Addressing racist parents in a paediatric setting: the nuance of zero tolerance policies
BMJ 2021; 375 doi: https://doi.org/10.1136/bmj.n3067 (Published 13 December 2021) Cite this as: BMJ 2021;375:n3067
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Dear Editor,
While this opinion piece attempts to address an important topic of racist abuse of healthcare staff in a paediatric setting, there are serious concerns that arise about its framework which are illustrated in the examples below.
Example 1. Harmful and contradictory language
The authors chose to present a fictitious example where a parent with a child requiring emergency care is requesting a 'white doctor' and the authors suggested that the situation may 'require temporary accommodation of a parent’s racist preferences'.
The choice of language i.e 'racist preference' is extremely reductive, because the incident described in the opinion piece meets the UK Crown Prosecution Service definition of a racist crime.
"Any incident/crime which is perceived by the victim or any other person to be motivated by hostility or prejudice based on a person's race or perceived race"[1]
It is racist abuse and falls under the definition of verbal abuse which is categorised as violence by the Health and Safety Executive (HSE) and British Medical Association (BMA ). [2,3] From the perspective of violence, it is then very clear that what should follow is not 'temporary accommodation' but instead safeguarding of staff under the NHS standard of zero tolerance to violence.
The authors at the conclusion of the opinion piece state that 'Racism is never acceptable.' Unfortunately, they have provided a very harmful contradiction within the piece that in their words justified the 'temporary accommodation' of racist abuse. It is disappointing additionally that the peer reviewers did not challenge this contradiction.
Example 2. Bias and lack of ethical considerations
The scenario presented in the opinion piece where a parent with a child requiring emergency care is requesting a 'white doctor' is heavily biased because it assumes that the emergency care for the child can be provided by other healthcare staff present. It is important to recognise this bias because there are other potential outcomes with serious ethical/safety implications for staff and the patient that could also occur from this scenario but were not considered by the authors. For example:
-what happens if the healthcare professional who is receiving racist abuse from the parent is actually the person best placed to provide the emergency care
-what happens if there is no other qualified person immediately available e.g lone workers
-what happens if the next qualified person available is also a minoritised healthcare professional who would also be subjected to racist abuse, is this ethically acceptable?
If the healthcare professional is being hindered in a manner that compromises the safety of a child, the person doing the hindering should be the focal point of interventions, not the healthcare professional attempting to do their job.
Example 3. Failure to address existing racism within the NHS
The premise of the article is 'the lack of clear protocols for responding to and reporting racism in paediatric settings' and the authors then go on to 'suggest the key principles that healthcare professionals and organisations should follow in response'. However, there is no real attention to organisational involvement beyond mentioning the legal obligations of employers and a statement on organisational leadership.
The NHS itself as an organisation has systemic and institutional racism that may greatly impact the process of establishing anti-racist guidelines. In essence, the question is - How well can guidelines against racial discrimination be created and implemented within an environment where racial discrimination is active?
I pose this question because racial discrimination within the NHS is at an all time high according to the NHS staff survey 2020 ( 'a record 8.4% of NHS staff reported discrimination from managers and colleagues' ) [4] . In a direct mirror of where a patient requests a 'white doctor', some hospitals are actively choosing to exclude non-white doctors during hiring to the extent that one London Hospital received 418 applications from Black doctors and hired none in 2021. [5] This form of institutional racism has repercussions e.g
-Some of the people showing bias against non-white doctors during hiring are the very same people who may be present and expected to corroborate incidents of racist abuse. Would they be biased during an incident of racist abuse as has been documented? [6]
-Would the resulting guidelines from this environment of systemic and institutional racism be effective or does it not mandate that the environment must be changed in tandem with the formation of guidelines?
Example 4. Stakeholder consultation
It is not clear who was consulted (beyond the named authors and acknowledgments) for this opinion piece but it would be insightful to know if any Black doctors or healthcare staff were consulted. The reason for this is that Black doctors experience the brunt of racial discrimination and this is present at medical school (e.g disregard and under-reporting of racist incidents by medical schools) [7] and right through to working life in NHS from both patients and colleagues. [4,5]
So it is an open question, how many Black doctors were consulted for this opinion piece? How many Black and minoritised people were involved in the formation of the suggested 'guidelines' in the 'A way forward' section?
Example 5. No discussion of safeguards for staff
This opinion piece has a section titled, 'A way forward' which gives a loose set of potential measures to deal with racist abuse in a paediatric setting. However, it is not a critical assessment as it does not illustrate the possible safeguarding issues that may arise. For example it is well known that minoritised doctors are referred to the General Medical Council (GMC) at a higher rate, are more likely to be investigated and receive more punitive sanctions which may impact their career progression. [7,8]
When a minoritised doctor is racially abused and takes action according to existing (or future) guidelines on violence there is a very real possibility of individual harm via being reported to the GMC even with no merit. There is a real possibility too of the racist incidents not being recorded or reported by senior staff as has happened before [6,7], leaving the minoritised doctor in a precarious position in terms of having no one else to corroborate their account.
