Stop. Give me 15 seconds of your time (I timed it). You can give more should you dare to accept the ugly truth of discrimination in the pride of Britain: The NHS.

Look in the mirror, or your phone screen.

Are you racist?

Can you be a racist if you’re already the minority?

Are you someone ‘who wouldn’t hurt a fly’, but never really tried to learn the full name of your colleague from Zambia properly?

2020 is the year to be anti-racist.

It is no longer enough to nod your head solemnly when poets lament over systemic racism. Allow me, if you will, to peel away the rose tinted glasses and show you the discrimination in the NHS.

Today’s tour includes: racial bias, discrimination in leadership, towards staff and towards patients. Sprinkled with anecdotes and a detour through history – enjoy!

The glass ceiling, doors and floors. 

At a Women in Surgery event during medical school, I had the pleasure of speaking to a Chinese Ophthalmologist. She began the conversation in the most unexpected manner: 

If you want to get to the top, you need to work doubly hard.

No, not because you’re stupid (surgeon banter?), but because you’re a woman.

And that too, the wrong shade of human.

At the time, I rationalised her comment. It had been significantly harder for women in surgery, harder still for those of colour. We’d definitely gotten over that nonsensery, surely. I saw plenty of consultants of varying backgrounds during my time as a medical student, and as a foundation doctor.

I promptly forgot about the interaction until a few months ago. 

One of my consultants, a fantastic Pakistani British doctor, had begun venting his frustration at the system:

When we do well, it’s a pleasant surprise for our own and the management. But when we screw up, we represent the entire ethnic community. We work from day one to give more than 100% every time, for we are constantly judged as a group. Not as an individual.

He paused.

We have a responsibility towards our non-white peers, every step of the way. 

Understanding Racial Bias

I finally allowed myself to understand.

Black and Ethnic Minorities (BME) doctors and nurses were only getting so far. We were becoming consultants and GPs and getting the odd representation in media (Turk from Scrubs, I see you. Dr Foreman (House), Dr Chatterjee – we see you all). 

But why were we not seen in the ivory towers of managers and leaders?

Bringing pen to paper, I did what our generations do best. Google became my best friend. I googled why there was a lack of representation higher up. I googled why BME members were not getting recognition, and disparities in various sectors and realms. 

There had to be a diagnosis, the ‘cancer’ that I would obsess over. I found Discrimination in the NHS.

Plan of Action

My research was messy, all over the place and difficult to decipher. Being a Type A personality, lists excite me. I organised my work into several components to tackle the challenges of discrimination in the NHS:

1. Leadership Challenges for BME members
2. BME Staff Experiences
3. BME Patient Experiences

However, before I were to elaborate and discuss the different realms of discrimination, we have to look at history. We must turn our attention to the policies and legislations that attempted to tackle discrimination in the NHS.

So far: we have a ‘why’ and a ‘how’. Now let’s find out ‘what’ I learned!

Discrimination in the NHS: A Quick Guide through the Ages

If you were given a time machine, something tells me that the meeting that preceded the Equality Act may not have been on the top destinations list. However, it’s my machine so I have dibs on the driving seat – and so here we are. 

The Race and Employment in the NHS was published following a meeting in 1983. This document included case studies of discrimination in the NHS. The report came soon after the Nationality Act which was, in theory, created to overcome racial bias in the workplace. 

The case study that caught my eye was related to the employment of nurses. Black candidates were more likely to be put on to the SEN (state-enrolled nurse) rather than state-registered nurse (SRN) course. Ways that this could be done included traditional requirements such as sending in photos or word of mouth. 

This is important to note as the SEN course was restrictive in nature. It did not allow the nurses to progress to leadership roles. SEN roles have since been phased out but this now seemingly bizarre concept accounted for significant discrimination in the NHS.

Taking Action

Acknowledging the problem was the first, momentous step. King’s Fund and Department of Health then followed up the evidence. They subsequently collaborated to create a model policy, to aid employers in having a fair application process. The policy included aspects from recruitment all the way through to promotion and career development. 

The Equality Act of 2010 meant that the NHS (the biggest public sector employer) had to implement diversity policies. The big bosses had a responsibility to promote diversity in the workplace to reflect the values of recruitment infrastructure.

