People from ethnic minority backgrounds constitute 14 per cent of the population but, according to a recent study, account for 34 per cent of critically ill Covid-19 patients and a similar percentage of all Covid-19 cases. These patterns are not unique to the UK – in Chicago, black people constitute 30 per cent of the population but account for 72 per cent of deaths from the virus.
Another analysis found that, of 119 NHS staff known to have died in the pandemic, 64 per cent were from an ethnic minority background (only 20 per cent of NHS staff are from an ethnic minority background). This disproportionate toll is shocking.
On 16 April the UK government announced a formal review, by Public Health England, into these higher death rates. We suggest that the review faces two key questions: why are people from ethnic minorities disproportionately affected by Covid-19 and what will we do about it? Our focus here will be on what must change in the cultures of NHS organisations. First, we consider why so many more staff from NHS minority groups are dying during this crisis.
We need to be careful about rushing to judgement before we have all the facts. We know that people from ethnic minority backgrounds tend to have higher co-morbidities. For example, those from BAME (black, Asian and minority ethnic) backgrounds have higher incidences of cardiovascular disorders and diabetes which can reduce people’s ability to recover from Covid-19. We also know that people from ethnic minority backgrounds constitute a disproportionately high number of key frontline workers – public transport drivers, cleaners, carers, Band 5 nurses, etc. In London, 67 per cent of the adult social care workforce are from minority ethnic group backgrounds. And those from ethnic minority groups are more likely to be concentrated in poorer areas, live in overcrowded housing and in inter-generational households.
In short, people from ethnic minorities are more likely to have underlying health conditions that make them more vulnerable to the virus, work in roles where they are exposed to it and live in conditions in which it is more likely to spread. As the Mayor of London, Sadiq Khan commented: ‘…the depth of inequalities is being laid bare in stark fashion’.
These inequalities are manifestations of the structural barriers and systemic discrimination faced by people from ethnic minority backgrounds. For health and care staff from minority ethnic groups, these barriers are also a daily work hazard. NHS staff from minority ethnic groups suffer discrimination and racism throughout their careers. For example, a survey of 487 doctors who became NHS consultants in 2017, showed that white doctors applied for fewer posts; were more likely to be shortlisted; and were more likely to be offered a job. On average, black doctors in the NHS earn £10,000 less and black nurses earn £2,700 less annually than white colleagues. Minority ethnic group staff are systematically over-represented at lower levels of the NHS grade hierarchy and under-represented in senior pay bands.
NHS staff are also subjected to racism by patients and other members of the public during their work with predictable consequences for their health and wellbeing. Staff survey data from the NHS shows that 29 per cent of ethnic minority staff have experienced bullying, harassment or abuse from other staff in the past 12 months, while the proportion experiencing discrimination at work from a manager, team leader or other colleague is more than twice as high as white staff. These trends are not diminishing.
Now, more than ever, it is essential to focus on addressing these inequalities and to value the diverse staff who make up the health and care workforce by developing and sustaining inclusive and compassionate workplaces.
What are we to do?
There is already good work under way focused on changing NHS structures and processes such as appointment and promotion processes, disciplinary procedures, and complaints handling (notably by the Workforce Race Equality team of NHS England and NHS Improvement). The greater challenge is to change cultures in which everyday discrimination goes unchallenged – for example, the leader who fails to see how their behaviour constitutes what Professor Alvin Alvarez of San Francisco State University has identified as everyday racism: ‘subtle, commonplace forms of discrimination, such as being ignored, ridiculed or treated differently’.
For those who think this couldn’t possibly be them or say this problem is too big to transform – yes, we can change. Look what we have accomplished nationally and as a health care system in the past eight weeks.
We don’t have all the answers (please share yours in the comments section below) but we have some suggestions.
First, we must recognise the role that white staff can and should play. It may be hard for white people to accept that we are all part of the problem. Almost all of us as individuals will say we are not – ‘it’s other white people’, but, in reality, we are all part of the problem and we should all be part of the solution. Research (yes, guided by the science www.workplaceedi.com) suggests how we might start.
We have focused here on what all of us working in health and social care can do, whatever the setting. Why? Because it’s right and because each one of us can take action to change, regardless of where we are in the hierarchy, whatever our role. If not now in this crisis, when? If not you, then who?
