Our recent report on stark ethnic inequalities in the NHS, published by the NHS Race and Health Observatory will make for uncomfortable reading for NHS managers, commissioners and government departments with health and social care responsibilities, alike. Uncomfortable because of the numerous pieces of evidence within the report that document racist experiences suffered by patients using the NHS, and the staff within it, the pervasiveness of ethnic inequalities across the healthcare areas reviewed, and due to the lack of change we have seen in racial inequalities in healthcare services in recent decades. This report adds to the long list of reviews and well-evidenced reports that detail ethnic inequalities in healthcare. But many of these previous reports have not been acted upon. This has led to anger, disappointment and disillusionment as well as raising questions around the value of conducting research in this area, and more importantly, why are policymakers not (really) listening? Which begs the question: how will this report be any different?
The answer is that this report may well not be any different. But a key difference in our report is its willingness to purposefully and overtly state that ethnic inequalities apparent in the healthcare system and suffered by the staff working in it are a result of structural and institutional racism. This key difference along with the continued spotlight the pandemic has thrown on ethnic inequalities in health provide a glimmer of hope that we have the ears of those in positions of power to instigate change. Since the beginning of the Covid-19 pandemic in early 2020, the disproportionate impact of the virus on ethnic minority groups has been a mainstay of news headlines. In addition, there have been numerous reports focussing on the racism faced by ethnic minority staff in the NHS. Could the events of the past two years make way for real change on racial inequalities in healthcare?
Well, we are certainly not short of evidence to support radical action on racial inequalities in healthcare. Our review, guided by the NHS Race and Health Observatory’s five priority areas (mental healthcare, maternal and neonatal healthcare, digital access to healthcare, genomic (or precision) medicine & genetic testing and the NHS workforce) provides a key base from which to launch a strong drive for change. In the process of the rapid review that formed the basis of the report, we screened over 13,000 articles and synthesised evidence from 178 studies from the past decade to summarise the state of ethnic inequalities in healthcare and the NHS workforce. We supplemented this with a survey with key stakeholders such as NHS clinicians and academics as well as discussion groups with community practitioners, identified and interviewed by our partners, Race Equality Foundation and The Ubele Initiative. We found ethnic inequalities across all the areas we reviewed, providing compelling evidence that the poorer healthcare outcomes experienced by people from racially minoritised groups are not isolated incidents, but a result of longstanding structural and institutional racism within the NHS.
What was apparent in the process of doing the review, is that there were major issues that cut across all the areas reviewed. These issues (outlined below with associated recommendations) are a major impediment to achieving racial equality in the NHS. Critical action by NHS England and Improvement (NHSEI) must be taken now to improve the quality of care provided to ethnic minority people.
Address the Ethnicity Data Gap: We found that there was poor recording of patients’ ethnic group in NHS clinical records (e.g., 30% of ethnicity data missing in some datasets). In addition, our review found a lack of good quality national data on the use of NHS services disaggregated by ethnic group, age, gender and other important demographic and socioeconomic variables, and adjusted for level of ill health. We recommend that patients’ ethnicity is (1) recorded and (2) recorded accurately (i.e., self-reported ethnicity) in all interactions with NHS staff. We also recommend that NHS Digital should provide national NHS statistics on service use by ethnic group, age and gender (at a minimum) and allow for clinical data to be linked across datasets in order to improve the monitoring of clinical outcomes for ethnic minority populations and to enhance the quality of research that can be undertaken with ethnic minority populations.
Work to build trust with ethnic minority groups and key VCSE organisations: Our review found that some ethnic minority people delayed or avoided help seeking for health problems due to past experiences of racist treatment by healthcare professionals or due to similar experiences of their friends and family. Improving ethnic minority people’s trust in NHS services will, subsequently, improve health outcomes through increased access to these services. Hence, we recommend that a plan of work to build trust with ethnic minority groups and voluntary, community and social enterprise (VCSE) organisations that work with ethnic minority populations, is produced and implemented.
Invest in Interpreter Services: we found that high quality interpreters were not being provided in mental healthcare, in GP surgeries and at various points along the maternal health care pathway. Greater resource needs to be allocated to the provision of interpreters in NHS Trusts; interpreter services need to be readily available for in person, telephone and digital appointments.
Invest in research to understand the impact of racism on healthcare: Finally, greater investment in research understanding the mechanisms that underpin and drive ethnic inequalities in healthcare is imperative if the mechanisms and systems that give rise to ethnic inequalities are to be disrupted.
So, what now? Primarily, as medical sociologists and sociologists of race, racism and ethnicity, we must keep talking about racism and its detrimental effects on the health and healthcare experiences of ethnic minority people. If we allow racism to be erased from the explanations and debates, we lose the ability to address racism as a fundamental cause of poor healthcare, and push for an end to racial inequality in healthcare.
Dr Dharmi Kapadia is Lecturer in Sociology at The University of Manchester, and longstanding member of the ESRC Centre on Dynamics of Ethnicity (CoDE), as well as Co-Lead of the CoDE Early Career Researcher Race Network. Dharmi is also Co-Investigator of the Evidence for Equality National Survey (EVENS), the UK’s largest survey of ethnic and religious minority people’s experiences of the pandemic.