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ABC of Equality, Diversity and Inclusion in Healthcare Improve inclusion, for both patients and staff, in your healthcare environment Fulfilment in personal and professional life is facilitated by feeling able to bring one's complete self to work. The promotion of Equality, Diversity & Inclusion (EDI) and its support in the workplace is crucial to achieving this. Diverse and inclusive teams are characterised by good people management, leading to better decision-making and improved performance which staff wellbeing and patient safety depend on. Though issues including racism, sexism and homophobia have roots in wider society, they also exist across healthcare systems worldwide. They contribute to problems with recruitment and retention of staff and can make patients reluctant to access the care they need and deserve. The ABC of Equality, Diversity and Inclusion in Health summarises the key issues and the impacts on both patients and staff of excluding people from good healthcare solely on the basis of who they are. As well as considering impacts on individuals and teams, we consider also how inclusion can be improved for the benefit of everyone--all patients and all staff. Topics include: * Racism in healthcare * Women in healthcare * Sexual orientation and gender identity * Disability, disparities and ableism in medicine * Teaching equality, diversity, and inclusion in healthcare The authors are distinguished healthcare practitioners whose personal and professional lives have been enriched by the diversity of all they meet through their work and who are passionate about ensuring positive change for colleagues and patients. This book aims to contribute to important discussions about how to ensure systemic change that will enable an inclusive culture by recognising and celebrating diversity. ABC of Equality, Diversity and Include (EDI) in Healthcare is essential reading for students and professionals who want to champion inclusivity and fulfilment in a workplace environment. About the ABC series The ABC series has been designed to help you access information quickly and deliver the best patient care, and remains an essential reference tool for GPs, junior doctors, medical students and healthcare professionals. Now offering over 80 titles, this extensive series provides you with a quick and dependable reference on a range of topics in all the major specialties. The ABC series is the essential and dependable source of up-to-date information for all practitioners and students in primary healthcare. To receive automatic updates on books and journals in your specialty, join our email list. Sign up today at www.wiley.com/email
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Equality, Diversity and Inclusion in Healthcare
EDITED BY
Shehla Imtiaz-Umer
Equality, Diversity and Inclusion (EDI) Director, General Practice Task Force (GPTF) Derbyshire, UKGeneral Practitioner, Wilson Street Surgery, UKGMC Associate, UK
John Frain
Division of Medical Sciences and Graduate Entry MedicineUniversity of Nottingham, UK
This edition first published 2023
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Contents
Cover
Title Page
Copyright
Preface
Contributors
1 Why Inclusion Matters
2 The Impact of Bias in Healthcare
3 Racism in Healthcare
4 Ethnicity and Disease
5 Representation in Healthcare Training
6 Women in Healthcare
7 Sexual Orientation and Gender Identity
8 Disability Disparities and Ableism in Medicine
9 Migrants and Displaced People
10 Mental Health
11 Privilege, Power and Intersectionality in Healthcare
12 Allyship and Being an ‘Active Bystander’
13 Teaching Equality, Diversity and Inclusion in Healthcare
Index
End User License Agreement
List of Tables
CHAPTER 01
Table 1.1 Summary of Workforce...
CHAPTER 03
Table 3.1 NHS Trusts...
CHAPTER 04
Table 4.1 Changing population diversity...
Table 4.2 Diseases traditionally...
Table 4.3 Life expectancy at birth...
Table 4.4 Life expectancy at...
CHAPTER 06
Table 6.1 Barriers to women...
Table 6.3 Summary of findings...
Table 6.5 Summary of women’s...
CHAPTER 07
Table 7.1 Definitions and terminology...
CHAPTER 08
Table 8.1 Barriers to care for people...
Table 8.2 Six core competencies for...
CHAPTER 10
Table 10.1 Overview of strategies...
CHAPTER 11
Table 11.1 Tenets of...
CHAPTER 12
Table 12.1 Aspiring ally...
Table 12.2 Allyship perspective...
Table 12.3 Institutional allyship...
CHAPTER 13
Table 13.1 Strategies for...
Table 13.2 Curricular design...
List of Illustrations
CHAPTER 01
Figure 1.1 How equality relates to...
CHAPTER 02
Figure 2.1 Weathering hypothesis for early...
CHAPTER 03
Figure 3.1 Chart illustrating changes...
Figure 3.2 Percentage of staff...
CHAPTER 04
Figure 4.1 Health in migrants...
Figure 4.2 Social determinants...
Figure 4.3 Health research inclusivity...
CHAPTER 05
Figure 5.1 Added pressures...
Figure 5.2 Moscovici’s definition...
Figure 5.3 What do you see...
Figure 5.4 The impacts of...
Figure 5.5 Factors contributing...
Figure 5.6 Individual as...
CHAPTER 07
Figure 7.1 Percentage of...
Figure 7.2 Percentage of...
Figure 7.3 Percentage of...
Figure 7.4 Increase in new...
CHAPTER 09
Figure 9.1 Key health-related...
Figure 9.2 Barriers to accessing...
CHAPTER 10
Figure 10.1 Bidirectional relationship...