Honouring the contributions of ethnic minority staff and the sacrifices they have made demands that we each commit to this. This is how the light gets in.
Its time to move from 'Everyday Racism' to 'Everyday Activism'
All support from our Allys is greatly valued, & very much needed. We are definitely in this together.
This is a very good piece of work thank you. I appreciate the fact that individuals have to make positive changes in addition to system changes in the NHS. Disciplinary policies and capability policies should not only be strictly adhered to for junior staff but also for senior staff.
Thank you Suzie and Michael - I type with tears in my eyes
I remain hopeful of an NHS that stands out globally for Inclusive Practice
Thank you Suzie & Michael. I read this article with hope and anticipation for a better future for BAME staff in the NHS. Its the first time I have seen real practical suggestions that our white colleagues can implement as individuals to improve the health & wellbeing of BAME staff in the workplace. These should be written in the senior leaders competency based job description and form part of their work plan as accountability is the key. Where there is no accountability and demonstrable evidence of implementation demonstrated then no change will be manifested. I hope what is written here will be read by all who will make it their responsibility to share empathy, compassion and real care for what BAME staff go through on a daily basis.
One of the big challenges is reaching those who do not believe they are rascist because of the preconceived beliefs they hold about 'others' (that's every single one of us!). Trusts are starting to deal with unconscious bias, but there is a lot of work needed to convince people that there is a problem to overcome and to ensure that the training / awareness solutions are robust enough to be successful.
A very enlightened blog on a hugely important issue. But on the other side of the "what are we to do?" coin, we need to deploy the best epidemiology/big data and clinical science to understand the underlying pathobiology of the problem. Clearly aspects of deprivation are a major factor, but we still do not know why some populations are more predisposed to the infection, or do worse when infected. Until we have better mechanistic insights, some ethnic minority groups will continue to have an added disadvantage.
Worrying figures, disturbing facts. But it is hard to see that workers in health care can achieve much while racism is deeply rooted in the country's governing political party.
I agree with all that has been said - we need the public inquiry to inform us and equally need to act on the data that we do have and take steps now to protect BME staff. But whatever steps are taken, however well intentioned, we must take heed of the underlying causes of structural racism and inequalities. I am still astonished that the images from the outset of this crisis didn't include BME staff in senior leadership roles- it seems a very basic thing to get right -and the importance of valuing and including all staff in such comms cannot be underestimated if we are to have inclusive leadership and equality.
"And those from ethnic minority groups are more likely to be concentrated in poorer areas, live in overcrowded housing and in inter-generational households."
A missing factor is the phenomenon of 'chain migration' and the social clustering in communal organisations, restaurants etc, whether linguistic, ethnic or religious. The Covid-19 disparity is also seen in Britain's Jewish community, especially amongst the ultra-orthodox, as seen in New York and in Israel. The degree to which these minorities are closely knit socially facilitates the spread of any virus.
I am pleased with the research outcome, Iam typing with tears, I am going to Jamaica aftet Covid19 and I will read this findings sitting on my grandmother's grave. She worked in the NHS for over 35 years she was a windrush girl. She begged me not to peruse a career in the field of nursing I did not take her advice, the way am feeling now I wish I had listened. There seem to be light close to the end of the tunnel.
Very Interesting and useful piece of work. Equality & diversity subject should form a major part of Health & Social Care courses. Inequalities attitude often are carried on from the grassroots. It’s about time every worker is treated fairly without prejudice.
Please see our open letter to NHSe
I was disappointed by this article, which appeared to be an investigation of the reasons for higher morbidity among ethnic minorities, but changed to a criticism of racial discrimination. Both subjects are important and need further attention, but no case was made for linking them. A jump was made from "In short, people from ethnic minorities are more likely to have underlying health conditions that make them more vulnerable to the virus, work in roles where they are exposed to it and live in conditions in which it is more likely to spread" to "These inequalities are manifestations of the structural barriers and systemic discrimination faced by people from ethnic minority backgrounds." Are the underlying health conditions really due to discrimination?
