Opinion

Covid lessons: allies against inequality

19 March 2021

Asha Day asks what lessons have been learned about health inequities during the pandemic, and what changes in risk assessments, vaccinations and structural racism are still needed. 

After my article ‘The empty echo’ appeared in the November/December 2020 issue of Community Practitioner (Day, 2020), I found myself reviewing the progress of the pandemic and how the NHS and, ultimately, the government have managed the pandemic in respect of its black, Asian and minority ethnic (BAME) workforce and population.

Covid-19 has disproportionately affected ethnic minority groups in developed countries. In the UK, people of black ethnicity have had the highest diagnosis rates (Razai et al, 2021). Data up to May 2020 shows 25% of patients requiring intensive care support were of black or Asian background (Razai et al, 2021).

The mortality risk from Covid-19 in BAME groups is twice that of white British patients after factors such as age, sex, income, education and area deprivation had been taken into account (Public Health England, 2020).

These differences are highlighted in the Covid-19 cases among key workers. BAME staff represent 21% of the NHS workforce, but early analysis showed that they accounted for 63% of deaths among health and social care workers (Razai et al, 2021).

What other lessons have we learnt, what do we still need to do to improve the situation, and what are the possible ways forward?

An avoidable crisis

The disparities in public health have never been starker than during the pandemic. But the 2020 death of George Floyd in the US was a springboard for conversations on racism and its impact on the health of BAME communities.

The report An avoidable crisis: the disproportionate impact of Covid-19 on BAME communities (Lawrence, 2020) makes 20 recommendations to address the causes of ethnic disparities, including ending structural racism, cultural barriers and overcrowded housing.

Questions are quite rightly being raised why we are still reviewing decades-old inequalities. However, the Race and Health Observatory, established last year, will supply the opportunity for more powerful, influential and credible voices to be heard. The agenda will benefit from these key leaders and it is hoped will lead to substantial and sustained change for these vulnerable communities.

The Race and Health Observatory will attempt to address the recommendations made by the Lawrence report, but outcomes from this will only be evidenced over time.

Workforce Race Equality Standard (WRES) and other studies have concluded that there is a lack of diversity in senior levels of the NHS. BAME staff make up around 20% of the overall NHS workforce but just 6.5% of its senior managers (NHS, 2020a).

In London, almost half of NHS employees are BAME, but 83% of NHS trust board members are white (NHS, 2020a).

Questions are quite rightly being raised why we are still reviewing decades-old inequalities

The NHS People Plan (NHS, 2020b) attempts to address this problem, building on the creativity and drive shown by our NHS people in their response to Covid-19. It places people and diversity at the heart of its themes, with high-quality health and wellbeing support for everyone, tackling discrimination and recruiting and keeping new people.

PHE, 2020; Razai et al, 2021.

 

Blocked career paths?

Another structural issue that needs to be addressed is the lack of progression for BAME staff. How can we help those whose careers have stalled? Data indicates disproportional under-representation of BAME nurses from Agenda for Change Band 6 upwards (NHS, 2020a). Development programmes have been undertaken, but measurable outcomes are still missing. Many nurses and community practitioners will have completed these programmes but not seen any career progression.

Solutions to address this are now being put forward and include talent management programmes – sometimes also called ‘high potential programmes’ – bespoke mentoring and coaching and, more importantly, sponsorship.

Many of these initiatives are aimed at Bands 6 to 8a, which in some part will address career progression. However, many Band 5 staff are excluded from these programmes, and an opportunity has been missed to accelerate nurses who have the expertise, experience, clinical credibility and qualifications – particularly bank staff.

BAME people make up a large proportion of many trusts’ bank staff. Bank staff say they appreciate the flexibility. But they can feel undervalued for their contributions.

To counter this, ‘stretch programmes’ are being developed and implemented. These challenge staff by placing them into uncomfortable situations in order to learn and grow developmentally. However, there needs to be the supportive infrastructure to allow this to be successful.

However, there can be disproportionate access. One programme gives as many as 50% of places to midwives with the remainder going to nurses. One rationale was that career progression for BAME midwives appears to be even more disproportionate than in general nursing, but one has to remember that midwifery, in the main, draws from general nursing.

