The NHS is the largest employer in the UK, has an ethnically diverse workforce, and its aim is to improve population health and wellbeing. It may be reasonable to propose, therefore, that the organisation would be ideally placed to promote the wellbeing of its staff irrespective of their ethnicity, and be a role model for other sectors. Our findings, illustrated in a review which I led with my co-author Jacqueline Stevenson to explain the persistently lower levels of wellbeing reported by black and minority ethnic (BME) populations in England, disproved this assumption. Far from being an exemplar for staff wellbeing, the NHS illuminated the consequences and impacts of ethnic inequalities in wellbeing across society, as well as the likely explanations for these differences.
Of all staff for whom data are available in the NHS and community health services, 11% are foreign nationals, while 14% of professionally qualified clinical staff and 26% of doctors are from outside the UK. Overall, 40% of doctors in the NHS are from a BME background. This ethnic diversity is not proportionately represented through the NHS hierarchy. A study by Roger Kline, The snowy white peaks of the NHS, examined BME progression in the health service in London and exposed the stark contrast between the city’s demography, with 45% of the population and 41% of its NHS staff made up of BME people, and BME representation of only 8% of trust board members, and 2.5% of chief executives and chairs. The London picture was reflected in every respect nationally, with BME representation absent from the boards of some national NHS bodies.
Ethnic discrimination was also highlighted by data and research on NHS recruitment and career progression, resulting in an “ethnic gradient” within the workforce, with BME staff being represented in larger numbers at lower pay grades and status roles. Racism and discrimination against staff take other forms too. A 65% increase in racist verbal and physical attacks against staff by patients was reported in the five years up to 2013 by one study we came across. Another report described how a hospital had acquiesced when parents requested that their child was to be treated by a white doctor.
Examinations and assessments may also be subject to bias as was shown by astudy based on the Membership of the Royal College of General Practitioners examination from 2010 to 2012. A fourfold difference was found in the likelihood of failing the clinical skills test between BME graduates trained in the UK and their white colleagues. BME graduates trained abroad were even more likely to fail this exam. “Subjective bias due to racial discrimination in the clinical skills assessment” was offered as the explanation. Particularly damning were the conclusions of two studies published in the British Medical Journal which concluded that, if a UK equivalent pass mark had been applied to the Professional and Linguistics Assessment Board (Plab) examinations which international medical graduates need to clear to be able to practise in the UK, most doctors who are serving the NHS would not have been allowed to enter the workforce. These conclusions have left overseas-trained BME doctors even more stigmatised. Our review highlights Prof Aneez Esmail’s argument that dishonesty is at the heart of the decision not to achieve self-sufficiency in terms of training enough doctors to staff the NHS, but instead, to make up the shortfall with overseas graduates and then to ignore their need for greater support to be able to achieve their highest potential.
Research has demonstrated that BME wellbeing is a good barometer for quality of care, and studies have shown a clear link between the wellbeing of BME staff and patients’ perceptions of care. If BME staff felt motivated and valued, patients were more likely to be satisfied with the service they received. Conversely, the greater the proportion of staff from a BME background who reported experiencing discrimination at work in the previous 12 months, the lower the levels of patient satisfaction in the study.
BME staff in the NHS endure these inequalities, against a background of daily struggles with racism and discrimination in many dimensions of life such as education, employment, law enforcement, across the criminal justice system and in the media. Yet, it is likely that their professionalism makes a significant contribution to the NHS’s position as the best healthcare system in terms of quality, efficiency, and performance, a ranking which has been reaffirmed time and time again, most recently by the Commonwealth Fund study of 11 health systems in the developed world.
Such glaring inequalities are unacceptable. But, in considering strategies which could improve BME wellbeing in the NHS, we had difficulty in identifying specific actors, organisations and entities that could be recommended for actions, while others could be exempt from responsibility. The impact of ethnic inequalities appeared to be so pervasive and was evident across so many aspects of NHS activities that, in our view, a system-wide recognition of the issue and its damaging effects must be called for. Every organisation which makes up the NHS, including the GMC, the Royal Colleges, and the trusts, needs to contribute to a deep introspection on how social justice, fairness and equality may once again frame the NHS as it did in 1948. Only then can we be confident that practical solutions will emerge which will truly make a difference.