I’ve known about the major findings of the BMA survey on disability for a few weeks, and I’ve thought about the implications many times. In 2019 3.6% of the non-clinical and 2.9% of the clinical workforce (excluding medical and dental staff) declared a disability through the NHS Electronic Staff Record. I became physically disabled in early adulthood, like some, and have had to learn and make reasonable adjustments to the way I might work. The BMA survey results are shocking but not surprising. The results from the annual assessment of the NHS Workforce Disability Equality Standard (WDES) also make for depressing reading. Headline findings from the 2019 WDES annual report include: disabled people are less likely to be appointed, disabled staff are more likely to experience harassment, bullying and abuse, and disabled staff are 7.4% less likely to believe that their trust provides equal opportunities for career progression or promotion, compared to non-disabled staff. The publication of the results of the BMA survey coincides with the end of the first wave of a pandemic, where disabled individuals in London have been described in the ‘Inclusion London’ report as struggling to access medicines, experiencing increased levels of distress, and even worried about the effects of alleged clinical rationing on them. Disability, both physical and mental, is important, and a significant number of the patients in NHS Practitioner Health identify as ‘disabled’. Any condition is considered a disability if it has a long-term effect on your normal day-to-day activity and this includes a range of mental health conditions alongside the more obvious physical disabilities.
The gamut of policy sensitivities around disability in the NHS is reflected even in the sensitivities around the language concerning disability. Some individuals (like me) prefer to be known as “disabled people”, to identify with the notion that they are actively disabled by society, but others prefer the term “people with disabilities”, highlighting the fact that they are ultimately ‘people first’ [1].
The relevance of disability to the NHS
Disability is not, in any conceivable way, a trivial issue in the NHS. Many bright disabled individuals are dissuaded from progressing in a career in medicine. Likewise, disabilities, if undetected, can potentially lead to problems; medical students and foundation trainees are not yet formally or ubiquitously screened for dyslexia [2]. A superficial knowledge of the lived experience of people with disabilities damages the quality of the “doctor-patient relationship” and subsequent medical treatment, and any experience of disrespect, lack of sensitivity and devaluation can lead to patients with disabilities forming negative views of healthcare providers [3]. Negative attitudes to disability in medical education, training and workplaces must be challenged, as the new BMA survey identifies. Disabled doctors have unique needs, including disability leave, and thus need both sympathy and expertise from their colleagues and managers. The recommendation of a fundamental review of these policies from the new BMA survey is highly welcome.
There can, unfortunately, be significant gaps in knowledge regarding support for medical trainees [4]. The medical regulator, General Medical Council, can be congratulated hugely for its contribution ‘Welcomed and valued’ concerning the regulation of disabled doctors in the workforce [5]. It suggested, a primary reason for the lower participation rates and underemployment of individuals with disabilities is that employers world-wide often have very negative views, sometimes involving outright stigma and prejudice about the work-related abilities of disabled individuals [6]. It is saddening, that this new BMA disability survey has identified that there exists a widespread belief that medicine does not have a disability-inclusive culture.
Experiences of disability in the NHS
It is staggering that, in this new BMA survey, many respondents have had experiences of disability-related bullying or harassment and, indeed, this appears more prevalent at senior levels. Some “bad behaviour” in the NHS towards disabled doctors is not formally captured by proven offences in the Equality Act [2010], such as victimisation or harassment. The term ‘microaggression’ was coined in 1970 to describe subtle dismissals and insults towards certain Americans of colour [7], but the use of the term ‘microaggression’ is expanding in scope and is now used to describe snubs, slights and insults towards members of other marginalised social groups including women, and disabled individuals [8]. For example, when a member of a non-dominant group (e.g. a physically disabled shopper in a wheelchair) is ignored by a retail associate who instead attends to a member of the dominant group (e.g. a person who appears able-bodied) who arrived much later.
In reality, the degree to which a local NHS organisational culture is ‘disability friendly’ has a huge effect on the interaction of certain individuals with that organisation. Take for example, the issue that a person’s disability could be described as ‘hidden’ (discussed in much greater depth in a preliminary report by the NUJ). This could be because such individuals with ‘hidden disabilities‘ or ‘invisible disabilities‘ may have decided not to disclose their disability to the institution, possibly for fear of discrimination, or they may not consider that their impairment or condition is a disability (and so may not have been in contact with any available disability service), or indeed because the disability appears to fluctuate. A common challenge that individuals with disabilities encounter in entering the workforce is deciding whether, when and how to disclose their condition and request workplace accommodations, which are so important and can help to improve work participation while supporting well-being. Non-disclosure could lead to eventual unemployment, unsafe working conditions, and could affect job performance [9]. We now know from this BMA survey that many disabled doctors and medical students struggle to get the adjustments they need and are entitled to and that many are reluctant to reveal what may be “hidden” disabilities related to long term mental health conditions.
