The coronavirus has shone a bright light on many challenges in health and care, most notably the deep impact of inequity. We cannot claim that this is something we had no knowledge of; health inequities have been present for many decades and widely studied and reported. For example, Sir Michael Marmot’s seminal 2010 Fair Society Healthy Lives report (also known as “The Marmot Review”) asserted that health inequalities in England resulted from social inequalities.

The hard truth is that those living with the most inequities around the world have suffered the most from COVID-19. Whichever way you look at the pandemic — whether it is the risk of contracting the virus, the poorest outcomes from the disease, or the likelihood of losing work — it is the same communities who are being most affected. Yet, as the international vaccine rollout efforts began to pick up pace, we saw that it was often individuals in those same populations who were less likely to get the vaccine than those living in more privileged communities. While it may be tempting to judge, criticise, and persuade, this approach would show a significant lack of compassion and understanding. 

We have largely chosen to ignore what we know about the devastating effects of embedded health inequality. For years we haven’t done enough in health and care to listen to, understand, and build trust with the diverse range of communities we serve. Now is the time to change that. This is not a box-ticking exercise; it is going to take time, concerted effort, and require a long-term commitment to acting and behaving differently.

At the heart of building trust is holding genuine conversations. Over the last year, COVID-19 has been the major topic of conversation around the world. In recent months, these discussions have focused on the vaccine. While most people have taken up the offer to get it, many individuals first have questions they want answered. They don’t want pamphlets from a public health team or to be hounded with letters or texts; they want to have an open, honest conversation with someone they can trust.

At Imperial College Healthcare NHS Trust, we have recruited over 120 vaccine advocates from across the organisation who are working hard to have conversations with their colleagues and listen to their concerns. By training our volunteers with conversational skills and key information about the vaccine programme, we have empowered them to lead this advocacy work and support their health and care worker peers to make a positive informed choice to have the vaccine.

At the heart of trust is instinct and emotion. As we work within our own organisation to support the development of trusted relationships, we have found the following behaviours key to open conversations:

• Acknowledge personal, institutional, and societal histories. This is an opportunity to look beyond COVID-19 and ask your patients — and your colleagues, friends, and relatives — more about what matters to them, and understand how they experience health care more broadly. What barriers and challenges are they facing?
• Be sincere and honest about your intentions. Be open about your agenda, particularly with the vaccine. These conversations should provide information so people can make informed decisions with which they feel comfortable. The goal should not be to force people to take up the offer. On this point, one of our community members said, “A ‘yes’ is meaningless if the ‘no’ doesn’t mean anything.”
• Be present in the community. It is time to move from our comfort zones, from inside our health care institutions, and into the communities and places where our patients spend their lives. We need to go to our patients, embed ourselves in their worlds, and build relationships on their terms.
• Really listen and seek to understand. If there are concerns about the vaccine, try to see the bigger picture. Listen without immediately providing advice.
• Build relationships over time. This is about patience. This work will take time. Don’t rush the process. As with any relationship, people will begin to open up slowly if you earn their trust.
• Show vulnerability. Being open about uncertainty can shift the power in the clinician-patient relationship. We are all human. None of us know everything and we grapple with decision making. Share this with your patients.
• Stay curious and open-minded. Put aside your assumptions. If all goes well, you will learn about your patients, their needs, and their challenges, and this will change how you provide care going forward. There is always more to learn.

Looking beyond our hospitals, we have been working closely with other health and care organisations, local government officials, and community leaders who are putting good conversations at the heart of their work on vaccines. We are moving away from using routinely collected data without context, towards integrating personal insights and experiences into our decision-making processes. 

Seeking to deeply understand and respect our communities, and ceding power, is showing us a way of working that we need to apply across all aspects of health care. This approach should be used to reduce rates of stroke, improve the experience of people with mental health issues, reduce childhood obesity, and much more.

The impact of COVID-19 has been profound, but the devastating toll it has had on our communities is not a surprise. The pandemic has unapologetically revealed the inequities within our communities that can no longer be ignored. The advice going forward is simple: listen, engage, and learn. By investing in these relationships, we can build trust which might well be the greatest remedy of all.

Hannah Fontana is a Strategy, Research & Innovation Programme Manager at Imperial College Healthcare NHS Trust. Bob Klaber is a Consultant General Paediatrician & Director of Strategy, Research & Innovation at Imperial College Healthcare NHS Trust, a member of the IHI Health Improvement Alliance Europe.

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