Why is it taking so long to achieve racial equality in healthcare?

18 September 2020

The pandemic has impacted BAME groups more severely and exposed yet more disparities. Inequality in healthcare (still) and structural racism in society are some of the reasons. Journalist Linsey Wynton asks why we are still waiting for action.

As UK deaths from Covid-19 exceed 40,000 and confirmed cases surpass 300,000 (UK Government, 2020), more staggering figures have emerged: the rate of Covid-related deaths in BAME communities.

Death rates are 4.7 times greater among black males (aged nine to 64) and 4.2 times higher among black females than their white counterparts in England and Wales (ONS, 2020). For all ages, that death rate is 3.3 and 2.4 times greater respectively. The age-standardised death rate is 2.5 times higher among Asian males and 2.3 times higher among Asian females compared with white people in England (Public Health England (PHE), 2020a).

A National Records of Scotland study also indicates that people from south Asian backgrounds are 1.9 times more likely to die of Covid-19 as white people (Woods, 2020). Northern Ireland does not record Covid deaths by ethnicity (NISRA, 2020).

Looking at the healthcare professions specifically, an analysis in April revealed that 71% of nurses and midwives, and 94% of doctors and dentists who have died from Covid-19 were from BAME backgrounds (Rajagopal et al, 2020).

The vital questions remain: why is the Covid-19 death rate so much higher for people from a BAME background, what can be done to improve it, and why on earth is action to do so taking this long?

The death-rate figures, coinciding with the Black Lives Matter (BLM) protests, have shone a spotlight on the health disparities suffered by BAME communities. A recent report from race equality think-tank the Runnymede Trust (RT) highlighted some of these. It found that BAME groups in the UK ‘face greater barriers’ when trying to protect themselves from Covid-19, and that they’re overexposed to the virus. It said BAME groups are more likely to be living in overcrowded housing, working outside their home, using public transport and working in key worker roles, but less likely to be protected with PPE (Haque et al, 2020).

Many experts say action to offer increased protection to BAME communities has been apathetic, and that countless reports of what is needed to tackle gaping historic health and social inequalities have been sidelined. This has led many BAME leaders to stipulate: ‘Our demand is for a Covid-19 Race Equality Strategy that will not only deal [with] the immediacy of saving lives, but also fundamentally rebuild many of our institutions that this disease has exposed as having huge racial disparities’ (Operation Black Vote, 2020).

Action so far – a reminder

As previously reported in Community Practitioner, PHE published Disparities in the risk and outcomes of Covid-19 at the beginning of June. This was followed by Beyond the data: understanding the impact of Covid-19 on BAME groups. The latter concluded: ‘Historic racism and negative experiences of healthcare or at work may mean that individuals in BAME groups are less likely to seek care when needed or as NHS staff less likely to speak up when they have concerns about PPE or testing’ (PHE, 2020b).

The main report author, Professor Kevin Fenton, and his colleagues asserted in the report that Covid-19 ‘did not create health inequalities, but rather the pandemic exposed and exacerbated longstanding inequalities affecting BAME groups in the UK’ (PHE, 2020b).

The report’s seven recommendations included better data collection on ethnicity and religion, risk assessments for BAME employees, culturally sensitive health messages, improved experiences of health services by BAME communities, and ensuring strategies create long-term change. But the government delayed publishing these until two weeks after the report. 

Labour’s Baroness Doreen Lawrence and the shadow secretary for women and equality, Marsha de Cordova, urged government to disclose a timetable for completing PHE’s recommendations: ‘This has become another example of the government acting too slowly to deal with this crisis. By failing to take urgent action, it is putting the lives of BAME people at risk’ (Proctor, 2020).

Although Kemi Badenoch, the equalities minister, has said she wants actions driven by evidence (Mohdin, 2020), the government has been criticised for setting up a race commission. Liberal Democrat shadow woman and equalities secretary Christine Jardine says: ‘We have reports, reviews and recommendations on the shelves in Whitehall, which are weighed down with them. What we need now is action’ (UK Parliament, 2020). Marsha agrees: ‘The time for more reviews has long since passed, we need a Race Equality Strategy now’ (Labour, 2020).

Labour MSP Anas Sarwar has said ‘Scotland’s ethnic minority communities deserve greater protection’ ensuring risk assessments are carried out for key workers and there are tailored messaging for BAME communities (Woods, 2020).  