Figure 10.2 Sexual orientation...
CHAPTER 11
Figure 11.1 Types of privilege...
Figure 11.2 ‘Equality...
Figure 11.3 Wheel of power and...
Figure 11.4 Intersectionality. This...
Figure 11.5 Compounding, transformation...
CHAPTER 12
Figure 12.1 The process of...
CHAPTER 13
Figure 13.1 Inclusive teaching...
Guide
Cover
Title Page
Copyright
Contributors
Preface
Table of Contents
Begin Reading
Index
End User License Agreement
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Preface
In their campaign ‘Equality Matters’, the British Medical Association (BMA) describes four key values. The first of these is:
“Equality matters because it’s morally right”
The campaign goes on to describe further reasons that demonstrate why equality matters – maximising the potential of medical students and doctors, improving the performance and wellbeing of staff, and the benefits for patient care and healthcare systems. All of these are true, and there are substantial benefits for everyone, but it always comes around to the same starting point – equality and inclusion matter because they are morally right. They increase the chances of individuals and groups being able to fully be themselves, utilise their talents and fulfil their potential. Who could possibly not want that?
However, this is not the experience for many people and for many groups who find themselves marginalised not only by wider society but even by healthcare professionals and organisations within healthcare systems. There is ample evidence for this. Historical evidence but also evidence of attitudes and practices prevalent today which tell individual patients and staff ‘You are not welcome here’ or ‘You do not belong here’. We cannot be bystanders to this and simply watch the effects on others – patients who lack the confidence to access healthcare, fearing how they will be received; colleagues, often more talented than ourselves, whose path is blocked by prejudice. Improving workplace diversity entails more than just implementing policies and procedures or increasing headcount or employment quotas; it also necessitates championing the unique aspects of every employee, regardless of their background. All of us need to reflect, examine our own attitudes and take steps to make ourselves and our teams in healthcare more inclusive to ensure patient safety is not compromised.
In authoring this book, we are responding to many enquiries and suggestions from our students and colleagues about how we can make our healthcare training more inclusive and representative. This has been an enriching experience both personally and professionally. We hope this book will be an educational resource to make a positive contribution to more inclusive curriculums and conversations about equality, diversity and inclusion (EDI) in healthcare. We also hope it will increase awareness of the substantial scientific and practical contributions made to healthcare by individuals from every single background.
We are grateful for the contribution of our authors, all of whom committed to their chapters during the COVID-19 pandemic, an event which has brought into much sharper focus so many of the themes we set out to explore in this book. Though we are based in the UK and the book reflects the perspective from the NHS, we are grateful for the contribution of colleagues in the United States. From our professional conversations, we believe the themes we have explored reflect concerns in many countries and health systems worldwide.
We hope the individual reader will find this book of interest and encouragement. Equality and inclusion matter because they are morally right. As so often with doing the right thing, we all benefit personally and professionally through improved wellbeing for staff and better outcomes for our patients.
Shehla Imtiaz-Umer
John Frain
October 2022
Contributors
Diana Akpeki LLB, LLM, PGCEFinal Year Graduate Entry Medical Student, University of Nottingham, Nottingham, UK
Mohammad Rizwan Ali BSc(Hons), MResPhD Fellow in Epidemiology, Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicester, UK
Zunaira Dara BMBS, BSc(Hons), PGCertFoundation Doctor, Greater Glasgow and Clyde, Scotland, UK
Anton Emmanuel MD, FRCPProfessor and Consultant Neurogastroenterologist, UCL, UCLH and NHNN; Lead of the Workforce Race Equality Standard and Interim Joint Director of Equality, Diversity and Inclusion, NHS England, University College London Hospitals, London, UK
Anna Frain MBChB, MRCGP, PGCertGP Teaching Fellow, University of Nottingham, Nottingham, UK; Programme Director Derby Speciality Training Scheme for General Practice, Derby, UK; General Practitioner, Derwent Valley Medical Practice, Derby, UK
John Frain MB, ChB, MSc, FRCGP, DCH, DGM, DRCOG, PGDipCard, SFHEAClinical Associate Professor and Director of Clinical Skills, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
Lisa I. Iezzoni MD, MScProfessor of Medicine, Health Policy Research Center, Mongan Institute, Massachusetts General Hospital; Department of Medicine, Harvard Medical School, Boston, USA
Shehla Imtiaz-Umer BSc(Hons), MSc, BMBS, MRCGP, DRCOG, DCHEquality, Diversity, and Inclusion (EDI) Director General Practice Task Force (GPTF), Derbyshire; General Practitioner, Wilson Street Surgery, Derby, UK; GMC Associate, UK
Olivia King MSc, MBA, LLMSenior Strategy and Policy Lead, NHS England, England
Diana Lautenberger MADirector, Gender Equity Initiatives, Academic Affairs, Association of American Medical Colleges, Washington, DC, USA
Duncan McGregor BMBS, BScCore Trainee Doctor, North West School of Anaesthetics, Manchester, UK; LGBTQ+ Health Activist, Ex-Chair for GLADD – Association of LGBTQ+ Doctors and Dentists, London, UK
Habib Naqvi MBE, BSc, MSc, DHealthPsyDirector, NHS Race and Health Observatory, London, UK
Olivia O’Connell MBChB, MRCGP, DCH, DRCOG, DFSRHGP Teaching Fellow, University of Nottingham, Nottingham, UK; General Practitioner, Osmaston Surgery, Derby, UK
Oluwaseun Oluwaranti MBCHB, FWACP, MRCPsych, EMBAHigher Trainee in Forensic Psychiatry, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
James Smith MBBS, MA, MSc, MScHonorary Research Fellow, Health in Humanitarian Crises Centre, London School of Hygiene and Tropical Medicine; Médecins Sans Frontières/Doctors Without Borders, England
Sylk Sotto-Santiago EdD, MBA, MPSAssociate Professor of Medicine, Vice-Chair for Diversity, Health Equity and Inclusion, Vice-Chair for Faculty Affairs and Professional Development, Indiana University School of Medicine, Indianapolis, IN, USA
CHAPTER 1 Why Inclusion Matters
Shehla Imtiaz-Umer1 and John Frain2
1 Equality, Diversity and Inclusion (EDI) Director, General Practice Task Force (GPTF) Derbyshire, UK; General Practitioner, UK; GMC Associate, UK2 General Practitioner and Clinical Associate Professor and Director of Clinical Skills, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
OVERVIEW
Equality, diversity and inclusion in healthcare are issues of human dignity and patient safety.
