Tackling Health Inequalities in Manchester: the impact of Covid-19 and what’s next

| Charli Dickenson

My name is Charli Dickenson and I am the Programme Manager for the Winning Hearts and Minds, a programme designed to improve heart and mental health across Manchester by stepping outside the traditional approaches to health improvement. I believe in doing work that is both exciting and scary, and having the courage to do what is right, rather than what is easy. But if it is easy as well as right, well then that’s a winner.

This is written in response to the brave and insightful blog recently written by someone working for a local authority in Public Health, reflecting on their Covid-19 response. They describe how it took “months to establish basic, meaningful networks of people who might reach excluded or vulnerable groups”, and in some areas they had to start from scratch. A lack of connectivity, embedded listening and engaged style of working hampered efforts to support people. This is something we are well aware of and have been overcoming for some time. In response, here is our story about what can be achieved in a crisis when your way of working is already, and always, driven by listening, building trust and collaboration.

Understanding Health Inequalities in Manchester

In 2018, data showed that Manchester had some of the poorest heart and mental health outcomes in England. This, combined with a growing awareness of the city’s wide ranging health inequalities, made it clear that a new approach was needed. Out of the collaborative efforts of the NHS, Local Authority and many VCSE sector partners, the Winning Hearts and Minds (WHM) programme was born. The programme was shaped by a series of community conversations that took place over twelve months, and in 2019, a team of ten people were recruited to continuing its work – including eight Community Development Fieldworkers who would be embedded in small communities across North Manchester.

From the beginning, the approach was underpinned by several principles:

  • Listening to people, in particular those within communities and community groups
  • Trying new things, embracing lessons from mistakes and failure, adapting quickly based on community need
  • Understanding wider social determinants of health and how they impact on health inequalities
  • Building relationships and trust with individuals in communities and the people who work there
  • Working collaboratively to create the conditions for health, actively resisting silos and competition between groups and organisations
  • Appreciating that this work takes time and we must be consistent and persistent in our approach to continue to do more

This approach shaped a culture for the team (both those specifically employed on the programme, and all of the collaborative partners) that has so far enabled us to learn and grow together, and begin to shape and influence services to expand our work across Manchester.

The Impact of Covid-19

In March 2020, along with the rest of the world, the Winning Hearts and Minds Programme found itself re-evaluating its role in the new world of Covid-19. Much of our work was community facing, and with a desire to keep people immediately safe from the threat of Covid. We pulled back from our scheduled work, pausing most projects and clinical work. But we were aware that due to the impact of Covid on individuals and communities, a new version of community support was needed to keep people safe – both from Covid, and from the effects of lockdown.

What became immediately clear, was that the Community Development Fieldworkers (fieldworkers) were in a prime position to help. The eight fieldworkers were originally recruited to be very different to the typical people you might find in more traditional community development. They are a diverse group, part of the communities they work in, have passion and interest in a huge variety of topics, and ultimately, care very deeply about the people they work with. I fielded so many calls and messages from them in the early weeks of lockdown, as they struggled with being held back from being able to help. We were waiting to be told what to do, for our efforts to be directed in the best place. But once we realised that everyone was waiting for the same thing, we decided to stop waiting, and do what we do best.

The team was involved in direct Covid response, such as food deliveries as part of the central Manchester City Council coordinated response, phone calls to vulnerable patients, coordinating mutual aid, door knocking to tackle disinformation in communities, and much more. Furthermore, they also coordinated work based on what they knew was needed in communities – knowledge they had carefully collected since coming into post nine months earlier.

For example, our fieldworkers set up a befriending service for isolated individuals to chat to a friendly voice over the phone and helped mobilise staff across the workforce to take part in running the service. The befriending service helped not only those isolated individuals, but also gave those making the calls an additional sense of purpose and connection when dealing with the isolation of lockdown themselves.

The fieldworkers connected care homes with local schools which allowed school children to send beautiful letters and drawings to elderly residents. In addition, the fieldworkers have created activity boxes full of puzzles, stationery and suggestions for family friendly physical activity, and even chair based exercises, to give out to families and individuals who were having a tough time. Partners who were giving out technology to tackle isolation asked the fieldworkers to become digital mentors for people who were unsure of, or even scared of using the technology. Due to the fieldworkers’ experience in the community and their enthusiasm they made people feel comfortable and safe and therefore able to get the most out of what they had been given.

Then there were the many small things they did to help. Like taking chairs and sitting outside an elderly resident’s window for a chat, taking a birthday cake to an individual who couldn’t see their family on their birthday, playing dominos with a gentleman with dementia to give his wife a small break from her caring duties. I could go on!

