Tackling inequalities in health

SouthwarkSouthwark Council Public Health team shares its findings from a review of systemic bias in public health commissioning.

At last year’s South East London Population Health Conference, hosted jointly by King’s Health Partners and South East London Integrated Care System, Southwark Council Public Health team delivered a workshop on systemic bias and shared learnings from an independent review into its own processes and practices.

The team has provided an overview of its findings from the project and the next steps below.


Southwark Council appointed COMUZI, a strategic design studio, to undertake an independent review, investigating potential systemic bias in the commissioning of public health services.

In response to the killing of George Floyd and the Black Lives Matter movement, Southwark Council developed the Southwark Stands Together framework to address racism, discrimination and inequalities affecting Black, Asian and ethnic minority people. As part of this framework, we appointed COMUZI, a strategic design studio, to deliver an independent systemic bias review to examine where systemic bias may be occurring and what actions we can take to tackle potential bias. 

What is systemic bias?

Systemic bias is the inherent tendency of a process to produce particular outcomes. Systemic bias can operate in such a way as to create or maintain inequalities in access to services and experience of care, leading to unequal outcomes for users. The COVID-19 pandemic in particular highlighted existing inequalities affecting Black, Asian and ethnic minorities.

What did we do?

We wanted to look at how systemic bias can affect how we commission our public health service such as the 0–19 services, sexual health, substance misuse, smoking cessation, and healthy weight services.

The systemic bias review involved in-depth interviews with commissioners, public health, service providers, race equality experts, service users, and community advocacy groups. The review took a close look at how bias can occur at each step of the commissioning cycle from how we record data, how we understand needs, how we design and develop services and monitor use, and how racial perceptions as well as ‘omissions’ can contribute to bias and thereby create or maintain inequalities. Using the feedback, COMUZI created a toolkit which included group and individual exercises and training to unpack and expose how bias can operate unconsciously or systemically to affect how we commission. 

The review also made some key recommendations for public health as well as for the wider health and care system:

  • The important role of community outreach;
  • Further work on identifying and addressing cultural barriers to services;
  • The importance of adopting an ongoing approach to challenging bias;
  • Challenging the limitations of data and making special efforts to mitigate this;
  • Ensuring service specifications are explicit on how gaps are addressed for Black, Asian and minority ethnic users;
  • Seeking and being open to user feedback; and
  • Developing and learning the necessary skills to co-design with communities including tackling barriers to community participation in co-design, service monitoring and service review.

Next steps

The COMUZI systemic bias toolkit is still being tested further and refined, as we review and re-commission public health services. We will expect commissioners to demonstrate how they have used the toolkit to look for systemic bias and to be clear on what actions they have taken.

The scale of the task and the difficulties are not to be underestimated as the toolkit is asking all of us to ‘confront’ our unconscious role in contributing towards inequalities, something that many of us will find difficult to hear. If you would like to find out more or join us on this journey, please reach out to us at rebecca.harkes@southwark.gov.uk .

Liked this article? Learn more about the KHP Population Health and Equity programme here.