They are not gifts to be bestowed by the powerful and the privileged but basic rights which should be defended and developed by everyone.
If equality and inclusion matter, they matter for everyone, and no one should be excluded.
The evidence base for healthcare in marginalised groups needs to be robust and applied in training and service delivery.
Equality is related to social justice and means fairness and opportunity for all.
Increasing inclusion is an urgent priority in ensuring the future provision of health services.
Introduction
The NHS Constitution establishes the NHS’s principles and values in England. It defines the rights patients, public and staff have, the pledges the NHS has made, and the responsibilities public, patients and staff have to one another for the NHS to operate fairly and effectively.
Behavioural science increasingly demonstrates the importance of healthcare culture in ensuring patient safety and staff wellbeing. A culture of rudeness within teams affects individual and team performance for both procedural and communication-based tasks [1]. A core value of the NHS is that ‘Everyone counts’. Unfortunately, for many patients and staff, the lived reality of this value is very different. British Medical Association (BMA) reports on racism, LGBT+ staff and students, and sexism have highlighted poor experiences for groups whose characteristics are actually protected by law (see Further resources). Sometimes, it is literally a matter of life and death (Box 1.1).
Box 1.1 A matter of life and death.
In the NHS, 63% of healthcare workers who died due to COVID-19 were from Black, Asian and minority ethnic backgrounds, 64% of nurses who died were minority ethnic, and 95% of doctors who died were minority ethnic.
Studies by the BMA and reviews by the government revealed that minority doctors were twice as likely to say they felt pressured to work in risky environments without appropriate protective equipment.
In the UK, a survey of more than 16 000 doctors by the BMA (2022) found that 48% of the respondents reported buying personal protective equipment (PPE) for personal use or using donated PPE due to a lack of supplies at their workplaces. The survey also found that 65% of doctors said they felt ‘partly or not at all protected’.
Source: BMA. How well protected was the medical profession from Covid-19? www.bma.org.uk/media/5644/bma-covid-review-1st-report-19-may-2022.pdf (accessed 25th October 2022)
Too often, we assume that values including freedom, democracy, equality, fraternity and liberty are fixed destinations at which humanity has arrived, never to look back. This is counter to the historical record and misunderstands that the need to develop and realise human rights for all is still evolving. Without continuing vigilance and commitment, freedom turns to slavery, democracy becomes a dictatorship and the inclusion of only some can lead to discrimination against others. We must all be alert in defending these values and, when necessary, active bystanders in preventing their elimination.
This book outlines historical and current priorities for equality, diversity and inclusion in healthcare. However, these are not exclusive to healthcare but values we should promote in wider society. This emphasises the healthcare professional’s responsibility not only as a worker and clinician but also as a citizen [2].
What is meant by equality, diversity and inclusion?
Diversity in healthcare reflects the range of experiences and identities of all patients and staff. It is related to the range of differences in wider society; everyone should see themselves represented at all levels. These differences include:
demographic
, e.g. gender, disability, race, sexual orientation, social class, – and/or
cognitive
, i.e. people who have different ways of thinking, different viewpoints and different skill sets in a team or department.
Wherever there are patients from ethnic minorities, there should be staff and leadership from ethnic minorities, and the same for women, the LGBT+ community, the disabled and the elderly. A responsive health service recognises and understands these differences and how they relate to individual clinical needs, not cultural or other stereotypes.