In order to have effective guidelines a wide stakeholder consultation must happen and the issue of safeguards for the Black and other minoritised staff must be present within the guidelines
Conclusion
In conclusion, the lack of critical assessment in this opinion piece is a key problem. It is my suggestion for the authors that any future work includes opinions and experiences from a large number of minoritised staff (mandatorily including Black doctors) and have extensive organisational involvement (surveying relevant staff, assessment of staff knowledge of racist abuse, assessment of effectiveness of current NHS zero tolerance guidelines for deterring racist abuse, addressing systemic racism within the NHS, working with external anti-racism consultants) that will broaden the discourse and create a set of guidelines that are evidence based, safe, effective, measurable, adjustable and continuously monitored while reducing the burden on minoritised healthcare staff.
References
1. CPS- https://www.cps.gov.uk/legal-guidance/racist-and-religious-hate-crime-pr...
2. BMA - https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/cre...
3. BMA- https://www.bma.org.uk/media/4569/2021-arm-resolutions-day-1-am.pdf
4 NHS staff survey 2020 - https://www.nhsstaffsurveys.com/static/afb76a44d16ee5bbc764b6382efa1dc8/...
5. BMJ 2021;375:n2460
6. BMJ 2017;359:j5178
7. BMJ 2020;368:m420
8. BMJ 2020;368:m530
Regards,
Dr. Ruby Zelzer, PhD
Competing interests: No competing interests
Dear Editor
This article [1] yet again reminds us about the ugly clinical dilemmas created by racist patients and parents. A specific case of parental racism was highlighted in this journal in 2014 [2] and I applaud Nadeem Moghal for his fearless expression of facts and opinions therein.
It would be convenient for some to hide behind the rights of an unwell, mentally incapacitous child in order to acquiesce in racially motivated requests of parents, and prima facie, this could be seen as being complicit in overt racism. However, I would like to think, it is not the case right across the NHS, and the individual rights of BAME healthcare staff are respected as suggested by the authors[1]; but my own experiences, and attitudes of some colleagues, indicate that overwhelming majority of overtly racist requests (of patients and parents) are honoured at some point; Moghal is case in point [2].
Indeed, it would be interesting to know on how many occasions the NHS has formally challenged overtly racist patients and parents through formal legal processes and/or assisted mentally injured victim-employees to pursue claims individually. Similarly, one wonders how many times, there have been any meaningful safeguarding interventions (with transparent consideration of rights of BAME staff) or in the extreme, urgent intervention of the Court of Protection sought when dealing with highly determined racist parents.
I previously cited an EAT judgment [3] to support my contention that racism is still downplayed in the NHS and hitherto, there are no signs that things would improve in the near future despite the much trumpeted concept of ‘zero tolerance’.
Like Moghal has done[2], I urge all healthcare professionals, BAME doctors in particular, to speak out about their own personal experiences of racism fearlessly so the real ferociousness of racism in the NHS can be exposed to a greater level.
References
[1] BMJ 2021;375:n3067
[2] BMJ 2014;348:g265
[3] https://www.bmj.com/content/367/bmj.l6425/rr
Competing interests: No competing interests
Dear Editor
We thank Kayode Oki for his response to our article, Addressing racist parents in a paediatric setting: the nuance of zero tolerance policies. We regret that the example used toward the end of our piece was interpreted as pandering to racist parents – this was not our intention and we are surprised that it was read in this way. We describe a range of potential responses to racism expressed by parents, including immediate de-escalation and statements that the view expressed is not acceptable, through to the potential for safeguarding procedures to be invoked if the resistance to accepting care meets the threshold for neglect, right up to criminal sanction. We agree that NHS organisations need to work to develop more meaningful operational policies to tackle racism in all its forms.
In our example of an acutely unwell child, where the extremity of the behaviour of the parent or carer is such that the initial healthcare professional cannot safely access the child to provide care, we do seek to expose the extreme tension between the right of the child to access care and the right of the healthcare professional to provide that care in safety and dignity. Where both cannot be achieved, despite maximal attempts at de-escalation, including the presence of security chaperones, we reach the uncomfortable, yet in our view inescapable conclusion, that the rights of the child to access emergency, life-saving care are paramount. This is not pandering to racism, this is fulfilling primary moral, legal and professional obligations to seriously ill children. We as the authors hold the view that were such an extreme situation to occur, then at least the threshold for child neglect would have been met, and that it would be likely that a hate crime had been committed, requiring involvement of the criminal justice system. We do not regard the potential involvement of the criminal justice system for hate crimes as “pandering” to racist parents or ignoring the dignity of health workers. It is precisely the tension between the rights of all health professionals to be treated with dignity and the rights and interests of extremely ill children that makes the scenarios we describe so challenging. The only plausible alternative response to the scenario would risk the life of the child, which in our view would be professionally intolerable.