Meanwhile, the Welsh Government launched an ‘urgent investigation’ in April into why BAME communities were being disproportionately affected. A report in June made more than 30 recommendations to the Welsh Government (2020) to address the socioeconomic and environmental risks it highlighted.


What’s behind the Covid figures?

Professor Emmanuel Ogbonna, who chaired the subgroup for the Welsh Government report, said: ‘There’s an overall theme running through our research for this report. It centres on longstanding racism and disadvantage and the lack of BAME representation within decision-making processes’ (Welsh Government, 2020).

The role of socioeconomic deprivation, occupational risk, structural issues including racism and distrust, and health comorbidities were all highlighted by Professor Fenton as points that struck him during his community engagements sessions for the second PHE report (Soni, 2020). There were similar outcomes in the recent RT report.

Dr Zubaida Haque, one of the report authors and RT interim director, says: ‘Our findings explain why we are seeing outbreaks in places like Leicester, densely populated areas with multigenerational households. Many people are also struggling to pay bills so have to leave their homes to work. Temporary housing and financial support should be made available to facilitate those who need to self-isolate’ (Collinson, 2020).

Put simply, she wrote, ‘While we have all faced the same storm, we are not in the same boat’ (Haque et al, 2020).

Regarding comorbidities, BAME communities have elevated rates of diabetes, cardiovascular disease is more widespread among people of Bangladeshi or Pakistani origin, and hypertension is more common in those of black Caribbean and African ethnicity (PHE, 2020a).  

Professor Jane Hendy, dean of Brunel University Business School, recently presented her research to government on why BAME communities may be disproportionately affected by Covid-19 and how targeted messaging could help mitigate the impact (Brunel University London, 2020).

Highlighting barriers to accessing healthcare for BAME groups, Professor Hendy says: ‘People can feel very alienated and threatened when accessing healthcare due to past experiences, cultural reasons and issues of language. Some migrants were not made to feel welcome, or entitled to health services.’

She adds: ‘A lot of the Covid info put out by the government and PHE addresses everything from a very white perspective. It assumes that people live in a family of four. Many BAME people don’t live like that, so those messages aren’t really aimed at them.’

Professor Hendy stresses the importance of working with cultural community leaders on Covid-19 messaging: ‘Although all classified as BAME, there’s not much overlap between south-east Asian and Afro-Caribbean people in how they might see themselves and these issues. Government need to have much more culturally targeted messages. You can’t just have one message going out to everybody, because it’ll miss its mark for huge swathes of the population.’

CPHVA executive committee vice-chair Asha Day stresses that translators must ensure the Covid safety concept exists among the population the message is for, and that it is back-translated by a second translator to ensure content is correct. She adds: ‘Leaflets are not enough because many communities don’t read or write their own languages – you need digital content with the spoken word.’

Covid-19 did not create health inequalities, but rather the pandemic exposed and exacerbated longstanding inequalities affecting BAME groups

Covid inequalities for healthcare staff  

NHS England has stated that trusts and primary care providers must complete risk assessments for all staff in ‘at-risk’ groups (NHS England and NHS Improvement, 2020a). As reported last issue, Unite has produced a Covid-19 guide on risk assessment for BAME workers, with guidance for employers and employees.

Obi Amadi, Unite lead professional officer for strategy, policy and equalities, says that initial risk assessments on staff who needed to shield or work from home because of raised risks from particular medical conditions were done fairly efficiently. However, this has not been her experience with subsequent risk assessments for BAME staff in England, though she says the other UK nations are further ahead. 

‘BAME people were not treated as a priority. The risk assessments should have been done urgently because Covid-19 is a work injury,’ she says, adding that some staff have even been asked to sign disclaimers to say if they are exposed to Covid-19 at work their employer will not being held liable.

Jackie Williams, Unite’s acting national officer for health, says: ‘Risk assessments must be culturally competent. Workers have got to have a conversation before risk assessments take place so this is not seen as another management tool to control them.’

CPHVA executive committee member Elaine Baptiste, who is based in north London, has been supporting a health worker whose employer would not allow her to work from home. ‘She has to use two buses and a train to go to work even though her husband needs shielding and she has health issues herself. She has been hounded and harassed to go into work and managers are not being understanding. A risk assessment has never been done on her,’ she says.