Recognising differences and protecting diversity facilitate fairness, equality and equity. Patients should feel confident to access the care they are entitled to, be listened to and have their needs properly assessed, knowing they will receive treatment according to their individual needs. Staff should feel represented in their training (see Chapter 5) and have equity of opportunity to jobs and career progression, including positions of influence and leadership (see Chapter 3). Equality does not necessarily mean treating everyone the same. It does mean creating and facilitating attitudes where people feel they can be themselves and ‘bring their whole self to any situation’. They should feel valued for both their individual talents and their contribution to the organisation.
Inclusion provides us with a sense of belonging. It is the extent to which staff or members of society believe they are valued by the community within which they live and work, receive fair and equitable treatment, and believe that they are encouraged to contribute to the effectiveness of the group. Being included allows us to release our energies by enabling us to be fully ourselves. Receiving respect increases our sense of self-esteem and gives us the confidence to speak up, to collaborate and, importantly, to raise concerns without fear of retribution. In inclusive organisations, there is [3]:
more innovation
greater employee engagement
improved problem solving
higher productivity
more sustainable and fair decision making
increased staff retention
identification of development opportunities
responsiveness in meeting the changing needs of service users
a better experience for service users.
Equality and justice
Societies and organisations prioritising equality and inclusion aspire to fairness for all – of health access, pay, housing, employment opportunities and in the courts. Social justice ensures that individuals assume roles in society and receive their due. This requires removing barriers to social mobility and increasing the availability of safety nets for the vulnerable. The roots of social justice should be deep not only in the hearts and minds of all citizens but also in the institutions and bodies that regulate society. Governments and institutions should promote co-operation and social responsibility through policies on taxation, education, health and public services, employment rights, distribution of wealth and equity of opportunity (Figure 1.1).
Figure 1.1 How equality relates to justice.
Source: © Dr Juliet Young, Clinical Psychologist, permission granted for use within this book.
The law
Given the historical and continuing injustices towards some communities, legal protection is required against discrimination (Box 1.2). In the UK, The Equality Act 2010 includes provisions that have direct implications for healthcare and serves as the legal framework for service delivery. It shapes our approach as both employers and key stakeholders in the system.
The Equality Act 2010 identifies nine protected characteristics:
age
disability
gender reassignment
marriage and civil partnership
pregnancy and maternity
race
religion or belief
sex
sexual orientation.
The Human Rights Act 1998 protects people’s human rights in the UK and enshrines the European Convention on Human Rights articles in British law. Protection is given against discrimination, harassment and victimisation (Box 1.2).
Box 1.2 Definitions.
Direct discrimination
Someone is treated less favourably than someone else due to a protected characteristic, e.g. an employer refusing to recruit a woman over a man who is less qualified for the role is sex discrimination.
Indirect discrimination
When a rule or policy that applies to everyone puts a certain group at a disadvantage, e.g. a job advert for a ward sister says applicants must have spent 10 years working in the role. By doing this, the department could be discriminating indirectly based on age because younger people are excluded.
Discrimination by association
Direct discrimination towards an individual because they are associated with someone who has a protected characteristic, e.g. an employee is overlooked for overtime because they care for an elderly relative.
Discrimination by perception
Direct discrimination against someone because others perceive they have a protected characteristic even if they don’t, e.g. refusing to work with someone with an Arabic name because you wrongly assume they’re Muslim.
Harassment
Unwanted conduct that has the purpose or effect of violating a person’s dignity or creating an intimidating, degrading, humiliating or offensive environment, e.g. a senior member of staff who makes sexual remarks or invitations to a younger member of staff.
Victimisation
Where someone is treated badly because they have made or supported a complaint under the Equality Act, e.g. a member of staff who has spoken up about an incident of religious discrimination and is then ostracised for having done so.
Why do equality, diversity and inclusion in healthcare matter?
Workforce
The NHS People Plan, published in July 2020, requires us to look after each other, foster a culture of compassion, inclusion and belonging, take action to grow our workforce, train our people and work together to deliver patient care. It outlines how the workforce can act with integrity, intelligence, empathy, openness and in the spirit of learning.
As COVID-19 has highlighted, we live in a society where patterns of discrimination and inequality dominate life chances, health status, education, housing, justice and employment and are influenced by our protected characteristics and birth class. Such factors significantly affect who is hired, how they advance, how they are treated and whether they continue their NHS career. Unfortunately, data on class and some other protected characteristics are lacking about recruitment, career progression and retention (Table 1.1) [4,5].
Table 1.1 Summary of Workforce Race Equality Standards (WRES) from 2016 to 2020.
2016
2017
2018
2019
2020
Relative likelihood of White applicants being appointed from shortlisting across all posts compared to BME applicants
1
1.57
1.6
1.45
1.46
1.61
Relative likelihood of BME staff entering the formal disciplinary process compared to White staff
2
1.56
1.37
1.24
1.22
1.16
Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months. White staff shown in brackets
3
28.4 (27.5)
28.5 (27.7)
29.7 (27.8)
30.3 (27.9)
28.9 (25.9)
Percentage of staff who personally experienced discrimination at work from a manager, team leader or other colleagues. White staff shown in brackets
14.0 (6.1)
14.5 (6.1)
15.0 (6.6)
14.5 (6.0)
16.7 (6.2)
Percentage of BME staff believing that trust provides equal opportunities for career progression or promotion. White staff shown in brackets
4
73.2 (87.8)
71.9 (86.8)
69.9 (86.3)
71.2 (86.9)
69.2 (87.3)
This table shows the various trends in data which reflect challenges in discrimination faced by staff from colleagues as well as members of the public.