Thanks for this. First step in accepting there is a problem Principle of conscious incompetence might apply. To many of us don’t think there’s a problem and we shrug it off, minimise or normalise it or just as bad, put it in the too difficult basket
As a moderately prominent care home activist there are some best practice principles we should consider. A Bill of Rights or set of pledges might be overstating this but we, white Care Home owners, should be proactive and take some egalitarian responsibility in asking ourselves ‘are we doing enough’ to address some deeply embedded attitudes that don’t help make things better for us all?
As a past Chair of a King's Fund supported BAME group nearly a couple of decades ago. I can say that we should not be constantly reinventing the wheel and only respond to issues that are proven statistical bias against BAME employees. Legislation dictates that management of all government bodies protect all protected groups. Corvid 19 and the Windrush hostile environment are evidence that the legislation and government managers are inadequate to protect BAME staff. Are we seeking platitudes to ensure that we can ask the same questions a decade from now?
People are against positive discrimination to attack negative discrimination because it may neutralise its effect, unless it is for women or the disabled in the UK. It is practised in NI by law and this is the only place that there is evidence of a systemic reduction in discrimination. The evidence would imply that we do not want to resolve the problem of discrimination but just to justify it.
The real question is when will we provide evidence based management and go back to monitoring the appointments to Boards as prima facie evidence that someone is taking this subject seriously?
When will we respond to data because every life matters rather than waiting for the BAME staff to complain about the realisation of worst case scenarios that are first denied, then promise an investigation, then do not deliver as promised because the media is no longer interested in this?
The problem is that this has happened when there was an over-representation of deaths in polices stations, over-representation of school exclusions, over-representation of the hostile environment in immigration, and now Corvid 19 deaths. How does this continue so we can work out how does this stop?
Some people want action because action speaks louder than words.
Here is a prediction that we could research for both health and social care. All those managers who sent staff to their death and risk the death of their family from Corvid 19 by insisting that they care for staff without adequate PPE, will be exonerated of all wrong doing. This will be done in the same way as Grenfell Tower will deal with its issues.
A very good article Research shows that systemic racism and discrimination have serious deleterious effects on mental and physical health and socio -economic status. The NHS is embedded in a wider social, political and media culture where subtle and overt “everyday racism” is used consciously and unconsciously to amplify and foster division to distract from policies and systems which cause and increase social inequalities. Neutrality on this issue is not an option for any of us.
Hi Peter - an interesting observation on your part. You may want to explore the research of Professor David Williams on weathering.
I felt sad too Banji. I am glad this article went further to explain Inequalities and Discrimination. Some conclusions in the media were made in absence of Systemic Racism and barriers faced by many people from BAME. We do have to engage and collectively facilitate positive and meaningful changes without prejudice & bias. Any True leader will not be comfortable with this issue.......
Yes racism and discrimination are unlawful criminal acts that needs to be well tackled and nipped in the bud, for upbringing of a healthy and productive workforce.
How dare any of you cite RACISM when you call us White privileged Workers.
I have worked for over 30 years for the NHS,I do not get treated differently, get paid more or have
a unique protection from the VIRUS due to the colour of my skin.
This effects all of us and if you look outside your slurs of racism you will see white people have died too.
Next time you say a prayer think about what kind of human being you are.....
It has to start somewhere with someone. MPs can lead (and sometimes do!) but they need to be pushed by their constituents - who are you, me and all of us, of course.
Thank you for these insights. I think in addition to what 'every white member of staff' and what 'every leader' can do, we can also think about what 'every BAME staff' can do. Sometimes we see/experience subtle racism but we may not call out the person on it. We need to be less complacent and challenge everyday discrimination.
The next question for the leaders are - how will they learn more about the research evidence? How will their performance as inclusive leaders be assessed? How will they create fair and just cultures in their team if they themselves have unconscious bias? What are the consequences if they don't create a fair and just culture? There needs to be more than just tick box exercises of doing an 'equality and diversity' training or celebrating BAME staff in a meaningless way.