Obi advises BAME workers whose managers have discriminated against them previously to request a union representative to accompany them for their risk assessment.

Asha’s employer, based in the Midlands, responded quickly in completing BAME risk assessments, adapting NHS shared best practice frameworks, co-designing with the BAME staff network. Managers were trained through workshops in completing risk assessments, based on compassionate conversations with staff. Risk assessments were also done with white staff who lived within a BAME household.

Asha says: ‘I manage a predominately BAME workforce and they work with a predominantly BAME population – and it’s been apparent that it was having a negative psychological impact on my staff. The people who were dying were predominantly from a BAME community. They were seeing newspaper headlines and the faces of people who worked in the NHS.’

Obi supports those who pointed out that the #ClapforCarers media coverage was not representative of BAME communities (Adebayo, 2020): ‘We had the clap for carers every week, but the majority of those that the media showed were white people clapping and white healthcare staff. There is nothing wrong with [showing] white people, but black healthcare staff called it the whitewashing of the Covid crisis – because you would not think that black people did anything – while in the background they were disproportionately dying.’

Inequalities faced by BAME healthcare staff

The most recent WRES highlighted:

  • Only 6.5% of staff at Very Senior Manager pay band are BAME despite BAME staff making up 19.7% of NHS England’s workforce
  • Only 8.4% of board members in NHS England trusts are BAME
  • 15.3% of BAME staff reporting discrimination by colleagues and managers compared with 6.4% of white staff
  • BAME staff were 1.46 times less likely to be shortlisted for promotion than white candidates

NHS England and NHS Improvement, 2020b

Racial inequality in healthcare

Obi calls out the lack of diversity in the original Covid strategy. ‘If any of the Covid taskforces had had more BAME people on them, we might have got to where we are now sooner. We started from a pretty much all-white landscape with white opinions, some well-meaning and some just ignorant, but when that is your starting place you’re deficient,’ she says.

Given the most recent Workforce Race Equality Standard (WRES, produced by NHS England since 2015), this lack of diversity is sadly not that surprising. For instance, the latest WRES found that only 6.5% of staff at Very Senior Manager pay band are BAME despite BAME staff making up 19.7% of NHS England’s workforce and only 8.4% of board members in NHS England trusts are BAME (NHS England and NHS Improvement, 2020b). See Inequalities faced by BAME staff above.

‘In NHS board and strategy meetings where decisions are being made, you don’t have BAME people there to speak out for themselves,’ says Obi. ‘BAME people will bring a perspective that somebody who is not from that background won’t know.’

Obi says that many white managers appoint white staff because of unconscious bias, seeing them as more familiar. ‘Although in London, BAME nurses outnumber white nurses, in all of the London hospitals there is not one director of nursing from a BAME background.’

Asha points out the need for more thoughtful recruitment: ‘Chief executives and boards should not just say: “I’ve ticked the box because a certain number of our directors are BAME.” The workforce needs to reflect the population that it serves at all levels of the organisation.’ She suggests that when senior managers leave, BAME talent should be brought in on positive action programmes.  

Asha also highlights that a fear of reporting or calling out racism at work remains: ‘Quite a lot of people say “I’ve put up with this for 20 years – I’ve grown a thick skin.” They have let it go because it’s easier than fighting – because you might lose your job or never get career progression.’

Elaine, who is also an HV and specialist paediatric continence nurse, agrees: ‘I’m 64 and I’ve been fighting my corner all my life. When white people meet me they see a black person before they see Elaine.’ Reflecting on her early nursing career, she says: ‘You were always made to feel that you weren’t good enough. I knew that when I was on the wards I stood out like a sore thumb and whatever I did I had to do it 10 times better than my white counterparts.’

You can’t just have one message going out to everybody, because it’ll miss its mark for huge swathes of the population

The bigger picture

Addressing PHE’s most recent report, Dr Jennifer Dixon, chief executive of the Health Foundation, says: 'The report makes no specific recommendation on tackling entrenched discrimination and racism. Black and minority ethnic communities speak loudly in this report and say discrimination is among the fundamental causes of ill health. They should be listened to’ (Dixon, 2020).

