Covid-19: Many trusts have not done risk assessments for ethnic minority staff, BMJ investigation findsBMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m2792 (Published 10 July 2020) Cite this as: BMJ 2020;370:m2792
Some NHS trusts in England are yet to complete covid-19 risk assessments for their staff from ethnic minority groups more than two months after the NHS first told them to do so, an investigation by The BMJ has found.
On 29 April NHS England’s chief executive, Simon Stevens, wrote to all NHS leaders telling them to carry out risk assessments and make “appropriate arrangements” to protect ethnic minority staff,1 amid growing evidence that they were at greater risk of contracting and dying from covid-19.
This was followed by a mandate to all hospitals on 24 June to complete risk assessments within a month,2 after a review by Public Health England had reiterated the need to risk assess ethnic minority staff.3
The BMJ asked England’s 140 acute care trusts for details of risk assessments they had carried out and what subsequent actions they had put in place. Seventy trusts responded (response rate 50%). Of these, 27 (39%) said that assessments were yet to be completed for all ethnic minority staff, and 43 (61%) indicated that assessments had been completed.
But the other 70 trusts were unable to provide a response within the 20 day deadline, citing “unprecedented challenges” posed by the covid-19 pandemic, so it is not known what stage they are at in risk assessing staff.
The findings come after a recent BMA survey of almost 7500 UK doctors in which more than a third (36%) of ethnic minority respondents said that they were not aware of any risk assessment in their place of work.6
Commenting on The BMJ’s findings, Chaand Nagpaul, the BMA’s chair of council, said, “Clearly, we know that a significant number of doctors have not been risk assessed. It is a shame that it has taken so long, because the risk assessments and mitigations would have been most useful and impactful during the peak of the virus.”
Finn O’Dwyer-Cunliffe, policy adviser on workforce at NHS Providers, which represents trusts, said, “Progress is increasingly being made, but more needs to be done, and there is obvious urgency here as well.”
A spokesperson for NHS England and NHS Improvement said, “We have been clear that trusts, as the legally responsible employers, should carry out risk assessments for their black and minority ethnic staff and other at-risk groups in line with publicly available protocols. They have been asked to ensure these are complete and to publish their progress in doing so, and if any member of staff believes they are being unfairly denied one they should raise this within their trust and be listened to.”
Caught off guard
Nagpaul said he believed that the NHS had been “caught off guard” when data first began to emerge of the disproportionate effects of covid-19 on ethnic minority staff. “The NHS was not prepared for this. There was no readymade template on how to risk assess, and there was a delay before NHS providers were given explicit central directives and information on what they needed to do,” he said.
O’Dwyer-Cunliffe added, “Trusts are used to undertaking risk assessments in partnership with their staff, but it’s fair to say that more support and more detailed tools were needed across the board than many had at their disposal in March and early April.”
Nagpaul wrote to NHS England on 28 April asking for a national risk profiling tool to help employers conduct risk assessments. NHS Employers subsequently signposted trusts to several risk scoring tools at the end of May.7
While Nagpaul praised trusts such as Somerset NHS Foundation Trust and United Lincolnshire Hospitals NHS Trust, which developed their own risk assessment tools and responded proactively (box 1), he said a “ single national” tool for the whole country would have provided greater consistency.
“Staff felt very supported”
Somerset NHS Foundation Trust was praised by both the BMA and the British International Doctors’ Association for being the first trust in the country to include all ethnic minority staff in the vulnerable and at risk group for covid-19,8 and for writing to all relevant staff in April offering them opportunities to discuss their concerns.9 Sunny Sander-Jackson, black and minority ethnic network lead at the Somerset trust, said, “I have been receiving many more calls and emails from BAME colleagues since the letter from our executive team went out to them. They have told me that they have felt very supported during this difficult time and that the letter had a real impact in helping to lift their morale.”RETURN TO TEXT
“Even now that we have the tools, many have been unclear as to which tool to use, and that further delays matters,” he said. “Different trusts are using different tools, and some give different results compared with others.”
Ramesh Mehta, president of the British Association of Physicians of Indian Origin (BAPIO), said that feedback from members indicated that the process of organising risk assessments was “very slow” and varied considerably from trust to trust.
Some trusts have said they found it hard to communicate the availability of assessments to staff.
O’Dwyer-Cunliffe said that early on there were some delays in identifying which staff needed risk assessments, partly because ethnicity is self-reported in NHS trusts. He added that larger trusts spread across different sites, and those with a high proportion of ethnic minority staff, “have experienced greater delays in completing all assessments, in large part due to the practicality of getting around thousands of staff in particular places.”
He added, “Trusts have really needed to listen to and respond to feedback from their staff so that they could offer reassurance in the face of some staff’s fears of being redeployed away from the frontline unnecessarily, facing unfair barriers to development or progression because of this, preferences to remain in the same location or with the same colleagues, and in some cases fears about visa issues.”
He said that trusts had put a “huge focus” on giving managers guidance and support on how to have potentially sensitive conversations with staff. “In some areas it has taken longer [than others] bringing those facets together,” he acknowledged.
Systemic race inequalities
Doctors’ leaders have suggested that systemic race inequalities in the workplace may have exacerbated delays in risk assessing staff. Nagpaul said, “The BMA survey found that doctors from a BAME [black, Asian, and minority ethnic] background felt under more pressure to see patients without adequate protection. So it does beg the question of whether there’s also been this added factor of BAME healthcare staff feeling unable to demand their right to being assessed and protected.
“This is something the NHS needs to tackle. This is an issue that predates covid. It’s vital that we have an NHS where anyone is able to voice their concerns. No one should have to suffer or have fear in silence.”
Mehta said there remained a “fear” among ethnic minority staff of raising concerns. “Saying and doing is different. Some trusts are not walking the talk,” he said.
Nagpaul emphasised that risk assessments were not an “end in themselves” and that subsequent mitigating action to protect staff was crucial.
Trusts that responded to The BMJ described measures such as redeploying staff to lower risk areas in the hospital, allowing them to work from home, ensuring they were prioritised for the highest level of personal protective equipment, and adjusting their working hours so they could avoid public transport or travelling in rush hour (box 2).
Mitigating measures being offered to protect ethnic minority staff
Redeployment to hospital areas with lower risk of infection
Using technology such as video to deliver care to patients
Removing staff from on-call rotas
Allowing certain procedures to be delegated to other staff
Shielding at home
Working from home
Adjusting working hours to avoid rush hour traffic or public transport
Adjusting the work environment, such as creating separate offices and not using shared telephones
Building new staff areas to make social distancing easier
Offering wellbeing support and voluntary health checks
Providing free vitamin D supplements
Prioritising staff for covid-19 swab testing
Providing additional PPE for staff and for patients during interactions with staff
But because some trusts began to risk assess ethnic minority staff only in June, measures have taken time to emerge in some cases.
Mehta pointed to feedback from BAPIO members that, in some areas, a lack of high grade PPE had prevented some staff from being redeployed. “The majority of staff who have mild to moderate risk could work on the front line if they were given proper equipment,” he said.
O’Dwyer-Cunliffe acknowledged that redeployment opportunities “aren’t limitless,” given workforce capacity constraints, but said there was an opportunity for neighbouring trusts to coordinate how staff could be redeployed across different organisations within their area.
“We have to make sure we’re in a position where those next steps are beneficial for the staff themselves and for the service as a whole,” he said.