevention (for example, stomach, liver and cervical cancer).

• Individual social needs and social determinants of health.

Programme priorities for 2020 to 2021:

• Supporting states, territories and tribes in identifying and sustaining health equity-promoting policies, programs and practices.

• Expanding the use of community health workers to address health and social service needs within ethnic minority communities.

• Strengthening cultural competence among healthcare providers throughout the country.

Recommendation 11: Promote fairness – Establish the Office for Health Disparities

This Commission recommends that the government establish a new office to properly target health disparities in the UK: The Office for Health Disparities

This Office would be an independent body which would work alongside the NHS, as part of, or in place of, the redesigned Public Health England, to improve healthy life expectancy across the UK and in all groups and reduce inequalities. As most of the causes of health inequalities (deprivation, tobacco, alcohol, unhealthy diet and physical inactivity) are not due to differences in healthcare, addressing them will involve multiple government departments and so the office would need to be cross-cutting across government.

a) Increasing programmes aimed at levelling up health care and health outcomes.

Use existing data and evidence to target those communities with the worst health outcomes (due to deprivation or ethnicity) for tailored health interventions, health education and communications. This function would work alongside existing local health workers and would utilise best practice examples from Local Authorities and Public Health regional offices/charities.

b) Improving the data, guidance and expertise in the causes and solutions for health disparities for specific groups.

This would include:

• Funding further research into health conditions which adversely impact specific groups.

This would include a large focus on research into health disparities affecting more deprived communities and different ethnic groups, including White people where they have worse outcomes, considering genetic and biological differences, cultural practices and socio economic drivers.

• Providing best practice for the inclusion of known health disparities, including those experienced by more deprived communities and different ethnic groups, including White, in clinical care guidelines. Work closely with the National Institute for Health and Care Excellence, and other bodies, to ensure all guidance includes information on disparities as standard.

• Providing expertise in how the health of different ethnic groups including White are affected by underlying conditions, cultural and linguistic practices, geography, and occupation. This expertise would be disaggregated to avoid unhelpful grouping of different ethnicity and to ensure proper tailoring of health services.

The first priorities for the new OHD should include:

Research:

• Mental health: Commissioning new research into the causes and mental health conditions and the reasons for disparities in levels and outcomes. Focused research into the most effective upstream interventions and best ways to improve access to these services.

• Clinical conditions: Commissioning further research into the causes of the disparities in life limiting health conditions identified above, including those conditions where White ethnic groups perform badly in comparison to ethnic minorities.

• Prevention: Commissioning further research into the most effective preventative approaches that can be fully tailored to different groups.

• Investigating barriers to increasing diversity of participants into clinical research studies including clinical trials and genetic studies and identifying solutions

Health education and communications:

• Improving health literacy in those with poorer health outcomes including those from more deprived backgrounds and some ethnic groups.

• Targeted campaigns to tackle the stigma associated with the mental care system in different groups.

• Campaigns to improve the participation in clinical trials, cohort studies under-represented groups including ethnic minority groups and more deprived populations.

• Campaigns to improve uptake of interventions to prevent diseases including screening and vaccination

Expertise:

• Establish a team of experts with cultural understanding of different communities, including White groups, to provide nationwide advice to health care providers. These should include community liaison contacts who have an in-depth knowledge of the communities that they work with as well as an in-depth knowledge of services available. These contacts aim to act as a conduit directing community members to the services that are most culturally appropriate to their needs. To work closely with existing third and public sector groups in this space.

Professor Sir John Bell FRS, Regius Professor of Medicine at Oxford University, has given his support for this recommendation, saying:

I fully endorse the Commission’s recommendation that the government launch a new Office for Health Disparities. This will help us to understand the key drivers of health disparities in the UK – particularly in relation to supporting research investigating the relative importance of genes, lifestyle and environment in different groups’ health outcomes. The soon to be launched ‘Our Future Health’ study of 5 million UK adults will be the largest such research study in the world and has been designed to ensure that it fully represents both ethnic minorities and deprived communities who have been under-represented in the past and we would welcome a strong focus from the government in this area to help achieve that objective.