excellent article - time to take ownership of the root cause of the problem exists within all of us - including BME. A key issue not to be forgotten is where the treatment was given - are we seeing disparity in mortality in the different hospitals - should we be establishing COVID centres ? Should we not learn from our experience in trauma , HIV , Stroke - to give everyone the best chance possible
The significant association between hypertension, CVD, diabetes with greater morbidity and poorer outcomes in COVID-19 has been noted extensively in a great many studies throughout the world. All the above co-morbidities reflect metabolic ill-health. The authors do note "For example, those from BAME (black, Asian and minority ethnic) backgrounds have higher incidences of cardiovascular disorders and diabetes which can reduce people’s ability to recover from Covid-19." The issue of metabolic ill health in itself would account for the disproportionate level of poor COVID-19 outcomes amongst BAME employees . . . But another serious issue, not mentioned in the report, is the low levels of vitamin D that tends to pertain amongst the BAME community. It has been shown in a number of studies that reasonable level of vitamin D protects against viral infection. A recent study . . . "Patterns of COVID-19 Mortality and Vitamin D: An Indonesian Study" . . . shows just the same results for COVID-19 . . . finding that . . . "When controlling for age, sex, and comorbidity, Vitamin D status is strongly associated with COVID-19 mortality outcome of cases."
I am a registered nurse with 25 years experience of working within the NHS, I am white but am an ethnic minority nonetheless. Whilst there can be no argument that the NHS is sadly a racist institution I think perhaps all diverse groups should take a peek in the looking glass. I have experienced racism from my colleagues of colour throughout my career ( whether in the form of exclusion/treatment or derogatory remarks ) and equally have been let down by the systems lack of robust enforcement of policies. So perhaps it’s time for US ALL to be more transparent with one another and get to the core of the problems as opposed to singling out 1 group.
With regard to the disparity of death rates within BAME groups it is alarming & hopefully post thorough review we will get the necessary answers needed in order to better protect out colleagues/communities.
In the meantime however nothing has changed on the ground & for our BAME colleagues It’s business as usual minus any risk assessments!!???.
We must be very careful with how the data from this work is used. The argument over genetic susceptibility is flawed by the lack of disease load in African and Asian nations. The concept of weathering too does not play out with the seasonal flu.
However, what we must be very careful of, is removing BAME staff from frontline work, which eventually will become a surrogate for eugenics and an excuse not to appoint BAME staff to certain pivotal jobs.
The discrepancy is multi-factorial, and will take into account socio-economic drivers as well as reflections of training and empowerment of BAME staff compared to their non-BAME colleagues.
But what we cannot facilitate is eugenics by the back door. Any such move will drive the equality battle by decades, one from which we may never recover from...
Thank you. I have been aware of the likely Vitamin D deficiency explanation for at least 2 weeks, how is that medical people are not? Another article regarding BAME deaths in Guardian today and no mention of Vitamin D at all.
The figures are scary for reading as a BAME person. So thank you for the insight you have offered. Indeed as a normal society who want to understand how this is so aside the biological, socioeconomic factors it is worth looking further. What we do not know at the moment, at least not as far as this blog has articulated is how many healthcare professionals have contracted the virus. That would perhaps offer some explanation regarding the death toll i.e. How many white people compared to BAME persons within the NHS have contracted the disease. I cannot go any further...
I’m hugely disappointed at the lack of ethnic minority participants in the research.
I’m also disappointed at the wholly speculative conclusions being illegitimately drawn around socioeconomic factors.
Can I please invite you to examine the COVID-19 research in Asia around its effect on red blood cells and haemoglobin and then examine the mortality rates of BAME community members with trace or full blown Thalassemia and Sickle cell trait or full blown anaemia.
BAME community members better understand their own hereditary risk factors than grant seeking non-BAME researchers looking for excuses to increase their research grant funding on unrelated pet projects.
Let’s focus on the issue please,.
You are jumping to conclusions to quickly. The data needs to be studied. The number 119 of NHS staff who have tragically died is a small sample group. We just past 30,000 deaths overall. 64% of the deaths of NHS are BAME people, but the peaks of deaths are in London and Westmidlands in cities where more BAME staff work for the NHS. In London you say 67% of social care workers are BAME, so a rate of deaths of 64% would be expected. Tragic how those deaths are the expected number would be higher at 67% as correlation of population.
I am all for research as long as its sensible. There seems to be a rush for an inquiry to prove that discrimination is happening. We might ask the government to publish research completed on ethnicity of grooming gang members. The government is shy on that research. but then that is bad research that we may not like the conclusions of. See official petition on release on the make up of grooming gangs. Almost 125,000 signature on the petition so far asking for the findings of the research to be released. The government have said the findings is not in the public interest.