1White applicants were significantly more likely than BME applicants to be appointed from shortlisting.
2In 50% of NHS trusts BME staff were more than 1.25 times more likely than White staff to enter the formal disciplinary process. There has been a reduction in the likelihood to be referred for formal disciplinary processes.
3Since 2015, a higher percentage of BME employees has been harassed, bullied or abused by patients, family or the general public than White employees. In 2020, it is still higher for BME staff (28.9% compared to White staff – 25.9%) The recent decline could be due to the impact of the COVID-19 pandemic, which reduced the amount of face-to-face contact between patients or service users and those providing NHS care.
4This is now at its lowest point since 2015.
Source: www.england.nhs.uk/wp-content/uploads/2022/04/Workforce-Race-Equality-Standard-report-2021-.pdf (accessed 24th October 2022)
Critically, not ensuring equality, diversity and inclusivity within the workforce can impact patient care and become a safety issue. Data have repeatedly shown adverse patient outcomes due to discriminatory practices within the workforce (see Chapter 3).
Despite collecting national data over several years in secondary care to understand the disparity within the workforce, there has been little sustained positive shift in workplace experiences for racial equality [6]. Discrimination experienced by NHS staff originates from both patients and colleagues. Whilst the focus on race discrimination has been challenged, the emphasis has been placed on this specific aspect as the dataset repeatedly demonstrates that discriminatory racial practices negatively impact patient outcomes [7].
While over 90% of patient consultations occur in primary care, there is no equivalent annual survey to understand the breadth and depth of discriminatory practices in general practice. Local teams have taken the initiative to understand the issues facing their workplaces. Every GP team undertaking a workforce survey has identified racial, ethnic or religious discrimination (see Chapters 2 and 3) (Box 1.3).
Box 1.3 Experiences of discrimination in non-hospital services in England [8,9].
The WRES (Table 1.1) does not cover primary care personnel or wider medical and dental personnel, even though over 60% of general practitioners (GPs) are people from a Black or ethnic minority background.
The first comprehensive primary care workforce survey was undertaken in London by NHS England and Health Education England in 2022, after smaller, local surveys were completed in areas including Humberside, Derbyshire and Leeds.
‘Experiences of racial discrimination and harassment in London Primary Care’ data showed that race was the most common characteristic associated with harassment and discrimination, above gender, age, religion and disability. Of those surveyed for the study:
1 in 3 reported racial discrimination or harassment from patients in the past 12 months (30%) and about 1 in 5 from staff they worked with (18%)
People from Black and Asian heritage groups were most likely to say they had experienced racial discrimination or harassment from patients and colleagues.
‘Unconscious bias is sewn into the fabric of the NHS. Very junior, inexperienced White colleagues were invited to senior positions … Relevant experience with additional qualifications is discarded if you are non-White … Ethnic minorities are there to do the coal face work whilst White colleagues get promoted to managerial and strategic roles.’
(Quote from GP participant in the study)
Source: Experiences of Racial Discrimination and Harassment in London Primary Care, 2022 www.hee.nhs.uk/sites/default/files/documents/Pan-LondonDiscrimination%26RacismPrimaryCareSurvey_Final.pdf
(accessed 25th October 2022)
Improving workplace diversity entails more than just implementing policies and procedures or increasing headcount or employment quotas; it also necessitates championing the unique aspects of every employee, regardless of their background, and actively calling out discrimination (see Chapter 12).
This includes examining how we recruit, retain and develop our workforce and how we support their wellbeing. It requires an assessment of how representative our leadership teams are and whether our workforce data reveal any disparities in representation based on any of the nine protected characteristics outlined in The Equality Act 2010.
When staff are not welcomed, their differences are not valued and there is no safe place for them to raise concerns or admit mistakes, patient care suffers. However, demographic diversity supported by inclusion can significantly improve creativity, innovation and productivity.
Patients
The NHS seeks to reduce health inequalities and discrimination against patients and staff. People become ill as a result of discrimination. For over two decades, we have known that aside from socioeconomic effects, both experiences of racial harassment and perceptions of racial discrimination make an independent contribution to health [7]. For example, those who are verbally harassed have a 50% greater chance of reporting fair or poor health than those who have not been harassed [7] (see Chapter 2). Racism is a recognised social determinant of health and contributes to ethnic health disparities.
Race discrimination is associated with a range of adverse outcomes, including coronary heart disease, worse maternal and neonatal outcomes, high blood pressure, lower birth weight, cognitive impairment and mortality. Additionally, in witnessed out-of-hospital cardiac arrest, Black and Hispanic persons are less likely than White persons to receive potentially lifesaving bystander CPR (see Further Resources). Discrimination, like other stressors, can have an impact on health through both actual exposure and the threat of exposure to discriminatory practices. Feeling excluded increases the risk of depression and psychological alienation, as well as poor cognitive functioning, impaired motivation and poor physical health (see Chapters 6, 7 and 10). The desire to belong is a strong human motivation.