Professor Nick Wareham (FMedSci), Director of the Medical Research Council Epidemiology Unit at the University of Cambridge, and of the The Centre for Diet and Activity Research, also supports the creation of the OHD, stating:

There is a need for a greater research focus on the causes for health disparities in this country and most importantly, on the development and evaluation of possible solutions. By establishing a home for the evidence, communications and expertise into one space, the Office for Health Disparities will ensure we can move forward in tackling these disparities. The recommendation to co-ordinate and enhance efforts to increase participation by people from ethnic minorities in observational and interventional studies trials would be of vital help to researchers, and we look forward to working alongside the Office.

1. Ali, R et. al. (2021), ‘Ethnic disparities in the major causes of mortality and their risk factors in the UK’. Available at: https://www.gov.uk/government/publications/the-report-of-the-commission-on-race-and-ethnic-disparities-supporting-research/ethnic-disparities-in-the-major-causes-of-mortality-and-their-risk-factors-by-dr-raghib-ali-et-al ↩

2. Gruer, L., Cézard, G., Clark, E., Douglas, A., Steiner, M., Millard, A., Buchanan, D., Katikireddi, S. V., Sheikh, A., and Bhopal, R., (2016), ‘Life expectancy of different ethnic groups using death records linked to population Census data for 4.62 million people in Scotland’. Journal of epidemiology and community health, 70(12), 1251–1254. ↩

3. Netto, G et al, (2011), ’A review of poverty and ethnicity in Scotland.’ Available at: https://www.jrf.org.uk/report/review-poverty-and-ethnicity-scotland ↩

4. Bhaskaran, K. et al, (2021), ‘Factors associated with deaths due to COVID-19 versus other causes: population-based cohort analysis of UK primary care data and linked national death registrations within the OpenSAFELY platform’. Available at: https://www.medrxiv.org/content/10.1101/2021.01.15.21249756v2.full.pdf ↩

5. ONS, (2020), ‘ Life expectancy for local areas of the UK: between 2001 to 2003 and 2017 to 2019.’ Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/lifeexpectancyforlocalareasoftheuk/between2001to2003and2017to2019 ↩

6. Cezard G, (2019), ‘Evidencing the gap between health expectancy and life expectancy for ethnic groups in Scotland’. Revue Quetelet/ Quetelet Journal. Vol. 7, n° 1, 2019, pp. 135-162. ↩

7. Public Health England, (2020), ‘The Burden of Disease in England compared with 22 peer countries: A report for NHS England.’ Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/856938/GBD_NHS_England_report.pdf ↩

8. Forman, D., (2009), ‘Cancer Incidence and Survival by Major Ethnic Group’, England, 2002 - 2006. National Cancer Intelligence Network ↩

9. Public Health England, (2017), ‘Public Health Outcomes Framework: Health Equity Report Focus on Ethnicity’, Public Health England. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/733093/PHOF_Health_Equity_Report.pdf ↩

10. ibid. ↩

11. Chaturvedi, N., (2003), ‘Ethnic differences in cardiovascular disease.’ Heart,. 89(6): p. 681-686. ↩

12. Hippisley-Cox, J., C. Coupland, and P. Brindle, (2017), ‘Development and validation of QRISK3 risk prediction algorithms to estimate future risk of cardiovascular disease: prospective cohort study.’ BMJ,. 357: p. j2099. ↩

13. Lawson, C.A., et al., (2020), ‘Risk Factors for Heart Failure: 20-Year Population-Based Trends by Sex, socio-economic Status, and Ethnicity.’ Circ Heart Fail,. 13(2): p. e006472. ↩

14. Forman, D., (2009), ‘Cancer Incidence and Survival by Major Ethnic Group’, England, 2002 - 2006., National Cancer Intelligence Network ↩

15. Chaturvedi, N., (2003) ‘Ethnic differences in cardiovascular disease.’ Heart, 89(6): p. 681-686. ↩

16. Hippisley-Cox, J., C. Coupland, and P. Brindle, (2013), ‘Derivation and validation of QStroke score for predicting risk of ischaemic stroke in primary care and comparison with other risk scores: a prospective open cohort study.’ BMJ : British Medical Journal,. 346: p. f2573 ↩

