The CRED (Commission on Race and Ethnic Disparities) published its Race report on 31 March 2021.
Although it confirms that we don’t yet have racial equality in the UK, it fails to acknowledge structural racism as a key factor in racial inequality.
Building on our members' experiences, our research and our evidence submitted to the Commission, we believe it is necessary to acknowledge the role of structural racism in racial disparities. This will address the root causes of racism in healthcare and help put in place a successful plan to move forward.
What our evidence shows
Over the years, the BMA has built a wealth of evidence and knowledge on the significant impact that racial disparity can have on health outcomes. For the medical profession, this translates into inequalities in treatment, experiences, and development.
In our original submission to the Commission, we focused on the main topical issues affecting the medical profession:
Ethnic minority disparities in NHS workforce
A 2018 BMA survey found that despite the growing numbers of black, Asian and minority ethnic doctors, 45% of them didn't feel there was respect for diversity nor a culture of inclusion in their main place of work.
The Race report celebrates the contribution of ethnic minority healthcare workers since the post-war period as a success story. However, it doesn't acknowledge how workers from some ethnic minority backgrounds continue to be overrepresented in lower pay grades and underrepresented in higher grade roles.
Underrepresentation at leadership level and fewer career progression opportunities are evidence of the structural inequalities that persist within our healthcare system. These same factors may have also helped foster an environment where some ethnic minority healthcare workers experience bullying and harassment more than their white colleagues.
This extends to treatment from patients. The BMA has shared experiences from BMA members who have suffered racial abuse from patients throughout their careers. The 2019 NHS Staff Survey supports the same evidence.
Medical education and career progression
Medical education also has a role to play in helping improve health outcomes and the diversity of the healthcare workforce. Our 2017 report showed that the biggest gaps in attainment during medical training are linked to race, both for British ethnic minorities and international medical graduates. Ethnic minority medical students report bullying and harassment at four times the rate of their white peers.
We also know that having role models that medical students can identify with is important to ensure the proper representation from ethnic minorities across the teaching faculty and in the medical school curriculum.
Race also plays a significant factor in the progression of doctors. There continues to be a pass rate gap in all medical postgraduate exams, between UK-trained white doctors (76%), UK-trained ethnic minority doctors (63%) and IMG doctors (41%).
There are also unequal opportunities to progress into more senior roles, with white CCT (certificate of completion of training) holders more likely to be offered a first consultant post (29% versus 12%). This widens the existing pay gap between doctors from
an ethnic minority background compared with doctors from a white background.
Cultural transformation is needed across all aspects of medicine and the NHS, including selection, attainment, progression, assessments, individual experiences, staff diversity and staff training.
Racial health inequalities
Underlying socioeconomic factors like education, unemployment and poverty are clear factors contributing to health inequalities.
However, evidence shows that structural racism leads to people from ethnic minority backgrounds having poorer health outcomes. The impact of COVID-19 on ethnic minority healthcare workers is confirmation of this.
Within the healthcare workforce, a shocking 85% of the doctors who died from COVID-19 were from ethnic minority backgrounds. It is less likely that socioeconomic factors can explain this disproportionate impact.
Our surveys of members during the pandemic found that doctors from ethnic minority backgrounds were more likely to feel pressured to work without adequate PPE, and were more afraid to speak out about safety concerns for fear of recrimination, or it affecting their careers.
BMA asks and recommendations
The BMA advocates for a ‘health in all policies’ approach to ensure that all government policies are focused on the impact they have on people’s health.
We ask the Government to consider our recommendations below to aid immediate implementation with support from the medical profession:
- any future analysis or reports about race disparities to include a clear definition of racism
- to ensure transparency in how the Commission reached its conclusions, as well as to aid further research, we ask that a summary of all the evidence presented to the commission should also be available for public view to show how the Commission reached its conclusions
- immediate evaluation of the impact of the work to increase vaccine take-up by different ethnic minority groups and engaging with those who continue to have low take-up to understand their concerns
- all recommendations agreed for implementation must have a monitoring framework with timelines for evaluation.
Support of the Race report recommendations
Although we consider the Race report to be a missed opportunity to address the underlying causes of racial inequality, we welcome some of its recommendations:
The CQC inspection process, in relation to general practice, appears to have resulted in disproportionate numbers of practices with ethnic minority doctors rated as “inadequate”. We believe that to address structural factors causing these disparities, all CQC inspection processes must embed meaningful assessments of equality at all stages.
This recommendation chimes with what we have publicly called in our 2019 report.
We support this recommendation. Our submission to the Commission urged further research into the ethnicity pay gap in the NHS.
If an Office for Health Disparities is established, the close relationship between systematic racism and socio-economic status must be recognised. We welcome this long-overdue focus on health inequalities as part of the wider conversation about race in the UK.
We would encourage some clarification of the relationship between the recently established Race and Health Observatory and any new office to avoid duplication and wasted resources.
We support a ‘health in all policies approach’. This must be accompanied by sufficient funding for public health services. The principal issue undermining local public health delivery in England has been severe cuts to the local public health grant since 2015.
We have called for a reversal of these damaging cuts, with a funding increase of £1bn to return the public health grant to 2015/16 levels. This must be accompanied by additional investment year on year, increasing to £4.5bn by 2023/24.
Our submission to the Commission highlighted our agreement with the Baroness Lawrence review that societal prejudices are learned from an early age. We asserted that efforts to diversify the national curriculum would help with this. It would also ensure that future generations of medical students will begin their medical training with a better understanding of the diversity and history of the UK’s population.
Recognition of the differences between groups requires a new and more granular approach to data and how it is collected and use. This is something that we have called for since the start of the pandemic.
More complete and broken-down ethnicity data will enable us to understand where race is a key factor in differences. It will also enable a greater interrogation of the intersection between gender, race, colour, ethnicity and faith.