Prior to the act, promoting race equality was entirely dependent on the goodwill of NHS bodies. As you can imagine, little had changed during that time. 

So far, lots of paperwork and little to show for accountability. Let’s continue the tour. 

Significant progress has been seen since the WRES programme was introduced in 2015. 4 indicators on the workforce statistics, 4 based on staff surveys and 1 related to board representation make up the 9 metrics. NHS bodies must show progress each year.

WRES, has forced increased transparency in the data available. For example, 38370 BME staff nurses (band 5) were identified of which only 6 (previously 3) held a leadership role (band 9). With our white colleagues being 1.6 times more likely to get a post from a shortlist of applicants, data like this can shape policies and create a sense of accountability in the organisation. 

And to summarise: We see the racism. We’ve discussed the racism. We’ve put in policies to tackle racism. Next, has it worked?

BME LEADERSHIP: Overcoming Discrimination to the Top

The ‘us’ vs ‘them’ culture has been ingrained in our systems since time began. Using this very sentiment to oppress and keep certain people at the bottom has a catastrophic impact on the community we serve.

Having ethnic executives is not about pleasing the PC (politically correct) Police. A report published by McKinsey found a statistically significant relationship between diverse leadership and better financial performance. This held true for companies across the UK and several other countries. Similar relationships between diversity and wellbeing of staff and patients have been noted. The evidence has never been so important given our current multicultural communities.

Reasons for BME Leadership include:

• Strengthening relations 
• Increase the talent pool 
• improve patient satisfaction
• Improve staff wellbeing

Over the last few decades, BME members have contributed massively to the NHS. From the cleaners all the way through to the higher management, our colleagues will be found from all walks of life.

The Workforce Race Equality Standard (WRES) data published shows that 20% of our colleagues are from a BME background, and yet only 7% hold very senior management (VSM) posts. 

This is important to address, given that the UK’s BME population is steadily increasing, with the last statistic (2011 census) suggesting 13% of the population identifying themselves as Black, Asian or Minority Ethnic. 

What are we doing to get to the top, the real top. The top that the ophthalmologist hinted to all those years ago?

With me so far? Despite the efforts, the stats suggest we’re not tackling lack of represenation as well as we could.

Overcoming Discrimination in NHS Leadership

Over the course of the decades, programmes such as the Ready Now initiative which would aim to fast track BME members to senior positions were funded. Currently programmes such as the Athena Programme and the annual summit for leadership and management are encouraging minorities to step forward and take on higher positions. 

Despite positive strides being made, the Snowy White Peaks of the NHS 2014 report by Roger Kline again highlighted the absence of BME (and female) members on the boards. As well as the negative impact on patient care and the community that the trusts served. 

At a seminar in 2018, the King’s Fund invited NHS leaders from across the country to discuss and debate the data at hand. Across the board, frank discussions were had over the latest results. Unsurprisingly, it was agreed that communication was at the root of any change.

By learning more about the individuals that worked in the institution, by examining case studies, accounts of discrimination and positive advances of inclusion, institutions could do more for the employees and patients. 

The Kings Fund analysed various steps taken by NHS organisations to tackle disparity in the workplace. They noted that opportunities to bring about maximal change occurred at the team level. This change was most effective, possibly because discrimination was also most prevalent here. 

Hit the brakes! To reiterate, workforce race equality is a powerful tool for increased sensitivity towards the community that is being served.

A diverse leadership can reduce health inequalities.

Discrimination in the NHS: Staff

Patient satisfaction is correlated time and time again to staff well-being. An important measure to consider when our colleagues suffer from mental and physical harm, secondary to discrimination.

Discrimination towards staff, by patients in the NHS

We introduced ourselves to the elderly gentleman as third year medical students who had been tasked to take blood from his vein. He took a look at us. Two Indian girls, one wore a hijab. He agreed to the venepuncture and began telling my friend how the head covering was oppressive to women.

Then, he turned to me next. The gentleman stated that the world was better 70 years ago. ‘When we had the Empire’, he said.

We thanked him for his cooperation and walked away. 