By extrapolating the experiences of racial discrimination to other protected characteristics, we can begin to understand the cumulative effect of these discriminatory practices on the health outcomes of many marginalised members of our society, including women and the LGBTQ+ community. These groups are ideologically assigned a different value, which leads to disparities in power, resources and opportunities. This intersectional identity can lead to the observed differential in privilege and power happening at both structural and individual levels (see Chapter 11).
Ageism
A protected characteristic shared by all is age. We are all mortal yet even here, there is inequality of experience. The healthcare impacts of ageing include effects on: [10]
healthcare seeking behaviour
diagnosis and treatment recommendations
internalised beliefs about ageing producing weakness and dependence on others
attitudes and reduced respect towards older patients
dismissing patients’ symptoms as ‘just old age’.
This can affect women disproportionately, and they may be refused more aggressive treatments due to perceived increased frailties [10]. Ageism may intersect with other marginalised identities, including gender, race and sexual orientation. Black patients with dementia were more than twice as likely to contract and die from COVID-19 than White patients [11]. Ageism affects the LGBT+ community, who report difficulties establishing social spaces and accessing healthcare, housing, social service and legal assistance. This affects those more who have felt less able to disclose their sexuality at a younger age [12].
Religious discrimination
We live in a society with an ever-expanding and diverse mix of religions and beliefs, which NHS organisations must consider when developing both public services and employment policies. Even within established religions, there are different branches and regional and sectional variants with different interpretations, rituals, moral guidelines, traditions and laws. Personal compliance can range from nominal to strict adherence. Furthermore, many people have strong feelings about not having a personal religious belief.
Additionally, research has revealed differences in the health and wellbeing of various religious communities, which provides an opportunity to target services. For example, the British Muslim community has the worst reported health, followed by the Sikh population. Females are more likely to report illness in both groups, as well as Hindus, whereas Christians and Jews have only a minor gender difference. It should be noted that this is not always a case of cause and effect but is more likely to be influenced by other factors such as the social determinants of health (see Chapter 4) [13].
The pandemic also highlighted the importance of providing faith-specific guidance in a culturally and linguistically specific context [14]. The success of this work has highlighted the importance of understanding the challenges faced by faith groups in accessing healthcare (Box 1.4).
Box 1.4 Faith-specific health inequalities review.
Low immunisations, high COVID-19 rates, and increased breast cancer risks – some of several health inequalities disproportionally found amongst Jewish communities in England. The NHS Race Health Observatory is undertaking a review to better understand the barriers to healthcare faced specifically by the Jewish community. The wide-ranging review will aim to include several factors, including the impact of communication in the following areas:
Hospital food for patients.
Difficulties with booking appointments, including on the sabbath and during religious festivals.
Poor experience due to staff educational/cultural incompetency.
Experience and impact of antisemitism from staff, patients or members of the public.
End-of-life care, including care of the bereaved.
Challenges in making use of trusted sources of health information from within the community.
Source: NHS Race Health Observatory. 2022. www.nhsrho.org/news/new-review-to-examine-health-inequalities-in-jewish-communities (accessed 25th October 2022)
The impact of religious discrimination must also be considered in the context of the workforce. Religious beliefs can profoundly affect how employees do their jobs. Because so few studies collect data on people’s faith, research on the intersection of religion and the workplace is scarce. Since 2016, all doctors who register with the General Medical Council (GMC) for the first time are asked to provide information about their sexual orientation, religion, or belief, and whether they are disabled (Box 1.5) [15].
Box 1.5 Number of licensed doctors in 2021 by religion.
Source: General Medical Council. The state of medical education and practice in the UK: The workforce report 2022. www.gmc-uk.org/-/media/documents/workforce-report-2022---full-report_pdf-94540077.pdf (accessed 24th October 2022).
The lack of any significant empirical research in this area indicates a critical gap in our understanding of workplace religious discrimination. A workforce analysis by the King’s Fund showed that people from all religions report experiencing discrimination based on their faith. Still, reporting is by far the highest among Muslims (Box 1.6) [16]. Staff belonging to any faith group continue to report discrimination and harassment (BMA, 2022 – see Further reading).
Box 1.6 Religious discrimination in the NHS.
Overall discrimination is reported most by Muslim (22.2%) and Hindu (19.4%) staff, compared with staff of no religion (10.0%). Reported discrimination on the basis of religion is highest by far among Muslims (8%), followed by those of other religions (all religions not including Christians, Muslims and Hindus 1.9%), Hindus (1.3%), Christians (0.4%) and staff of no religion (0.2%).
Muslims and Hindus also report a far higher rate of discrimination on the basis of ethnic background.
Source: West, M., Dawson, J. and Kaur, M. (2015) Making the difference. Diversity and inclusion in the NHS. The King’s Fund. www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Making-the-difference-summary-Kings-Fund-Dec-2015.pdf (accessed 24th October 2022).