I agree with this article and with also the need to look at Vitamin D which is coming out as a very strong signal in risk groups including BAME. I am increasingly frustrated that we cannot do more to protect our colleagues and the elderly. If Vitamin D is important then we must talk about it alongside this. To deny specific health needs of groups within the population is itself a form of institutionalised racism/ ageism.
The review led by PHE and the NHS is a good thing. I really hope that there will be properly-diverse input into the strategic planning, implementation, analysis, and reporting phases. There are a lot of BME professionals across all sectors who can help to make this exercise a potentially landmark contribution to the cause of greater socio-economic equality and mobility. I also hope that they look into the worrying report in the Nursing Times that some BME staff have felt pressured into working on Covid-19 wards. I wish PHE and the NHS well on this endeavour.
An inquiry will be too late to help people dying now - so what can be done? I suggest a simple possibility is to supplement with Vit. D. Vit D is essential for a healthy immune system. Most of our Vit. D comes from exposure to the sun, but can also come from diet, oily fish, eggs, mushrooms exposed to sunlight and some foods that are supplemented (eg All Bran). Estimates of up to 80% of people in the UK have low levels of Vit D in winter/early spring, which is more prevalent with people living and working inside and with those with darker skins - not so much uv light penetrates through the skin. Vit. D deficiency causes rickets in children which is more prevalent with ethnic minorities. Recently low Vit. D levels have been linked to a worse outcome from covid19. Public Health England has recently recommended GPs give Vit. D supplements to their most vulnerable patients.
Thank you for this blog, but I would really appreciate some more solid recommendations from the Kings Fund,
about the steps that can be taken to mitigate these inequalities and differential outcomes.
I have been very impressed by NHS Somerset FT, and the very practical 5 steps that they are putting in place
to support their BAME staff:
Could the Kings Fund as a minimum, set out some good practice ,such as these 5 steps, and mitigating steps like additional Vitamin D provision, from the NHS and Social care, and other areas.
We need to consider ways to try to mitigate this risk for health and care staff and for all other key workers.
We also need to consider how we look at ways which take the first steps to mitigate risk for patients and the public.,
and consider how to provide services equally for those on the wrong side of the digital divide.
Unfortunately it does seem that there is a real lack of accountability, and no place to question decision making at present.
Are there any good Equality Impact Assessments being done? Is there any good work on coproducing Covid 19action plans?
Having a KF review of good practice would be really useful to patient and public representatives.
Happy to discuss further.
Please can you clarify how black doctors on average get paid £10k less? Possibly my naivety as still in training but if junior doctors are on a fixed pay scale and consultants nhs pay is fixed (+/- private work) where is the disparity and why? Is this taking trust grade roles in to account? Am an ethnic minority myself so was possibly again naively assuming/hoping that our profession is exempt from gender pay gap and racial inequality?
I seem to agree with you. Simply because we do not even know how many NHS professionals all together have contracted the disease. If we do, then these figures will begin to make absolute sense. At the moment, this conclusion is cherry-picking hence the bleak figures. Assuming there are fewer white NHS professionals who have contracted the disease as opposed to more BAME professionals, this will have impact on the percentages.
BAME covers more than 1 race.. so how is it comparable to the white people stats.
If you split the BAME into race.. I.e. black African, Philippine, Muslim.. maybe these figures would be more balanced. You can't compare white Brits against the rest of the world. It's an imbalance of figures!
I have been investigating the incidence of sickle cell anaemia and thalassaemia in British minority ethnic groups in relation COVID-19 death rates published by The Institute of Fiscal Studies. Since May 3 I have been contacting the Sickle Cell Society, the mayor of London, etc., etc., but have received few replies. My son and daughter-in-law, both consultant radiologists, are looking into this possible relationship.
Thank you for your question. The data for this blog was taken from John Appleby’s article Ethnic pay gap among NHS doctors
(https://doi.org/10.1136/bmj.k3586), which was published 05 September 2018. You may also find Jane Dacre's review of the gender pay gap in medicine useful: https://www.bma.org.uk/pay-and-contracts/pay/how-doctors-pay-is-decided….