Authors: Chantal Edge, Al Story, Andrew Hayward

As the UK continues to wage war against COVID-19 the news is awash with stories speculating when vaccines and diagnostics will become available, and when life can return to ‘normal’ for the general population. Yet amongst these reports we hear very little about society’s most marginalised groups. What has the UK been doing to protect and support the most vulnerable – homeless, prisoners, drug users, and what problems do they foresee for these groups in the near future? We asked the UCL Collaborative Centre for Inclusion Health (CCIH) what they’ve been up to in support of pandemic response.

What is the UCL Collaborative Centre for Inclusion Health?

The UCL Collaborative Centre for Inclusion Health (CCIH) was set up by a multidisciplinary team of researchers, experts with lived experience and frontline professionals who are dedicated to reducing health inequity amongst socially excluded groups. Inclusion Health is a service, research, and policy agenda that aims to prevent and redress health and social inequities among the most vulnerable and excluded populations such as homeless, prisoners and drug users. The Centre is co-directed by UCL’s Professor Andrew Hayward and Dr Alistair Story, Clinical lead of the London Find&Treat Service.

COVID-19 and socially excluded groups

Homeless accommodation

At CCIH we were very aware early on in the outbreak that excluded groups would be highly vulnerable. There was a well-timed conference – 2020: A Decade for Inclusion – on homeless and inclusion health justbefore the UK went into lockdown, which we used to raise awareness across the homeless sector about what needed to be done to prevent outbreaks, particularly within overcrowded hostels, night shelters and day centres. We were able to secure a lot of support from different agencies, for example, the Ministry of Housing, Communities and Local Government set up an initiative to place those living on the streets in hotels and to close down the large hostels in which people share dormitory-style accommodation. This was achieved incredibly rapidly, over the course of about a week. We’ve also done a lot of work to raise awareness in settings which remain vulnerable to outbreaks, including improving social distancing by encouraging closure of communal areas, and strict rules about social distancing measures. We’ve been able to bring in drug treatment services and addiction services for people with very challenging addiction issues. A pan-London methadone-prescribing service has been established so that homeless people can get access to substitution treatment for addictions much more easily than they would have done on the streets. This video tells the story about one such homeless hotel in Shrewsbury.

We’ve also established what we’re calling a COVID-CARE hotel in East London for homeless people who are diagnosed as having the disease. They are referred from the streets, hotels, hostels, Secondary Care and A&E departments across the capital to be clinically monitored in a safe infection control environment. The accommodation is provided by GLA, while the medical staff are provided by the UCLH Find&Treat team working with Médicins Sans Frontières (MSF) – this is the first time MSF have deployed in the UK, a video about this work can be found here.

Another aspect of our work has been to establish a surveillance system with UCLH Find & Treat and led by Miriam Bullock, through which we survey hostels for COVID-19 control and social distancing measures, suspected COVID-19 cases and related hospitalisations or deaths. This surveillance system triggers telephone triage and advice from the Find&Treat team who are outreaching same day testing to homeless people across the city with three outreach teams.

Prisons

Public Health England and the prison service have published guidance on their management strategies for COVID-19 in prisons and have as yet managed to avoid the ‘explosive outbreaks’ predicted at the start of the pandemic. Yet healthcare delivery in prisons remains challenging now that inmates are confined to their cells for up to 23 hours a day and many staff are off sick or isolating with COVID-19 symptoms.

One of the CCIH PhD fellows, Chantal Edge, has paused her work on local prison telemedicine implementation in Surrey, to go to the central NHS England Health and Justice team to lead on the rapid deployment of prison telemedicine nationally. Telemedicine will be scaled up across 135 secure sites in England including prisons, immigration removal centres and secure children’s homes. Approvals have also been secured from the prison service to deploy NHS 4G enabled tablets in prisons to support the telemedicine work, a ground-breaking change seeing as mobile devices are traditionally strictly prohibited in prison settings.  Telemedicine will remain in prisons after the pandemic and support improved access and quality of healthcare services for prisoners, so in this way the pandemic has driven forward innovation.

Migrant health

Ines Campos Matos, who has a joint appointment between PHE and CCIH has led PHE’s investigation of the high levels of COVID in BAME groups showing how poverty is compounding this inequality.

Advocacy in the media

We have also been working closely with the press to advocate for inclusion health groups including articles on prisons, and homeless hotels and GP surgeries.

Looking to the future

As COVID-19 decreases in the general population following lockdown, we’re moving to a stage of continued vigilance. This is going to be really important because there are likely to be more transmissions when the lockdown is eased. So far, we have avoided large outbreaks of COVID-19 in the homeless community and in prisons. In other countries such as the USA up to half of people in big, night-shelter-type hostels are being infected, our screening finds only about 3 or 4% of homeless people have been infected. Prisons in countries such as Italy and the USA have also seen huge outbreaks, whereas cases in England remain controlled.

There is a concern that people will begin to think the outbreak is over and will start to relax both the social distancing across society but also in the homeless hostels. As the numbers decrease, there will be pressure to close down the COVID-CARE facility and the hotels. Prisons will likely need to keep measures in place to isolate the vulnerable and enforce social distancing for many months, the mental health consequences of this enforced isolation remain as yet unknown.

