Intended for healthcare professionals


NHS doctors face racism, exclusion, and discrimination, report finds

BMJ 2014; 349 doi: (Published 31 July 2014) Cite this as: BMJ 2014;349:g4960
  1. Matthew Limb, freelance journalist, London, UK

The NHS, with its highly ethnically diverse workforce and a specific focus on people’s health, ought to be an exemplar for staff wellbeing, but this is far from the case, a study has found.1

Experiences of racism, exclusion, and discrimination contribute to low levels of wellbeing among black and other minority ethnic (BME) groups, including staff in the NHS, the study report said. A decade on since the NHS Race Equality Plan, “there is little evidence of progress in achieving its goals,” the report said. Far from being an exemplar, “the NHS helps to illuminate the impact and consequences of lower wellbeing as well as specific drivers for differences in wellbeing between different ethnic groups.”

The report, published last month, was written by Mala Rao, professor of international health at East London University, and Jacqui Stevenson, an expert in gender equity and human rights. “The need to address racism and discrimination within the NHS is incontrovertible,” they said.

Their research examined a range of literature on ethnic disparities in wellbeing and included interviews with NHS staff, clinicians, and senior leaders and a summary of a roundtable discussion. It highlighted ethnic discrimination in the NHS recruitment process and cited research by BMJ Careers showing that white doctors were almost three times as likely to be successful in applying for hospital jobs as doctors from ethnic minorities.2

The research by BMJ Careers showed that black or black British applicants were the ethnic group least likely to secure hospital doctor jobs (2.7% success rate), followed by doctors of mixed ethnicity (3.5%) and Asian and Asian British doctors (5.7%). White doctors were more likely to be shortlisted for jobs and to be appointed to roles once they had been shortlisted.

The report also highlighted a lack of ethnic diversity on NHS boards and in leadership roles. Although BME people make up 45% of London’s population and 41% of the capital’s NHS staff, just 8% of NHS trust board members and 2.5% of chief executives and chairs are from these groups. That picture is broadly reflected nationally, Rao and Stevenson said.

Nigel Crisp, a former chief executive of the NHS who worked on the NHS Race Equality Plan, which was developed in 2004, told researchers that the plan had achieved some successes. But he said that there were also limits to what had been achieved, particularly on improving BME representation at senior levels. Under-representation affected staff morale and this in turn “inevitably” affected the care of patients and outcomes, he said. “This is a health issue and not just an equal opportunities one,” he said.

The study cited data from the Health and Social Care Information Centre on the ethnic composition of the NHS workforce. These data show that an “ethnic gradient” exists, with BME staff being represented in larger numbers at lower pay grades and in lower status roles among medical and non-medical grades of staff, Rao and Stevenson said. Overall, ethnic minority NHS staff felt pushed towards less popular specialisms and roles and found routes of progression “closed off,” they added.

Aneez Esmail, a professor of general practice at Manchester University who has studied discrimination against doctors, told the researchers that many BME staff members were, at one level, pleased to get secure jobs. “At another level, they see themselves in dead end jobs which other people don’t want to do. And that invariably impacts on their assessment of the NHS as an employer and the ability of the NHS to offer them job satisfaction,” he said.

Rao and Stevenson said that barriers to progression were identified by “all study participants” and that the effects, with discrimination seen as a major driver, were “significant and pernicious”. They were particularly concerned that “no assertive action” seemed to have been taken to eliminate under-representation in applications or the lower likelihood of BME staff to secure clinical excellence awards, despite this under-representation being reported as a problem year after year. They pointed out that BME women faced the “dual disadvantage of gender and ethnicity,” which again had not been adequately tackled.

The study also found that BME staff faced “disproportionate” rates of complaints and disciplinary actions. It highlighted problems of racist verbal and physical attacks, bullying, and harassment. “The links between race, racism, and complaints, and the impact that has on staff both directly affected and those aware of such incidents and made insecure by them, were highlighted at the roundtable [discussion],” the researchers said.

“Experiences of actual or perceived discrimination, barriers to progression and other inequalities are broadly agreed to have an impact on staff wellbeing.” It was “broadly accepted” that there was a link between the wellbeing of staff and the care and outcomes patients received, they added.

Carol Baxter, who leads on NHS equality and diversity for NHS England, told the review, “In those areas in which staff report harassment and bullying, patient experience is worse.” She added, “I think the NHS knows that happy staff means happy patients, but what the NHS needs to do more of is to find out the things that are making staff unhappy and to look more at the unconscious biases that exist with the services that make BME staff unhappy. That is a harder nut to crack: they know in theory, but addressing the solutions is where the challenge is at right now—the knowledge is already there.”

Umesh Prabhu, medical director at Wrightington, Wigan and Leigh NHS Foundation Trust, told the researchers that staff wellbeing and the prevalence of racism and discrimination had a direct effect on patient safety. Poor leadership, a culture of bullying, and discrimination created an atmosphere that was not conducive to people admitting mistakes or raising concerns, he said.

The study said that the experience of BME staff was a “good barometer” of the climate of respect and care for all in the NHS. The researchers said that urgent action was needed to ensure equality in recruitment, career progression, and rewards and recognition.

“The NHS must undergo a cultural change to increase understanding of and commitment to equality and diversity, with a focus on the benefits of diversity to staff, patients and the NHS system,” they said. “This must include all levels and branches of the NHS system as well as the wider medical community including the General Medical Council and the Royal Colleges.”

They also called for better training and induction programmes for BME staff recruited from overseas, improved NHS leadership, and systematic analysis and reporting of data by the NHS on the extent of ethnic differences in the quality of care. In addition, they said that more research was needed on the potential effects and determinants of inequalities in wellbeing.

Yvonne Coghill, who leads on inclusion and coaching for the NHS Leadership Academy, spoke at the launch of the report at the House of Lords. She said that training in equality and diversity had been of “variable quality” and must be improved. “It raises antibodies in people—they don’t want to engage,” she said. “It doesn’t change hearts and minds or get people to change behaviour.”

David Prior, who chairs the Care Quality Commission, welcomed the report and said that there was a clear correlation between good care and staff engagement. The CQC would look to see how issues raised in the report could be dealt with, such as in the process of inspection of hospitals and general practices, he said.