We have been lucky to exist in a part of the system that strives to understand the complexity that makes up people’s lives. The people and culture that created the space for WHM and gave permission to work in new ways three years ago, has continued to grow throughout this time, supported and pushed by the WHM team itself. The effects of this proactive approach have still been spreading, even in the reactive state that Covid-19 put us in.

Working proactively to tackle health inequalities is essential. It is prevention work, in overdrive, because it needs to go above and beyond prevention, understanding the many things that contribute to someone’s health, and the years of historical, societal, economic inequality that have created the situation we currently have. Covid-19 initially saw us forced back into reactive work, but that understanding didn’t disappear the moment we went into lockdown.

Yes, it stopped our scheduled work; but because we had spent two years building a programme that was ready to flex and adapt depending on community needs, that’s exactly what happened – we flexed and adapted our approach more quickly, because it was understood that this was how we worked. We did feel the strain of lockdown and, even knowing we were doing everything we could we still felt the self-imposed pressure that we weren’t doing enough. Every day we wished we could do more, however we made every effort to figure out what was best for as many people as we could based on the knowledge we had gained so far. Reflecting on it now, I can see how that our reactive response was the result of our years of proactive efforts and we could see it with partners too, who were picking up the phone to each other and asking for help. Manchester has been committed to working in this collaborative way for a long time, and this was evident in its response to Covid.

This isn’t to say we didn’t get things wrong. Of course not! We pushed people too hard on some things they weren’t ready for, we underestimated the importance of GP buy in to a project, we overestimated people’s capacity – but again, we learned, flexed and tried something else.

For the Winning Hearts and Minds programme, Covid-19 has provided an opportunity, one that we have not ignored. While stopping many of our plans, circumstances catapulted our work months ahead of schedule in many respects – the relationships we were building with individuals, groups and partner organisations, the digital connectedness of our communities, the awareness of our approach and the reputation of the team as a reliable, proactive workforce. 

People also started talking more about health inequalities. The concept (and reality) of health inequalities isn’t new, but the effects of Covid, both directly and indirectly, have shone a light on it and proven that this needs to be a driving force within our approach to public health now and in the future. As shown in the ‘Four waves of the Covid pandemic’ graphic (below) used in the first blog, there will be ongoing waves of impact due to Covid – but what it doesn’t show is the scale of the health inequalities this pandemic exists in. We’d suggest there’s another line, perhaps a ‘5th wave’ that’s needed on this graph, one that reflects the pre-Covid position of those with the worst health inequalities and shows the possible or even likely harsh reality facing those people post-Covid.

A graph showing 4 waves of the Covid 19 outbreak impact on health

There’s a major challenge here though. Whilst our understanding of health inequalities is improving, capacity across the public sector to tackle it is spread more thinly than ever, as people are stuck in reactive mode, not only from reacting to Covid, but also in order to tackle those ongoing Covid after-effects. This could last for a very long time, and though it is obviously very important to help with immediate health needs, if we don’t create some space to address health inequalities, then we are going to fall into a vicious cycle where communities are not enabled to thrive, where inequalities become even more stark and where people only receive support once they are unwell, and we are faced with increasing pressure on the health system.

This is going to need commitment across the system. It can’t just be the same people sat in closed meetings agreeing with each other that health inequalities are bad and debating how to write and implement strategies. We all need to get on with it, and it needs to start with the people who are having to live with the impact of these health inequalities. 

What’s next for us?

So, what does that mean for our future in Manchester? Well, for starters, we carry on with this approach. We don’t know for sure where it will take us, but we think we’ve made a good start. Our fieldworkers don’t want to be another person nodding in a meeting about health inequalities, they want to be a proactive part of the solution. The fieldworkers are continuing to meet members of their communities, finding new ways to engage with people and seek out opportunities to connect them. We want to help grow a sustainable and supportive network of community members and organisations that enables those within communities to have their voices heard and for work to be done in a way that they want.

For me, personally, I’m going to keep putting my trust in the fieldworkers, and in the people they’re working with in communities. I’m going to listen to what they’re saying and amplify their voices. I’m going to work even more collaboratively with partners to continue to build the conditions for health across Manchester. I’m going to talk about where we’ve failed and what we’ve learned.  I’m going to continue to challenge the system to recognise that while we work to tackle health inequalities, we are also a part of what creates and perpetuates them and we must work together to even have a hope to address this.  

The Winning Hearts and Minds team is currently developing a report documenting community stories, lessons learnt so far, and reflections on the impact of Covid-19, which will be published in April 2021. For further information please contact Charli Dickenson on c.dickenson@mcractive.com and follow us on Twitter @WHMmanchester.

Photo provided by the Winning Hearts and Minds programme.

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