Dying of discrimination? - RSA

Dying of discrimination?

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  • Picture of Glanville Williams FRSA
    Glanville Williams FRSA
  • Accessibility & inclusion
  • Health & wellbeing
  • Public services

Glanville Williams FRSA asks whether discrimination could be the reason why black and minority ethnic healthcare workers are at a disproportionately high risk of becoming critically ill with Covid-19.

Data emerging on a daily basis from the US and the UK has exposed what is an uncomfortable and unpalatable truth: that black and minority ethnic (BAME) healthcare workers are dying from Covid-19 at an alarmingly higher rate than their white counterparts. And no one seems to know the reasons why. At the time of writing, of the 12 doctors who had died in the UK after contracting the virus, all were non-white.

More than 90 percent of doctors and dentists that have died from Covid-19 are from a BAME background. The Health Service Journal analysis of 106 deaths among healthcare workers found that 63 percent of deaths were BAME, despite accounting for only 21 percent of the workforce.

In the UK, after Dr Chaand Nagpaul (council chair of the British Medical Association) called for a review, our politicians have reacted by belatedly scrambling for answers, with both the government and the official opposition announcing respective inquiries into the matter in short order.

As ever, the media has not been backwards in coming forwards, with a number of seemingly plausible reasons for the disproportionality in mortality rates. Predictably, they mostly focus on traditional socio-economic and socio-behavioural memes such as obesity, the high rates of heart disease among BAME populations, or that BAME families are more likely to be living in overcrowded, multi-generational households and so on. Few, if any, touch on the 'elephant in the room' and what I believe to be the root cause for the differences we are seeing in mortality rates: discrimination.

Some may be familiar with the term 'allostatic load'. Broadly speaking, it refers to the 'wear and tear' on our psychology and physiology (our mind and our body) which accumulates over time as an individual is exposed to repeated or chronic stress. Several studies have shown that black-white disparities in mortality persist, even after adjusting for socio-economic and socio-behavioural factors. One such study involving 4,515 black and white individuals between the ages of 35 and 64 concluded that allostatic load burden did indeed partially explain the higher mortality rate among black individuals in the US.

Work-related stress is widely recognised as a significant problem in the health service, with the Heath and Safety Executive confirming that health and social care workers have some of the highest rates of self-reported illness due to stress, anxiety and depression. Add to this already difficult work environment the additional stress factors which stem from repeated exposure to discriminatory behaviours within the NHS, and you have in my view the logical starting point for any public inquiry.

We all know that stress, specifically chronic stress, is not only dangerous and potentially disease provoking, but is known to suppress immune function and increase susceptibility to viruses, infections and cancers by damaging the body's defences against disease. 

So, what do we already know about the types of discriminatory treatment that BAME workers within the NHS are routinely exposed to which may induce chronic stress-related symptoms? 

In 2008, D. Vivienne Lyfar-Cisse published the first ever Race Equality Review, covering 27 NHS Trusts represented in the south east coast region. The data revealed widespread disadvantages faced by BAME staff evidenced by the disproportionality in recruitment, bullying, grievances and disciplinary rates. Subsequent annual reviews have only served to re-validate those findings.

The study showed that while BAME staff comprised 15 percent of the workforce, they were involved in more than half of the bullying and harassment cases in the region's mental health trusts, and in 25 percent of disciplinary cases across all the trusts surveyed. In terms of the employment penalties faced by BAME candidates, the data showed that BAME applicants accounted for 31 percent of those shortlisted but only 16 percent of final appointees. 

In 2019, an independent study, commissioned by the General Medical Council (GMC) and conducted by Dr Doyin Atewologun, Roger Kline and Margaret Ochieng, found that BAME doctors had double the rate of referrals to the GMC by their employers as compared to white doctors. Similarly, non-UK doctors were 2.5 times more likely to be referred by an employer to the GMC as compared to UK graduate doctors.

Another report, commissioned by the Race Equality Foundation and conducted by Roger Kline in 2015, found that while BAME people constituted 45 percent (after adjusting for illegal and undocumented migrants) of London's population and 41 percent of London's NHS workforce, white staff were three times more likely than BAME staff to hold senior management positions.

The Freedom to Speak Up report, also published in 2015 reported that BAME staff who had been brave enough to report concerns at work were:

  • more likely to be victimised by management than white staff raising concerns;
  • more likely to be ignored than white staff raising concerns;
  • more likely to be victimised by co-workers for raising concerns;
  • less likely to be praised than white staff by management for raising concerns; and
  • less likely to raise concerns again having done so once, than white staff were.

While we wait with keen anticipation for the conclusions of both the government and the Labour inquiries, I want to strike a note of caution. Any report that fails to address the link between Covid-19 mortality and allostatic load burden differences between BAME and white NHS workers, and the reasons for any differential, is in my view not only a sham report but also a real missed opportunity to tackle the scourge of racial discrimination in the workplace.

Glanville Williams is the founder of InclusionQuery, a think tank specialising in workforce diversity metrics. He is a regular blogger and the publisher of the InclusionQuery Index, a bi-annual benchmarking report which ranks local authorities in terms of workforce diversity. He is also the proud recipient of the 2010 prestigious Business Award in Excellence, by the African Leadership Magazine, awarded in recognition of his quality contribution to African communities in the UK.

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  • Hi Smriti, I read your commentary of NHSI's performance during the Covid10 lockdown / protecting NHS beds etc. Whilst it is entertaining to watch the battle of the beasts to gain top dog status (i.e. NHSE, NHSI, PHE, DoH), as a doctor in the NHS for 36 years (in care of elderly psychiatry, covering 24 care homes), it is also profoundly saddening.. Regards the enforced transfer of untested elderly to any available care home bed (as you say 15,000) beds, I think of this as reminiscent of the 10,000 deaths due to placing elderly people on to the LCP in order to access a NHS England pot of cash (the Mid Staffs 'experience'). I published an article in 2005 linking Mid staffs with a political movement in Weimar Germany called 'Life unworthy of living' following a paper published by 32 eminent professors (psychiatry and law). If you recall the Weimar health economy was also focussed on saving money. So, lots of elderly, learning disabled and  psychotic patients were transferred to institutions, starved / dehydrated, not treated for infections and finally (if they hadn't died) given lethal injections. 

    I would contest if these big quangos can be rained in, one option is to privatise them (including their staff pensions), leaving clinical bodies constituting the true NHS. as you say, mayors have the power to organise local social / health / third sector commissioning, but it depends on them having the balls to do so, despite fearing defunding by NHSI.  the other option is to have a 'true' internal market by giving each National Insurance holder a card (Chip & Pin) budget and / or e vouchers for elective referrals / treatments (I have published on this). So, they can go to ANY NHS approved provider to get their assessment and treatment anywhere in the UK (possibly in Europe). This will rapidly bring down waits and improve quality outcomes, AND devolve power from the big NHS beasts. What do you think?  

  • Really pertinent points that absolutely need to be made. Whilst we applaud the work of front line staff, it's essential that we don't avoid difficult truths.

    In 2014, the NHS commissioned an independent report into race discrimination. The resulting report, 'the Snowy White Peaks' was pretty damning. The stats have since then become worse - over 1M workforce with fewer than 18 executive positions held by people who are BAME. 

    BAME medical staff are much more likely to do more hands-on front line work - they are a disproportionately represented in the so-called 'service' jobs (as opposed to those with an academic/ managerial element) and over-represented at the junior nursing grades.

    That a hugely disproportionate number of deaths of minorities in the NHS is tragic but not surprising from a system that is institutionally racist.