Specific workplace policies can result in reduced access to career opportunities due to religiously discordant practices such as ‘bare below the elbow’ and a ban on wearing hijab in theatres. The lack of whole-system engagement in overcoming these barriers has resulted in some healthcare-related faith groups, such as the British Islamic Medical Association, having to innovate and provide religious-specific solutions to the issues faced by their colleagues [17]. Muslim doctors report discrimination within dress code policies, and the Prevent policy fostered an institutional culture of fear and mistrust of Muslim colleagues. Notwithstanding the imperative of patient safety and infection control, solutions still need to be negotiated respectfully and be inclusive of everyone. The experience of Muslims is not unique – the King’s Fund report [16] highlighted that Hindu colleagues also experience higher rates of discrimination based on their ethnic background, demonstrating the impact of having intersectional identities.
Religion should be considered in the drive for equality and diversity to ensure that healthcare systems are truly inclusive and compassionate for both staff and patients.
Improving the evidence base
Being fully inclusive is not just about having visual changes. These changes are relatively straightforward but unless there is better inclusion of content and evidence in policy, education and training reflected in the attitudes of all patients and staff, visual change only risks being perceived as tokenism. Whilst inclusive and visible diverse leadership is critical, there also need to be a cultural change and system shifts to ensure that people of all backgrounds can progress through their chosen careers. It is only by being authentic and compassionate that there will be an improvement in not only health but also social equity.
The research base of equality, diversity and inclusion needs urgent improvement. The misconceptions about ethnicity and disease (see Chapter 4), women’s health (see Chapter 6), LGBT+ healthcare (see Chapter 7) and mental health (Chapter 10) need to be corrected (Boxes 1.7, 1.8, and 1.9). These include issues around:
the social determinants of health
presentation of symptoms in women
the experience of accessing healthcare by LGBT+ patients
mental health in patients and staff with protected characteristics.
Box 1.7 Impact of colonialism.
The disease profile for non-communicable diseases, particularly type 2 diabetes (T2D), is on the rise in South Asian countries [18], with disparities between people of European ancestry compared to South Asian ancestry being particularly stark [19]. The differences in the prevalence of T2D between Europeans and South Asians have been postulated to be linked to lean free mass (muscle and organ mass), with ethnic-specific differences consistently reporting lower lean mass for South Asians compared to other ethnicities [20,21].
These differences in lean body mass could be a key signal for why Asians are more likely to develop T2D compared to their European counterparts. An adaptation to the many famines that were experienced in the nineteenth and twentieth centuries, which led to increased mortality, may have contributed to the selection pressures on genes [22]. This meant that these genes allowed the excess storage of calories, allowing South Asians to survive periods of famine adequately, yet increased body weight compared to their height. This postulated adaptation shows that global weather patterns and, more recently, racist and colonial policies may have led to generational negative health consequences for South Asians for developing T2D.
Box 1.8 Race correction in obstetric algorithms.
An example in obstetrics is the vaginal birth after caesarean (VBAC) score. This algorithm identifies that non-White mothers have a lower likelihood of success than White mothers. However, ethnicity is not incorporated into the algorithm, and non-White women have higher caesarean section rates than White women. Given the increased morbidity associated with caesarean section, using a score that underestimates successful birth outcomes for ethnic minority mothers is striking, given the up to fivefold increase in mortality seen in non-White mothers.
Source: Vyas, D.A., Eisenstein, L.G. and Jones, D.S. (2020) Hidden in plain sight – reconsidering the use of race correction in clinical algorithms. New England Journal of Medicine, 383(9), 874–882.
Box 1.9 Regulatory inequalities due to patient demographics.
‘We have a much younger population compared to … nationally, and […] the majority of these patients have English as a second language. Our CCG as a whole has the second highest proportion nationally of [Black and Ethnic Minority] patients (I think). Our population is much more deprived with some of the highest incidences of [Serious Mental Illness], with double the national prevalence of type 2 diabetes. Many of our newly registered patients have only recently arrived in the UK, mainly from Romania, Afghanistan, Iraq and Iran. These patients have massively complex needs – either due to not having access to healthcare for many years, mental and physical health issues due to their traumatic experiences, poverty and different health beliefs due to cultural factors.’ (Quote from GP, London, in Care Quality Commission 2021 report on minority-led general practice services)
Source: Care Quality Commission (2022) Ethnic minority-led GP practices: impact and experience of CQC regulation. www.cqc.org.uk/publications/themed-work/ethnic-minority-led-gp-practices-impact-experience-cqc-regulation (accessed 25th October 2022)
What does the future hold?
There has to be political will and recognition of ongoing issues, but we must move from reports and analysis to positive action. One recent development is the NHS commitment to investigating racial inequalities for the first time [23]. Unfortunately, at the time of writing, the Secretary of State for Health had shelved plans to publish a White Paper on the stark health inequalities exposed by the COVID-19 pandemic.