Covid risk assessments

How have risk assessments improved the landscape for BAME staff? It is a mixed picture. A survey by the British Medical Association (BMA) found that less than half (46%) of BAME doctors in the NHS felt their employers had made the correct Covid risk assessments and were confident the necessary safety adjustments had been made to their role (BMA, 2021). 

The findings also showed that 14% of BAME respondents said they had not been assessed and thought adjustments were needed, while 15% said they had been assessed but their safety measures needed updating (BMA, 2021).

In comparison, more than half (55%) of white respondents indicated they had been properly risk-assessed, with just 7% saying their adjustments needed refreshed (BMA, 2021).

In the spring and summer of 2020, we have seen the development and implementation of Covid risk assessments for staff within the NHS. These risk assessments are expected to be regularly reviewed, as recommended by NHS England and NHS Improvement. However, as of December 2020, BAME staff have reported that these assessments are yet to be started or signed off. As members of Unite and other unions, they have been advised to seek support from their representatives and line managers.

There has been a wide range of experiences among BAME staff undertaking these Covid risk assessments. Many organisations introduced assessments with workshops, via Microsoft Teams, for managers, which included:

  • How to undertake a Covid risk assessment
  • Compassionate conversations
  • Psychological safe spaces
  • FAQ briefings.

More negatively, other organisations have introduced the Covid risk assessment almost ‘by memo’ and told staff to complete the risk assessments themselves.

Many NHS trusts have enabled staff assessed as vulnerable to work from home. However, those trusts and departments with a high percentage of BAME staff have found this challenging, and in some cases staff have reported that they felt bullied by line managers to work in high-risk environments or with high-risk patients. At regional BAME support meetings, I have also heard reports that when the Covid risk assessment was completed, it stated that they had declined to work from home, even though the real issue was a lack of computer equipment to work remotely.

In addition, at the height of the crisis last year, many staff were forced to work with inappropriate PPE. Other trusts made the brave decision not to allow staff to deliver care until they had PPE (a very short window of time).

Organisations with active BAME networks/staff support groups have been invaluable in being advocates and supporting individuals and managers with the development, introduction and undertaking of Covid risk assessments.

Proactive and forward-thinking bodies are starting to look beyond the risk assessments and painting an informed picture of racism, micro and macro aggressions and gaslighting. They are moving forward in an attempt to become truly anti-racist organisations. The concept of allyship has become an integral part of the narrative (see What is allyship? opposite). Within the NHS, the ‘7 As of allyship’ have been developed by Yvonne Coghill, director of the WRES for NHS England (see The 7 As of allyship, below).

Psychological safety

‘Psychological safety’ is a new term that has increased in popularity since the beginning of the pandemic. To encourage this, each NHS trust will have a freedom to speak up guardian (FTSG). But one criticism is that are very few BAME FTSGs. This has some part been addressed by the BAME networks/staff support groups or by the introduction in some trusts of FTSG ambassadors drawn from BAME staff. Trusts must ensure that there are psychologically safe spaces for BAME staff to be able to articulate concerns without fear of redress.

The concept of psychological safety builds on the activities happening in BAME networks/staff support groups and on the success of BAME FTSG, allyship and the fast-moving agenda around organisations becoming anti-racist.

Vaccine hopes

NHS BAME staff, who were rightly applauded for their hard work during the crisis, might have expected they would be prioritised in the queue for vaccination. In December 2020, the Joint Committee on Vaccination and Immunisation (JCVI) made its recommendations on who would receive the Covid vaccine. These were identified into nine tiers, prioritising care home residents and those over 80.

Many NHS BAME staff were angered that BAME populations and the BAME workforce would not be prioritised for the vaccine. Organisations such as the British International Doctors Association and the chair of the Royal College of General Practitioners challenged the JCVI’s decision. One of the reasons for the introduction of the Covid risk assessment was to keep the BAME workforce safe by reviewing individuals’ risk and duties in their environment. It was not, at that time, developed to identify the populations that would get the Covid vaccine; however, one could argue that the risk assessment should be used to prioritise the Covid vaccine.