Despite walking past the zero tolerance posters across the Trust, I often find myself silent or dismissive of discriminatory behaviours from patients. As healthcare professionals, we often find comfort in picking at a medical puzzle and would choose this over the headache of calling out racism. I often find myself excusing their hurtful notions as a symptom of their physical conditions: ‘he has dementia’, ‘she’s old, frail and has cancer’, ‘they’re just intoxicated’.

Nearly 30% of staff have reported harassment, bullying or abuse from the community that they serve, regardless of skin colour. Anecdotally, I found that the Accident and Emergency Departments are the least tolerant of abuse. However, once on the ward eyes were rolled but the care was mostly given.  

Tackling Discrimination from Patients

Guidance has been made regarding violence and abuse, but it seems weighted towards staff training. Some initiatives such as only treating the patient whilst a security personnel is present, or a warning ‘yellow card’ system have been suggested. 

Staff will no doubt suffer physically and mentally as a result of abuse. Stress-related absences, sick leave and those leaving the profession are genuine risks to complacency when addressing patient inflicted abuse. 

Trusts need to continue to provide support to those that suffer from discrimination. An excellent example of leadership was from the executive at Wigan Hospital who called out a patient who demanded treatment by a white doctor in the emergency department.

These acts of standing up to discrimination, education of different cultures in wider society and robust action against abusive patients and relatives can empower our staff to continue to provide excellent care, without fear. 

Not all heroes wear capes. Like the guy who called out a racist, for being a racist. He was in a suit!

Discrimination towards staff, by staff

On the wards, the nurses remembered single syllable, shortened ethnic names and English ones too. Some stated it was not worth learning the longer names as it was too difficult. Despite working for countless years, many were absolutely at ease at not being able to pronounce the Nigerian Consultant’s surname properly. White seniors would confuse their juniors, who shared no similar features bar their skin colour.

Reported discrimination in the NHS varied by trust and depended on many factors including age, gender, race and religion. Black employees reported the highest levels of discrimination based on ethnicity. Muslims reported highest levels based on religion. 

A foreword in the 1984 Race and Employment in the NHS written by Robert Maxwell highlighted the fact that:

white supremacy in the more desirable jobs perpetuates itself. Weight is given to ‘fitting in’… with predominantly white public expectations.

From obstructive practices in career development to exclusion from social activities, discrimination was the rule rather than the exception. Reports of increased sickness, absence and reduced productivity were noted then, and can be found 30 years later. 

It has been evidenced that tackling discrimination and having staff that represent the community can increase patient satisfaction. A positive working environment will reduce illnesses, increase productivity and thus improve patient care. 

Very simple things like the interaction of an elderly gentleman from Somalia being able to explain their symptoms to the doctor in his native tongue. The Pakistani midwife being able to understand the cultural needs of a new, young urdu-speaking mother. The psychological needs of a Syrian refugee from a Ugandan, Indian therapist.

All of these experiences stay with the patient and can improve their stay or care. 

Inclusion strategies appeared to be best addressed in middle management, for those were the areas in which discrimination was at its highest.

Shared team leadership, clear goals, transparency and accountability all appeared to be effective in reducing discrimination. 

Microaggressions and Lack of Role Models

There has been a shift from overt racism to subtle bias over the decades. One may not be subjected to obvious racial slurs by their peers but note that they have not been invited to the pub quiz with their colleagues. They may be taunted for their accent, the way they pronounce words, or their practices made to feel ancient and dismissed. 

Many note that there is a lack of relatable role models at higher levels, and often find that the damned pigment stunts their networking and mentoring opportunities.

A fellow doctor observed that non-white seniors would consciously not favouritise the ethnic juniors for fear of being called biased. Furthermore, the white seniors would favour the white juniors. There was no winning!

Disciplinary Action and BME staff

BME staff were twice as likely to be called for disciplinary action compared to their white peers in London. Could this be due to differences in communication methods or lower tolerance for mistakes? An article in the BMJ took this apart and found a couple of things to note:

• poor inductions left overseas doctors grossly unprepared for their new jobs in a vastly different environment
• Expectations for overseas doctors to simply adapt to new societal norms and nuances at a drop of a hat were absurd and needed re-evaluating
• BME doctors were less likely to raise concerns and thus become more vulnerable to the blame culture
• Some feel unsupported by colleagues and bosses. This can result in GMC referrals being harsher
• We must scrutinise any unfair disciplinary processes

Personally, I too found that my hospital employs a significant number of doctors from South Asian countries. The doctors often came with significant clinical knowledge but little exposure to British culture.

