Following on from the powerful blog “After the speeches…” that outlined actions needed to reduce discrimination, we are delighted to publish a ten part blog series by Roger Kline with suggestions on how to tackle structural racism in the NHS.

At least 272 NHS staff died from COVID-19 (1). They were disproportionately of Black and Minority Ethnic (BME) heritage. Early research suggests that many of those deaths were likely due to “occupational exposure”. Many of those deaths were also likely linked to patterns of workforce discrimination.

There have been two NHS responses.

One response is a determination to improve. I met with two NHS Trust Boards recently whose Workforce Race Equality Standard (WRES) data is significantly better than the flatlining national data on recruitment and career progression. Despite their progress, both Boards said this was not good enough: we have more to do, we are determined to treat our BME staff fairly. One Trust CEO was prompted to recently write to staff saying she has “been “culpable” and “complicit” when it comes to understanding the inequality and discrimination faced by Black, Asian and Minority Ethnic people and was determined to change (2).

A different response is where action to both reduce the impact of COVID-19 on staff generally and to specifically address the cause of disproportionate impact on BME staff has been too late and too slow. No one doubts the immense effort by NHS bodies to respond to the pandemic but in some (including at least one national body and the Department for Health and Social Care (DHSC)) addressing discrimination was seen as something to be parked in the crisis, not a key issue to be addressed. According to Public Health England (PHE) researchers it was likely that 89% of NHS staff had contracted Covid 19 through “occupational exposure” (3). At one point “half of all new infections reported last week were among healthcare workers. This has now become the leading edge of the spread of the disease” (4). Fifteen weeks after the World Health Organisation declared a pandemic, Trusts had only individually risk assessed one quarter of NHS staff (5). Many Trusts have still not acted on organisational risk assessments to reduce occupational exposure.

Local NHS organisations could legitimately ask of national NHS organisations why national guidance on risk assessments was so late they each had to create their own risk assessment tools. They could ask why, if the treatment of BME staff is so important now, WRES data collection was suspended at the start of lockdown (apparently because some didn’t see it as a priority). They could ask why the track record of national organisations on race equality has been poor (6).

But to do so would be to miss the point.

Staff infected at work die, become very ill, or have to self-isolate along with work colleagues they have been in contact with. It is a patient safety issue too. 20% of coronavirus infections among hospital patients may have been caught in hospital (3), a significant number presumably from those infected staff.

This is primarily a governance failure. Staff are entitled to know their employers have taken all reasonably practicable steps to assess risks and mitigate them as required by the Management of Health and Safety at Work Regulations and the Personal Protective Equipment at Work Regulations. Had these assessments, and Equality Impact Assessments, been carried out they would have shown some groups of staff were probably at greater risk of infection than others. Even when risk assessments were started they emphasised individual staff health rather than a key cause of occupational exposure: the racialised patterns of staff treatment. That failure made doing timely individual health risk assessments so important.

Research forecast a flu type pandemic infection would especially impact on BME communities (7). Early data confirmed a disproportionate number of BME people as a result of COVID-19 (8). 20% of the NHS workforce are of BME heritage. By late April we knew that 63% of NHS staff who died from Covid-19 were from BME background, 71% of the nurses and midwives, 94% of doctors and dentists, 56% of healthcare support staff and 29% of other staff (3).

NHS England/Improvement first asked NHS Trusts to undertake risk assessments on 29^th April 2020. They published updated guidance on 28^th May and when it became clear progress was far too slow, finally issued a June 24^th data request to all NHS organisations to ensure they were indeed risk assessing “at risk groups” (9).

Trusts should have welcomed these prompts as a means of saving lives and latterly as preparation for the likely “second wave” of COVID-19. Good employers use such data to understand risks to staff well-being and prompt steps to ensure staff were safeguarded (and reduce in-hospital patient infection), especially those staff such as BME staff who might be especially at risk. Collecting data and listening to those staff (notably BME) who are at greater risk if infected should prompt preventative steps including transferring some from riskier areas whilst also reducing risks by:

• Ending the disproportionately poor provision of PPE (and fit) to BME staff
• Ensuring BME staff safety concerns are sought and heard
• Ensuring no disproportionate redeployment of BME staff into higher risk areas
• Ensuring clarity about the risk assessment and PPE of agency and contractor staff insisting their employers don’t penalise them for self-isolation
• Ensure social distancing is strictly enforced in communal areas and  meeting rooms
• Strongly encouraging regular testing of all NHS staff as now planned for care home staff
• Providing culturally sensitive mental health support to all staff, notably those from BME communities, who have suffered much higher death rates.

Unfortunately, the views that prompted suspension of WRES data collection at the pandemic lockdown remain. The view that there is now “too much emphasis on BME issues” somehow “at the expense of other staff” has silent traction. I’ve heard it myself. Yet when a house is on fire, we pay attention to that house in particular and also try to ensure it can’t happen again. The attitudes towards BME staff that have led us to the current waste of talent and disproportionate risk of death still exist in some quarters as evidenced by the recent treatment of the NHS Chief People Officer who is of BME heritage (10).

COVID-19 risk assessments, done properly, can improve staff safety and also open up better conversations with BME staff which in turn can spur organisations into the practical steps needed to accelerate workplace race equality. Many NHS leaders now accept that tackling race discrimination is crucial for the future of the NHS.

The UK’s COVID-19 healthcare staff death toll is apparently the second worst in the world (1). It is deeply regrettable some Trusts have not approached staff safety and the causes of staff deaths with appropriate urgency and focus. As a second wave approaches, national bodies are right to challenge local employers to do what their duty of care should have led them to do anyway – and to tackle the contributory discrimination as a priority.

References

1. https://www.amnesty.org.uk/press-releases/uk-among-highest-covid-19-health-worker-deaths-world
2. https://drive.google.com/file/d/1WrOmEZWmxMeT54fg4mpfuMmR4zuSQL34/view
3. Stephanie Evans, Emily Agnew, Emilia Vynnycky, Julie V Robotham The impact of testing and infection prevention and control strategies on within-hospital transmission dynamics of COVID-19 in English hospitals doi:https://doi.org/10.1101/2020.05.12.20095562 https://www.medrxiv.org/content/10.1101/2020.05.12.20095562v2
4. Anne Johnson https://www.theguardian.com/world/2020/may/03/uk-lockdown-must-not-be-lifted-until-covid-19-transmission-is-understood-say-scientists
5. https://news.sky.com/story/coronavirus-nhs-england-apologises-after-investigation-finds-only-23-of-health-trusts-have-risk-assessed-bame-staff-12015363
6. https://healthcareleadernews.com/views/the-nhs-needs-to-up-its-game-on-diversity-at-senior-level/
7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4504373/
8. https://wellcomeopenresearch.org/articles/5-88
9. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/06/C0625-risk-assessments-for-at-risk-staff-groups-letter.pdf
10. Joliffe, Tracie. Time to Speak Up: some necessary words about racism https://www.kingsfund.org.uk/blog/2020/07/necessary-words-racism

Roger Kline

Roger Kline is Research Fellow at Middlesex University Business School. He authored “The Snowy White Peaks of the NHS” (2014), designed the Workforce Race Equality Standard (WRES) and was then appointed as the joint national director of the WRES team 2015-17. Recent publications include) the recent report Fair to Refer (2019) to the General Medical Council on the disproportionate referrals of some groups of doctors (co-authored with Dr Doyin Atewologun) and The Price of Fear (2018), the first detailed estimate of the cost of bullying in the NHS, co-authored with Prof Duncan Lewis.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.