17. Bhopal, R.S., et al., (2012), ‘Ethnic variations in the incidence and mortality of stroke in the Scottish Health and Ethnicity Linkage Study of 4.65 million people’. Eur J Prev Cardiol, 19(6): p. 1503-8 ↩

18. Gilkes, A., et al., (2016), ‘Does COPD risk vary by ethnicity? A retrospective cross-sectional study.’ Int J Chron Obstruct Pulmon Dis, 11: p. 739-46 ↩

19. Bhopal, R., et al., (2015), ‘Risk of respiratory hospitalization and death, readmission and subsequent mortality: scottish health and ethnicity linkage study’. Eur J Public Health, 25(5): p. 769-74 ↩

20. Pham, T.M., et al., (2018), ‘Trends in dementia diagnosis rates in UK ethnic groups: analysis of UK primary care data.’ Clin Epidemiol, 10: p. 949-960. ↩

21. Simpson, C.R., et al., (2015), ‘Ethnic variations in morbidity and mortality from lower respiratory tract infections: a retrospective cohort study.’ J R Soc Med, 108(10): p. 406-17 ↩

22. Public Health England, (2017), ‘Public Health Outcomes Framework: Health Equity Report Focus on Ethnicity,’ Public Health England. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/733093/PHOF_Health_Equity_Report.pdf ↩

23. Al-Sharifi, A., C.R. Krynicki, and R. Upthegrove, (2015), ‘Self-harm and ethnicity: A systematic review. International Journal of Social Psychiatry,’ 61(6): p. 600-612. ↩

24. Forman, D., Cancer (2009), ‘Incidence and Survival by Major Ethnic Group, England, 2002 - 2006. National Cancer Intelligence Network.’ ↩

25. Ali, R., et al., (2013), ‘Incidence of gastrointestinal cancers by ethnic group in England’, 2001-2007. Gut, 62(12): p. 1692-703 ↩

26. Shirley, M.H., et al., (2014), ‘Incidence of breast and gynaecological cancers by ethnic group in England, 2001-2007: a descriptive study’. BMC Cancer,. 14: p. 979. ↩

27. Public Health England, (2017), ‘Public Health Outcomes Framework: Health Equity Report Focus on Ethnicity 2017’, Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/733093/PHOF_Health_Equity_Report.pdf ↩

28. Knowles, R.L., et al., (2017), ‘Ethnic and socio-economic variation in incidence of congenital heart defects.’ Arch Dis Child,. 102(6): p. 496-502 ↩

29. Bhopal, R.S., et al., (2012), ‘Ethnic variations in heart failure: Scottish Health and Ethnicity Linkage Study (SHELS).’ Heart, 98(6): p. 468-73. ↩

30. Ali, R., et al., (2013), ‘Incidence of gastrointestinal cancers by ethnic group in England, 2001-2007’. Gut, 62(12): p. 1692-703 ↩

31. Steinbach, R., et al., (2010), ‘’Race’ or place? Explaining ethnic variations in childhood pedestrian injury rates in London.’ Health Place, 16(1): p. 34-42. ↩

32. Cézard, G., et al., (2020), ‘Ethnic variations in falls and road traffic injuries resulting in hospitalisation or death in Scotland: the Scottish Health and Ethnicity Linkage Study’. Public Health, 2020. 182: p. 32-38 ↩

33. NatCen Social Research and the Department of Health Sciences, (2016), ‘Mental Health and Wellbeing in England: Adult Psychiatric Morbidity Survey’. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/556596/apms-2014-full-rpt.pdf ↩

34. Forman, D., (2009), ‘Cancer Incidence and Survival by Major Ethnic Group, England, 35 - 2006’. National Cancer Intelligence Network. ↩

35. Bhala, N., et al., (2009), ‘Alcohol-related and hepatocellular cancer deaths by country of birth in England and Wales: analysis of mortality and census data.’ J Public Health, 31(2): p. 250-257. ↩

36. ibid. ↩

37. Forman, D., (2009), ‘Cancer Incidence and Survival by Major Ethnic Group, England, 2002 - 2006’. National Cancer Intelligence Network. ↩