Could this be addressed through smaller group inductions, longer periods of shadowing, or buddy systems? 

Things to talk about over coffee:

• Are we giving our staff the best start to a new job/role?
• Are we giving BME members GOOD role models?
• Are we trying our hardest to support each other? (no not by doing each other’s shifts guys)

Discrimination in the NHS: Patients

Patients deserve holistic care, regardless of colour or creed. Despite significant efforts to improve patient care, invisible biases can result in visible dissatisfaction.

Discrimination towards patients, by staff

The patient has a knife under her pillow. She keeps talking to me in a language I don’t understand. She is scaring me. Doc, can you go figure out what she’s saying?

This particular memory makes me smile for two reasons. Firstly, the assumption was that I would be able to speak whatever language this lady did based on our similar skin colour. Secondly, the nurse was terrified of the lady that she could not understand.

We speak at our patients from various backgrounds, expecting them to understand and cooperate when we brandish our cannulas, scalpels and pills towards them. And yet, we are at a loss when we are spoken at by the same patient. Discrimination in the NHS is not just about staff, it is about patients and families too.

Dismissed and Disengaged

Many individuals in various communities will not be able to speak English. This barrier is hard enough on an average day, the terror they may feel when they are unwell and vulnerable must be significant. Communication is vital for each one of us.

However, we often dismiss the importance of communication during ward rounds. Translators are tricky to get a hold of, family are not always present and it is difficult. But are we trying our hardest to aid the patient, every single time?

Multiple accounts of poor satisfaction can be related directly to lack of effective communication. Many BME patients who struggle with the English language report anxiety and reluctance to ask further questions for the fear of wasting our time. 

Cultural differences may mean that some communities show less engagement in treatment options, not because they do not wish to co-operate, but because they feel that the doctor should not be challenged. 

BME members can feel dismissed, their concerns not felt as important and thus reduce their engagement in services. This remains a significant issue in the mental health sector whereby attitudes towards mental illnesses may not be mirrored by the white demographic. 

How to Improve?

Therapists and care providers may be unfamiliar with cultural practices, stigma surrounding mental health and therefore may not be able to gain the trust and engagement from their patients. Wider education, with a genuine spotlight in caring for BME patients is key to improved engagement. 

The tour pauses: The patient is more than a medical problem. They are entire worlds of emotions, beliefs and stories. Be curious, take the time!

Discrimination in the NHS and Cancer

Macmillan carried out some research and found that 35.1% of BME members reported depression following a diagnosis of cancer. Communities stigmatise cancer. As a result, they do not discuss it in families/communities, which makes the bad news, worse. Many BME members felt dismissed, or rushed by their doctors.

BME members are more likely to be lost in follow up compared to the white communities. BME members were also less likely to participate in clinical trials and bone marrow transplants. The latter, along with organ donation in the BME community is a challenge that has gained significant traction and awareness has been increasing steadily. 

Case studies found that merely translating information into the various languages was not enough. Patients wanted help in breaking bad news to their own loved ones, information on how the diagnosis would impact their finances, and practical support such as information on disability allowances. 

Due to significant cultural differences, we may not even consider some of the problems that BME members may face.

Some communities do not talk about emotions, and there is an underlying ‘get on with it’ attitude which can leave patients feeling isolated and alone. 

There is a strong reluctance to speak about death and palliation for the fear of ‘inviting bad luck’ and ‘tempting the devil’. This has often led to misunderstandings between families and doctors regarding palliative care.

As a result of the survey and findings, Macmillan are working with BME members of society to bring about change on a local and national level and address health inequalities. 

And to Conclude:

• Discrimination has been ingrained into the system for a very long time for the sake of preserving ‘us’ vs ‘them’

• Massive strides have been taken to acknowledge and overcome the problem but there is much work to do

• Increased diversity in leadership accounts for better patient care

• Patients feel the impact of discrimination resulting in poorer outcomes for them

• Talk. Listen. Educate. Let’s relearn equality and diversity in the truest sense