We suggest one potential algorithm for operationalising our approach here (reference 18 in our piece), How should we deal with racist carers? - Don't Forget the Bubbles (dontforgetthebubbles.com).1 This is “clear tangible action”. Medical schools and healthcare providers could begin teaching it today. The RCPCH have already commented that it is welcome to see “recommendations presented on how real change can be achieved”2 and are engaging with us further. We already have a potential test site to implement our algorithm. None of this would have happened if our paper hadn’t been published and we are grateful to The BMJ for having the courage to stand up to racism alongside us. We welcome further debate on this topic.
1. https://dontforgetthebubbles.com/how-should-we-deal-with-racist-carers/
2. https://www.rcpch.ac.uk/news-events/news/rcpch-comments-article-bmj-addr...
Competing interests: No competing interests
Dear Editor
Whilst feeling a deep sympathy with Kayode Oki's concerns, I did feel they, Bishop et al, have set out fairly and comprehensively the issues.
For me, the central issue is "how to best deliver care to an innocent sick child?".. of racist Parents..
I suggest Kayode re-read the article, which does in my view answer his question "why" this was published.
The question was also extensively debated back in 2014.
Competing interests: No competing interests
Dear Editor,
I am deeply concerned by the conclusions of this article. The authors make interesting and valid comments on the rights of the parents, child and health care workers. However, I cannot help but feel very little tangible actions have been put forward to tackle racism in the NHS. To put it simply, the conclusion simply offers a scenario in which it is okay to pander to racist parents.
The status quo already excuses, accommodates and privileges racism. Do we really need to explicitly be given a scenario in which the dignity of healthcare workers can be ignored?
The final paragraph starts with "Racism is never acceptable". This feels very empty as no suggestions were made on what policies can be put in place to empower staff. No suggestions were made on what needs to change in organisational leadership. Instead, it enables racism. One has to ask, "what new information has been added to the literature by publishing this article?" . In the current climate where racism within the NHS is rife, I cannot help but feel it is deeply irresponsible of the journal to publish an article that gives organisations a reason to not take their responsibility for their employee's dignity at work seriously.
Kind regards,
A concerned, Black, soon-to-be Doctor
Competing interests: No competing interests
Re: A critical assessment is necessary to establish effective guidelines
Thank you Dr Ruby Zelzer for your comments - they have helped advance this debate by exploring the nuance of how to apply the broad principles set forth in our article to healthcare specifically, as well as tackling racism more generally. Whilst we were constrained by the word count for our piece, your letter stands usefully alongside it as an addition for those looking for a deeper exploration of the practical challenges of implementing zero tolerance policies, as well as wider reflections on the problem of racism. I’ve ensured your rapid response was read by all the authors of the article.
Thank you for emphasising how Black voices are essential in this debate. Having only had lived experience within my own ethnic group, I fully acknowledge that my experience is not Black lived experience.
To answer your question in regards to whether any Black people were specifically involved in this paper: we had two Black people contribute a particularly significant amount: one who read the whole article immediately pre-submission and discussed it over a one hour Zoom call - this included how they wanted to be credited (which was as part of the EDI group), and guidance for substantial revisions of the final piece, including deleting a whole section that they helped us realise wasn’t a good fit. Additionally, The BMJ had this piece peer reviewed by three individuals before accepting it, with one reviewer identifying themself as Black in their peer review comments.
More broadly, this article was merely one opinion piece, which we were advised to put out by those involved in policy (which included a Black person) for the very purpose of encouraging debate from many diverse voices, which I’m pleased you’ve participated in.
We were later invited to comment on the BMA guidelines in this area, which now mirror many of our recommendations.(1) We had no say over the final content of the BMA guidelines; doctors from all ethnic backgrounds were consulted for it, including Melanin Medics and the BMA forum for race and ethnic equality.(2)
I am happy with how the BMA’s guidelines now support me as a paediatrician, and have, for the first time, given trade union backing to firmly tackling racist parents, whilst also considering the wellbeing of a child. RCPCH, NHS England, and the GMC are also keen to consider this area further.(3) Policy may change in the future as the debate continues, but I now feel more empowered in my personal practice to stand up to racist parents than in my last decade or so working in paediatrics.
Thank you again for sharing your perspective through both your expertise and your lived experience as a Black individual. I acknowledge that Black voices are often under-represented in policy and academia, and I am committed to continuing to work collaboratively with Black individuals.
I’m glad we both can contribute to the shared knowledge that helps advance the debate to challenge the evil of racism. We may disagree on the specifics of how to challenge racism, but we both recognise the need to move to an anti-racist society.
Thank you again for writing in. I’m happy to continue this conversation privately or via further letters.
1) BMA. How to deal with discrimination from patients March 2022. Available from: https://www.bma.org.uk/media/5144/bma-guidance-on-how-to-deal-with-discr...
2) Qureshi Z, Suleman M. Bringing diverse voices together. March 2022. Available from: https://www.bma.org.uk/news-and-opinion/bringing-diverse-voices-together
3) RCPCH. RCPCH comments on the article in the BMJ on addressing racist carers and parents in a paediatric setting. December 2021. https://www.rcpch.ac.uk/news-events/news/rcpch-comments-article-bmj-addr...
Competing interests: No competing interests