Many NHS trusts have, by way of the priority groups, offered Covid vaccinations to all staff working in the NHS. But this still leaves wider BAME groups outside of the priority groups. There is also the problem of vaccine hesitancy among BAME communities (see Big story on page 14). In a study of more than 12,000 UK people, vaccine hesitancy was particularly high in black (71.8%), Pakistani/Bangladeshi (42.3%), mixed (32.4%) and non-UK/Irish white (26.4%) ethnic groups (Robertson et al, 2021).

The question of ethnicity has only just been introduced as part of the data collection when giving Covid vaccinations, a missed opportunity given the disproportionate impact of the virus on BAME people. Ethnicity data has routinely been collected in the NHS, so why was it missed here?

We should also consider venues for vaccinations and look to areas that are trusted by BAME people: Sikh gurdwaras, Hindu temples, mosques and community centres used and trusted by BAME populations.

An anti-racist future?

Covid-19 continues to highlight the disparities in health in our population; the Black Lives Matter (BLM) movement has sharpened our focus on structural racism from which the NHS is not exempt. BLM calls for fixing faultlines in wider society, such as the lack of education about the UK’s colonial past, and the damaged trust caused by the Windrush scandal.

As we move forward in 2021, we do so in the hope that we can deliver a better service to BAME staff and groups to create a brighter future.

Asha Day BEM is CPHVA vice-chair, and clinical team lead and chair, BAME Network, Leicestershire Partnership NHS Trust.


What is allyship?

A lifelong process of building relationships based on trust, consistency and accountability with marginalised individuals and/or groups of people.

It is not self-defined – work and efforts must be recognised by those you are seeking to ally with.

Allyship is an opportunity to grow and learn about ourselves, while building confidence in others. (Atcheson, 2018)

The 7 As of Allyship

  • Appetite: are you ready to immerse yourself in the complex, emotive world of race equality? See illustration above
  • Ask questions about race: be curious, read, learn and educate yourself
  • Accept there really is a problem. More data isn’t needed
  • Acknowledge that the problem needs to be dealt with
  • Apologise: express sympathy that racism is affecting people of certain races
  • Assume: don’t. Instead develop informed views by seeking to understand individuals
  • Action: take demonstrable action steps to establish equality and be accountable.

Image credit | Shutterstock


References

Atcheson S. (2018) Allyship – the key to unlocking the power of diversity. Forbes. See: forbes.com/sites/shereeatcheson/2018/11/30/allyship-the-key-to-unlocking-the-power-of-diversity/?sh=7146258849c6 (accessed 5 February 2021).

British Medical Association. (2021) BMA survey shows, a year on, Black, Asian and other minority ethnicity doctors still don’t feel protected from coronavirus in the workplace. See: bma.org.uk/bma-media-centre/bma-survey-shows-a-year-on-black-asian-and-other-minority-ethnicity-doctors-still-don-t-feel-protected-from-coronavirus-in-the-workplace (accessed 5 February 2021).

Lawrence D. (2020) An avoidable crisis: the disproportionate impact of Covid-19 on Black, Asian and minority ethnic communities. See: lawrencereview.co.uk (accessed 5 February 2021).

NHS. (2020a) NHS Workforce Race Equality: 2019 data analysis report for NHS trusts standard. See: https://www.england.nhs.uk/wp-content/uploads/2020/01/wres-2019-data-report.pdf (accessed 5 February 2021).

NHS. (2020b) We are the NHS: People Plan for 2020/21 – action for us all. See: england.nhs.uk/publication/we-are-the-nhs-people-plan-for-2020-21-action-for-us-all (accessed 5 February 2021).

Public Health England. (2020) Disparities in the risk and outcomes of COVID-19. See: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/908434/Disparities_in_the_risk_and_outcomes_of_COVID_August_2020_update.pdf (accessed 4 February 2021). 

Razai MS, Kankam HKN, Majeed A, Esmail A, Williams DR. (2021) Mitigating ethnic disparities in covid-19 and beyond. BMJ 372: m4921. See: bmj.com/content/372/bmj.m4921 (accessed 4 February 2021).

Robertson E, Reeve KS, Niedzwiedz CL, Moore J, Blake M, Green M, Katikireddi SV, Benzeval MJl. (2021) Predictors of COVID-19 vaccine hesitancy in the UK Household Longitudinal Study. See: https://www.medrxiv.org/content/10.1101/2020.12.27.20248899v1.full.pdf (accessed 18 February 2021).

 

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