The critical imperative is therefore how to catalyse a “disability inclusive culture” without delay. “Disability champions” have an important role to encourage employers to audit and improve disability policies and offer independent advice and guidance on disability issues to employees. The concept of “disability champions” is not new. What is of concern, however, is that in recent research they report greater influence on employer willingness to conduct disability audits and to amend and improve employer equal opportunities practices with regard to disability than employer willingness to make reasonable adjustments [10]. The new BMA survey suggests a streamlining of processes for reasonable adjustments, including funding and engagement of occupational health services in a timely and constructive way. This is very much welcomed. One important adjustment is the provision of “flexible leave”. A key finding of this BMA survey was that workplaces and medical schools do not pay sufficient regard to the realities of living and working with a disability or health condition.
Intersectionality
The findings about intersectionality from this new BMA survey really struck me hard. White disabled doctors and medical students reported a more supportive environment than disabled doctors and medical students who are from non-white backgrounds. It is convenient to think of discrimination in the various protected characteristics as separate and divisible, partly because the law of direct discrimination under the Equality Act frames it that way in relation to a legal comparator (where the victim does not have multiple protected characteristics). This therefore mandates a ‘joined up’ approach with evidence from elsewhere, such as historic analyses over ethnicity and the NHS by the BMA [11].
Conclusion
If we are to enable those living with disabilities and working (or aspiring to work) in the NHS to feel valued, we need to do much better. A joined-up approach to examine deep-seated structural and functional problems within the NHS would be worthy of a NHS ‘people plan’, would it not?
References
[1] Shakespeare T, Iezzoni LI, Groce NE. Disability and the training of health professionals. Lancet. 2009;374(9704):1815-1816.
[2] Cullen J, Darby L, Rahmani M. Dyslexia: an invisible disability. Br J Hosp Med (Lond). 2019;80(8):426-427. doi:10.12968/hmed.2019.80.8.426
[3] Dungs S, Pichler C, Reiche R. Disability & Diversity studies as a professional basis for diversity-aware education and training in medicine. GMS J Med Educ. 2020;37(2):Doc23. Published 2020 Mar 16.
[4] Vogel, L. Major gaps in supports for medical trainees with disabilities CMAJ May 2018, 190 (20) E632-E633
[5] GMC report: Welcomed and valued, https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/welcomed-and-valued (accessed 8 August 2020].
[6] Bonaccio, S., Connelly, C.E., Gellatly, I.R. et al. The Participation of People with Disabilities in the Workplace Across the Employment Cycle: Employer Concerns and Research Evidence. J Bus Psychol 35, 135–158 (2020).
[7] Sue DW (2010) Microaggressions and Marginality: Manifestation, Dynamics, and Impact. New Jersey, USA: John Wiley & Sons.
[8] Barber S, Gronholm PC, Ahuja S, Rüsch N, Thornicroft G. Microaggressions towards people affected by mental health problems: a scoping review. Epidemiol Psychiatr Sci. 2019;29:e82. Published 2019 Dec 16.
[9] Lindsay S, Osten V, Rezai M, Bui S. Disclosure and workplace accommodations for people with autism: a systematic review [published online ahead of print, 2019 Jul 7]. Disabil Rehabil. 2019;1-14.
[10] Bacon, N, Hoque, K. The influence of trade union Disability Champions on employer disability policy and practice. Human resource management journal, 2015, vol 25(2), pp. 233-249.
[11] Singh D. Racism rife in the medical profession, BMA report says. BMJ. 2003;326(7404):1418.
Dr Shibley Rahman
Dr Shibley Rahman is currently a special advisor in disability for the NHS Practitioner Health. He still actively researches in dementia and delirium predominantly, having successfully completed his Ph.D. from Cambridge. After his junior medical hospital posts, he became physically disabled, but he completed in London successfully his MBA (with a special interest in performance management) and his Master of Law (with a special interest in equality and discrimination).
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.