We’re planning to launch a major health needs assessment (HNA) led by Dr Binta Sultan, to systematically identify the health needs of people within the hotels. We’ll have 38 clinicians doing telephone interviews, and have established referral pathways into mental health, sexual health and drug and alcohol services. We’ll be screening everybody for hepatitis C, then starting people on treatment with the aim of completion while they’re at the hotel. This could have a major impact on the transmission of hepatitis C in the homeless population. We’re hoping to do the same thing for latent TB infection. The HNA will also identify people who need shielding, therefore requiring their own self-contained accommodation. This will move people up the priority list for permanent housing and will help with advocating for their needs.

During this pandemic, many of us are having to change what we do and prioritise everything towards this response. It’s too serious and awful to feel any excitement about the research: it feels more like a war. We’re trying to use every resource and opportunity that we have – and every waking hour – to work out what we can do to help in the fight against COVID-19. It is rewarding to feel that you’re able to make a difference, but it’s heart-breaking to see how terrible it has become.

Chantal Edge is an NIHR Clinical Doctoral Research Fellow and Specialty Registrar in Public Health, researching the use of telemedicine for hospital appointments in prison. Dr Al Story leads the Find&Treat Outreach Service based at UCLH and is Co-Director of the UCL Collaborative Centre for Inclusion Health. Professor Andrew Hayward is the Director of the UCL Institute of Epidemiology and Health Care and Co-Director of the UCL Collaborative Centre for Inclusion Health.

Since their arrival in the UK in 2010/11, electronic cigarettes (e-cigarettes or vapes) have rapidly become the most popular aid to help people quit smoking. With evidence continuing to grow showing that vaping 1) poses a small fraction of the risks of smoking and 2) improves smoking quit success, Public Health England have restated that smokers who are struggling to quit should ‘try switching to an e-cigarette’ along with seeking help by trained specialists. But what does this mean for existing inequalities in smoking?

Following a steady decline over the past decade, 15% of the population in England are estimated to currently smoke. However, smoking rates fall along a social gradient, with one in four people from disadvantaged socio-economic groups smoking, compared with one in ten from more affluent groups. This means that a disproportionate number of the ~78,000 deaths and the ~485,000 hospital admissions caused by smoking in England each year fall upon the disadvantaged.

Given their popularity (used by >30% of smokers making a quit attempt) and generally lower cost compared with cigarettes, e-cigarettes have potential to help reduce inequalities in smoking cessation. However, a concern during the early period in which e-cigarettes first arrived on the UK market was that they were more popular with better off smokers. If the devices boost quit success, which appears to be the case, then these differences in use across the social gradient could potentially lead to disadvantaged smokers being left behind, thus worsening the existing inequalities.

Keeping up with change

Since their creation in 2003 by a Chinese pharmacist Hon Lik, e-cigarettes have continued to evolve with novel designs and more effective nicotine delivery systems being rolled out each year. The Smoking Toolkit Study (STS), set up by the Tobacco and Alcohol Research Group at UCL to monitor population trends in smoking in England, is one way that researchers and policy makers can keep up with this ever-changing landscape of e-cigarette use and assess whether they promote or detract from reducing smoking rates.

Using STS data from 2014 to 2017, our recent research published in the journal Addiction was the first of kind to look at the use of e-cigarettes by different socio-economic groups at the population level. Our study analysed data from over 81,000 adults in England, including 16,000 past-year smokers, 5,300 smokers making a quit attempt and 13,500 long-term ex-smokers. E-cigarette use in each group was assessed using participant social grade (based on occupation) or housing status as key indicators of socio-economic position.

Narrowing differences among smokers

Our analysis indicated that in the three years from 2014 to 2016, disadvantaged smokers were around half as likely to use e-cigarettes. However, by 2017 this difference was no longer evident. Similarly, there were no differences in e-cigarette use by smokers making a quit attempt. Should this absence of difference between socioeconomic groups remain going forward then it is unlikely that the use of e-cigarettes among smokers and quit attempters will have a persistent impact on inequalities. However, it will be important to investigate whether there are socio-economic differences in the success of quit attempts with e-cigarettes, something which researchers in our group have been looking into.

Greater e-cigarette use among disadvantaged ex-smokers

Our research also showed a different pattern among smokers who had been quit for over a year, with disadvantaged ex-smokers more than twice as likely to use an e-cigarette. This could have important implications, and really depends on whether e-cigarettes prevent ex-smokers from relapsing back into smoking tobacco. If that were true (unfortunately there isn’t much research on this yet) then e-cigarette use would protect more disadvantaged smokers from slipping back into smoking and act to reduce inequalities; an equity-positive effect.

The wider picture

Inequalities in smoking are driven by a complex and nuanced system acting at the population, community and individual level. Reducing disparity requires action at all levels such as tobacco taxes, public health media and education campaigns and individual specialist support that targets the neurobiological and motivational components of nicotine addiction that dependent smokers struggle with. E-cigarettes are not a magic wand for quitting smoking. Rather, given their popularity and similar effectiveness to other forms of nicotine replacement therapy, they are part of a toolbox of interventions that are contributing to the continuing decline in smoking in the UK. If they are available, affordable and able to deliver nicotine effectively without the loss of social identity that some smokers subscribe to, e-cigarettes may also help redress the persistent inequalities in smoking.

Loren Kock (@loren_kock.) is a Cancer Research UK funded PhD student in Epidemiology and Public health, working within the UCL Tobacco and Alcohol Research Group. His research focusses on how e-cigarettes and other smoking cessation interventions impact on socio-economic inequalities in smoking cessation.