38. Ali, R., et al., (2013), ‘Incidence of gastrointestinal cancers by ethnic group in England, 2001-2007’. Gut, 62(12): p. 1692-703 ↩

39. Forman, D., (2009), ‘Cancer Incidence and Survival by Major Ethnic Group, England, 2002 - 2006.’ National Cancer Intelligence Network. ↩

40. ibid. ↩

41. Maruthappu, M., et al., (2015), ‘Incidence of prostate and urological cancers in England by ethnic group, 2001-2007: a descriptive study.’ BMC Cancer, 15: p. 753. ↩

42. Forman, D., (2009), ‘Cancer Incidence and Survival by Major Ethnic Group, England, 2002 - 2006.’ National Cancer Intelligence Network.ibid. ↩

43. Shirley, M.H., et al., (2013), ‘Incidence of haematological malignancies by ethnic group in England, 2001-7.’ Br J Haematol. 163(4): p. 465-77. ↩

44. Forman, D., (2009), ‘Cancer Incidence and Survival by Major Ethnic Group, England, 2002 - 2006.’ National Cancer Intelligence Network ↩

45. Ali, R., et al., (2013) ‘Incidence of gastrointestinal cancers by ethnic group in England, 2001-2007.’ Gut,. 62(12): p. 1692-703 ↩

46. Forman, D., (2009) ‘Cancer Incidence and Survival by Major Ethnic Group, England, 2002 - 2006.’ National Cancer Intelligence Network ↩

47. ibid. ↩

48. Shirley, M.H. et al., (2014), ‘Incidence of breast and gynaecological cancers by ethnic group in England, 2001-2007: a descriptive study.’ BMC Cancer,. 14: p. 979. ↩

49. Bhala, N., et al., (2009), ‘Alcohol-related and hepatocellular cancer deaths by country of birth in England and Wales: analysis of mortality and census data.’ J Public Health,. 31(2): p. 250-257. ↩

50. Bhala, N., et al., (2016), ‘Ethnic Variations in Liver- and Alcohol-Related Disease Hospitalisations and Mortality: The Scottish Health and Ethnicity Linkage Study. Alcohol Alcohol,’ 51(5): p. 593-601. ↩

51. Cancer Research UK, (2019), ‘Cancer mortality for all cancers combined.’ Available at: https://www.cancerresearchuk.org/health-professional/cancer-statistics/mortality/all-cancers-combined#ref-1 ↩

52. ibid. ↩

53. (Mortality data is generally not available by ethnicity but by country of birth and shows decreased cancer mortality for those born in South Asia, Africa and similar for the Caribbean compared with those born in the UK.) Cancer Research UK, (2019), ‘Age-standardised incidence rates and rate ratios (adjusted by age, sex and income) for by ethnic group.’ Available at: https://www.cancerresearchuk.org/health-professional/cancer-statistics-for-the-uk, and Forman, D., (2009), ‘Cancer Incidence and Survival by Major Ethnic Group, England, 2002 - 2006.’ National Cancer Intelligence Network. ↩

54. Forman, D., (2009), ‘Cancer Incidence and Survival by Major Ethnic Group, England, 2002 - 2006.’ 2009, National Cancer Intelligence Network ↩

55. ibid. ↩

56. Ali, R., et al., (2013), ‘Incidence of gastrointestinal cancers by ethnic group in England, 2001-2007’. Gut, 2013. 62(12): p. 1692-70 ↩

57. Shirley, M.H., et al.,(2014), ‘Incidence of breast and gynaecological cancers by ethnic group in England, 2001-2007: a descriptive study’. BMC Cancer, 14: p. 979. ↩

58. Shirley, M.H., et al., (2013), ‘Incidence of haematological malignancies by ethnic group in England,2001-7.’ Br J Haematol,. 163(4): p. 465-77. ↩

59. Ali, R., et al., (2013), ‘Incidence of gastrointestinal cancers by ethnic group in England,’ 2001-2007. Gut, 62(12): p. 1692-703 ↩

60. Shirley, M.H., et al.,(2014), ‘Incidence of breast and gynaecological cancers by ethnic group in England, 2001-2007: a descriptive study’. BMC Cancer, 14: p. 979. ↩

61. ibid. ↩

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