Intended for healthcare professionals

Rapid response to:


Addressing racist parents in a paediatric setting: the nuance of zero tolerance policies

BMJ 2021; 375 doi: (Published 13 December 2021) Cite this as: BMJ 2021;375:n3067

Rapid Response:

A critical assessment is necessary to establish effective guidelines

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

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.

1. CPS-
2. BMA -
3. BMA-
4 NHS staff survey 2020 -
5. BMJ 2021;375:n2460
6. BMJ 2017;359:j5178
7. BMJ 2020;368:m420
8. BMJ 2020;368:m530

Dr. Ruby Zelzer, PhD

Competing interests: No competing interests

04 March 2022
Ruby Zelzer