Is our NHS racist? How white-washing and institutional racism impact race disparities in British healthcare

By Laura Whitter

Special mention to ‘Why I’m No Longer Talking to White People About Race’ by Reni Eddo-Lodge, which significantly aided the writing of this article and is an absolute must-read.

In the wake of the Public Health England report into the disparate risks and outcomes of COVID-19, the demand for investigation into racial inequalities within our NHS is paramount. It is a vital question: is the NHS racist?

PHE finds increased fatalities amongst BAME groups

The report, released in early June, summarises the increased likelihood of being diagnosed with and dying from COVID-19 if from a Black or Asian ethnic group — contrasting with findings from previous years which indicate mortality rates among these ethnicities to be significantly lower than those displayed by White ethnic groups. In fact, compared to the same period in previous years, mortality was almost 4 times higher than expected.

Some weeks later, following public outcry for further analysis of these conclusions, a stakeholder review was released by the government to qualify the data explored in the initial report.

“COVID-19 in their view did not create health inequalities, but rather the pandemic exposed and exacerbated longstanding inequalities affecting BAME groups in the UK” the review stated. It went on to describe a ”legal duty and moral responsibility to reduce inequalities” in housing, professional, and community environments. Specific steps required to initiate such a reduction were omitted.

Appearing clear in its conclusions, the review evidenced a stark inequality that exists not only in the UK health sector, but across institutions: a systemic problem of racism that affects people from BAME groups, and puts them at increased risk of contracting and dying from COVID-19.

What does it mean to be a Black patient in the NHS?

In the UK, when visiting a doctor for examination of a simple rash, you may expect them to refer to textbook descriptions or photographic comparisons to aid their diagnosis. A basic step in any modern medical investigation. Yet, a lack of documentation of diseases and healthy norms in Black patients has centralised health in White skin as the baseline from which disease develops.

For instance, doctors commonly use descriptors such as ‘flushing’ to identify symptoms and assess blood flow in conditions such as COVID-19.  But, despite BAME people making up roughly 14% of the UK population and 30% of all COVID cases, equivalent descriptors do not exist for non-White skin.

Consistent with the slavery-era myth that Black people have higher pain thresholds than White people, which, despite those still believing it, has needless to say been proven as false, the underrepresentation of Black patients in research and medical resources may be a key factor in the apathy and disinterest reported by people from BAME communities when seeking medical advice.

In a nation where Black women are 5 times more likely to die during or within 6 weeks after childbirth than White women, the need to address the stigmas and biases surrounding Black people, specifically Black women, and their personal experiences of illness and pain is clear.

In a nation where Black men are 4 times more likely to be detained under the mental health act than White men, the need to combat acknowledged prejudices about Black men with mental illnesses and address the lack of appropriate public sector unconscious bias training is clear.

In a nation where, despite a higher prevalence, Black people are less likely to receive a timely dementia diagnosis, the need to examine healthcare accessibility within Black communities and improve cultural awareness in medical training is clear.

Systematic racism in the NHS and healthcare

While racial inconsistencies in care highlight the day-to-day discrimination in healthcare, this is but an echo of larger, systematic racism occurring across all sectors.

Unsurprisingly, there is a large overlap between emergent service workers and so-called ‘key workers’ during the COVID-19 pandemic. People of colour constitute roughly 21% of emergent service workers, earning less on average than people in the traditional working class, who are predominantly White British.

When figures indicate race as a risk factor for COVID-19, we should draw a parallel between the continued failure of the UK government to provide sufficient PPE for frontline staff and the longstanding failure to tackle the entanglement of class and race in UK society.

Socioeconomic status and health themselves are correlated, with lower socioeconomic status associated with poorer physical and mental health. For migrant groups, including those of the Windrush generation, xenophobia additionally threatens the accessibility of healthcare, given the vast increases in the NHS migrant surcharge as well as urges for the NHS to turn-in Windrush migrants for deportation. They confound a message that migrants, specifically those from BAME groups, are not welcome to use NHS services.

Can experiencing racism make you sick?

Research suggests yes. The International Journal of Public Health  indicated a negative correlation exists between racism experienced and health outcomes. Negative health outcomes included higher risk of high blood pressure) diabetes, conditions such as heart attacks or strokes, and depression.

But, as medical research fails to discuss the factors underlying this pattern of prevalence, or adequately represent black people and people of colour in their resources, people from BAME communities continue to be placed at higher risk of disease and of poorer healthcare.

Working for the NHS

As if to reflect the socioeconomic disadvantage of many BAME patients, the NHS as an institution upholds disparate standards of career progression, workplace harassment, disciplinary action, and pay.

According to government data, for every £1 a Black female doctor earns, a White female doctor earns £1.19, and a White male doctor earns £1.38. The 2019 NHS Workforce Race Equality Standard demonstrated that Black doctors and doctors of colour are more than twice as likely to be reported to the GMC than their White counterparts. People from BAME groups representing just 6.5% of senior manager pay bands despite a representation of 19.7% in the workforce.

According to the report, White applicants were 1.46 times more likely to be appointed from shortlisting compared to BAME applicants. Some 15.3% of NHS staff from BAME groups reporting discrimination in the workplace compared to just 6.4% of White staff.

What can be done?

Looking at these percentages, it seems the systemic racism impacting the NHS is not exclusive to those receiving treatment. Objectively, the underrepresentation and poorer professional treatment of BAME NHS staff indicates the work yet to be done in battling every branch of racism that seeps into our health system.

Without addressing the existing discrimination for BAME NHS employees, is it really possible to combat the discrimination faced by NHS service users? Without properly representing non-white figures in the NHS workforce, in senior management and in public-facing roles, can we really improve the accessibility of the NHS to Black people and people of colour?

Whilst it’s taken a pandemic to acknowledge the effects of systemic racism on public health, the cards are now on the table. COVID-19 may have exacerbated existing inequalities within the UK health system, but the drastic reform required to combat racism in the NHS will extend far beyond the duration of the pandemic.

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