Others agree. ‘Members report a lot of covert racism – it used to be overt,’ says Asha. ‘They’re seeing more micro-aggressions – subtle ways to attack them. The BAME community are feeling that blame is being put on them. For example: “It’s your fault you live with a lot of family in overcrowded housing – they’re spreading Covid.” Actually it’s a societal, systemic effect of racism over many, many years.’

Asha says that ‘this has been going on for centuries. For children it starts before birth. Look at the magazines for motherhood – do you see a BAME mother or baby? Until recently, if you wanted to get a children’s book that told Asian or African or Caribbean stories you had to go somewhere specialist and order it from abroad.’ She criticises shops that have sold BAME dolls for less than white dolls, saying: ‘This is society placing a monetary value on colour.’

The recent Colour of power report, which is presented in a visual format, revealed just how few BAME faces are in top positions in UK organisations (52 out of 1099 possible roles), including government (Green Park, 2020). Asha says: ‘The photos speak for themselves. Diversity is simply not there.’

Elaine adds: ‘BAME people don’t want an easy route to the top, but we need a level playing field. Within our media we need more positive BAME role models so young people can see they can get there. They also need mentoring – it’s vital that all BAME people have the mindset that they feel they can do and that parents are given the confidence that their children can and will achieve.’

Meanwhile, the RT’s Zubaida Haque expressed concern in a recent blog that a 2019 TUC report showed BAME groups were twice as likely to be in precarious employment, including zero hour and agency contracts. She says: ‘These labour market inequalities between ethnic groups explain the substantial poverty rates among BME households with, for example, 60% of Bangladeshi children living in poverty after housing costs’ (Haque, 2020).

Equality for all?

  • More than 1/3 of black communities are in key worker roles
  • 50% of Bangladeshi key workers, 42% of Pakistani and 41% of black African key workers had not been supplied with adequate PPE
  • 54% of white groups reported they had not been affected financially by the pandemic, compared with 35% of BAME people
  • Bangladeshi (43%) followed by black African groups (38%) were the most likely to report the loss of some income since COVID-19, compared with 21% of black Caribbean groups and 22% of white British people

Haque et al, 2020

What is needed?

While BAME people have always been aware of the level of systemic racism they face, Covid and BLM have made this harder for those in power to overlook, experts say.

‘Systemic racism has been kicked under the carpet,’ says Obi. ‘But we have got to a place where some people feel guilty. Lots of statements about BLM is all well and good – but what we need is action.’

The government is now funding six research projects to investigate Covid-19 and ethnicity. Professor Hendy is working with a team, including Professor Aftab Ala from the Royal Surrey NHS Foundation Trust and King’s College Hospital, on one such project to consult BAME communities and design culturally relevant health messages and videos (UKRI, 2020).

She hopes the work will amplify the BAME communities’ voices at policy level, adding: ‘Covid has got people to change at a huge pace that wouldn’t have been achieved if we had not had this crisis.’

Jackie says: ‘Unite has already started working on the recommendations from Professor Fenton’s report [PHE, 2020b]. Our ask of government would be to also take those seven recommendations seriously – to start working through them and having a joined-up approach.’

As stated earlier, Labour and Liberal Democrat politicians have echoed the need for a timetable on PHE’s seven recommendations and a Race Equality Strategy now.

A government spokesperson for Kemi Badenoch said: ‘We know that Covid-19 has had a disproportionate effect on people from BAME backgrounds, and we are determined to take the right steps to protect them and minimise the risk.’

The spokesperson also explained that the NHS Confederation, which covers England, Wales and Northern Ireland, recently created the NHS Race and Health Observatory to investigate the impact of race and ethnicity on health and identify and tackle the specific health challenges facing people from BAME backgrounds. The Observatory will involve experts here and internationally, analysing policy recommendations to improve health outcomes for NHS patients, communities and staff.

As for the RT’s report Over-exposed and under-protected, among its six main recommendations were: ‘The government must address the root causes of health, housing and employment inequality.’ It went on to say: ‘The government must also develop a national cross-governmental strategy for action on the social determinants of health, with a specific focus on deprived and black and minority ethnic communities, as recommended in the [2020] Marmot review’ (Haque et al, 2020).

Asha concludes: ‘Progress on tackling racial inequalities in healthcare has been inches over years. However, because of Covid putting a sharp focus on this, we have the opportunity now to go miles within months.’  


See next issue for more on holding organisations to account and how CPs can best serve BAME families


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