The team behind the Digital Health Inclusion Project check in with the Breakfast and Browsing group at Burmantofts Community Friends. This blog was written by Lily Arnold and Emma Carta (UCL Research Assistants).

Introduction

The Digital Health Inclusion Project at UCL has been researching Digital Health Hubs across Leeds for the last year. These hubs are part of a community based approach to digital inclusion, facilitated by 100% Digital Leeds, in collaboration with VCSOs and the health sector.

As the project wraps up, we took a last visit to the Breakfast and Browsing club run by Burmantofts Community Friends, to check in with the group members about our initial findings. Some members have given their time to the project already, but this workshop allowed us to open up discussions with the group and hear more experiences and perspectives.

Digital exclusion has wide-ranging implications for individuals, including poorer health outcomes, increased social isolation, and limited access to essential services. The National Government has been criticised for lacking a credible strategy and failing to prioritise the issue of digital exclusion effectively. But local authority led interventions in Leeds, which are delivered through community hubs and partnerships, play a crucial role in reaching digitally excluded individuals and building essential skills and confidence.

Workshop Overview

We began the session thinking about what works well at the Breakfast and Browsing group, asking the members why they enjoy coming along to the sessions. Then, armed with craft supplies, we turned these discussions into recipe books coming up with recipes for getting online.

While participants mostly only finished the covers of their recipe books, the conversations happening around the table were very insightful! As the workshop drew to a close, instead of a recipe book, members of the group asked for their work to be turned into a poster which could advertise the Breakfast and Browsing sessions to a wider audience.

Key Findings from Field Notes

• Participants enjoyed and appreciated the warm and welcoming atmosphere of the group, and talked often about the importance of social connections and friendship. Multiple times, and in different contexts, the word ‘family’ was used to describe the bond the group felt to each other.
• Breakfast and Browsing meets the need for personalised and flexible approaches to digital inclusion, and it recognises the diverse needs and preferences of individuals who attend the session.
• In depth, ad hoc, one on one digital inclusion work takes place at the periphery of the sessions, with light touch scaffolding at the centre for those who want to engage.
• The breakfast element of Breakfast and Browsing is so much more than just a meal, eating together contributes to the warm atmosphere of the group and establishes a trusted routine.
• The time the group runs on a Monday morning was also noted as being useful, with participants describing their participation as starting the week off on the right foot.

Checking in with the Breakfast and Browsing group provided valuable perspectives from participants on what makes Digital Health Hubs successful. Just as the group requested, here is a poster which combines their different ideas together to advertise the session for more people to join:

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.