Both the UK’s GMC and BMA have incorporated into their core documentation specific guidance for professionals and patients on the need for better care for all patients. They are also providing leadership in ensuring that the needs of marginalised groups such as LGBT+ and migrants are better addressed (Box 1.10).
Box 1.10 General Medical Council – LGBT patient guide.
Your rights as lesbian, gay, bi and trans patients
All patients must be able to trust doctors with their lives and health. They should all be treated with dignity and respect, regardless of their sexual orientation or gender identity.
This guide explains the standards that lesbian, gay, bi and trans (LGBT) patients should expect from their doctor; what we’re doing to support LGBT patients; and information about organisations that provide advice or advocacy services.
Source: General Medical Council. LGBT patient guide. www.gmc-uk.org/ethical-guidance/patient-guides-and-materials/lgbt-patient-guide (accessed 25th October 2022)
Discriminatory incidents occur daily, and there needs to be more understanding about how one can address these instances. There are steps we can take within our spheres of influence, even if that is a single interpersonal interaction; everyone has the potential to change the outcome of a possible discriminatory experience. Chapter 12 outlines the importance of being an ally and how to be an active bystander, which we hope our readers will be able to implement immediately (Box 1.11).
Box 1.11 I saw … but I did not speak out.
I saw a Black patient being refused adequate pain relief
And I did not speak out
Because I am not Black
I saw a Gay colleague being denied a job opportunity
And I did not speak out
Because I am not Gay
I saw a junior female colleague being harassed
And I did not speak out
Because I am not a woman
I saw a disabled patient who needed workplace adaptations
And I did not speak out
Because I am not disabled
I saw a Transgender patient being ridiculed
And I did not speak out
Because I am not Transgender
I saw someone unable to keep their religious observance
And I did not speak out
Because I am not religious
I saw a talented Asian nurse denied a leadership position
And I did not speak out
Because I am neither Asian nor a nurse
I saw an elderly man being spoken to like a child
And I did not speak out
Because I am not elderly
Then I needed someone
To speak up for me
But I had not enabled anyone to help me
Source: Adapted from Pastor Martin Niemoller, ‘First they came’ (1946)
However, there are changes we can make within our organisations and educational institutions. Chapter 13 provides valuable guidance on how we can better train future colleagues.
Content of this work
It is outside the scope of this book to address each protected characteristic in detail. We have introduced key concepts and historical context to the issues identified as perpetuating discriminatory experiences within the workforce but also, more worryingly, against our patients. This is not to diminish the experiences of other protected characteristics; we have attempted to ensure all are mentioned.
Terminology is important and particular terms, including proper pronunciation of names, is valuable in signalling respect to a person. We recognise there is ongoing debate regarding the use of ‘BAME’, ‘ethnic minority’, LGBT+ and terms of reference to communities containing various cultures. We have not requested our authors to use particular terms but let them use the terminology with which they are most comfortable.
Conclusion
Our ability to provide comprehensive healthcare is currently in jeopardy. The most important resource – the people in it – is being squandered, with problems in both recruitment and retention. Addressing equality, diversity and inclusion is vital in remedying this. How urgent is this? In the extreme. How soon should we start? Yesterday would have been ideal; tomorrow will be too late. Today is the time. These problems are made by human beings, so we can solve them by being bigger than who we are or believe ourselves to be.
‘Change will not come if we wait for some other person or some other time. We are the ones we’ve been waiting for. We are the change we seek.’(Barack Obama)
Further reading/resources
Civility Saves Lives.
www.civilitysaveslives.com
(accessed 26th October 2022)
BMA (2016) The experience of lesbian, gay and bisexual doctors in the NHS. British Medical Association.
www.bma.org.uk/media/4225/bma_experience-of-lgb-doctors-and-medical-students-in-nhs-2016.pdf
(accessed 26th October 2022)
BMA (2022) Racism in medicine. British Medical Association.
www.bma.org.uk/media/5746/bma-racism-in-medicine-survey-report-15-june-2022.pdf
(accessed 26th October 2022)
BMA (2021) Sexism in medicine. British Medical Association.
www.bma.org.uk/media/4487/sexism-in-medicine-bma-report.pdf
(accessed 26th October 2022)
Department of Health and Social Security (1980)
Inequalities in Health: Report of a Research Working Group
. London: Department of Health and Social Security.
Garcia, R.A., Spertus, J., Girotra, S., et al (2022). Racial and ethnic differences in bystander CPR for witnessed cardiac arrest.
New England Journal of Medicine
,
387
(17),
https://www.nejm.org/doi/full/10.1056/NEJMoa2200798
(accessed 27th October 2022)
NHS East of England (2021) No more tick boxes: a review on the evidence on how to make recruitment and career progression fairer.
www.england.nhs.uk/east-of-england/wp-content/uploads/sites/47/2021/10/NHSE-Recruitment-Research-Document-FINAL-2.2.pdf
(accessed 26th October 2022)
NHS People Plan 2020–21.
www.england.nhs.uk/ournhspeople
(accessed 26th October 2022)
Strategic Review of Health Inequalities in England post-2010 (2010)
Fair Society, Healthier Lives: The Marmot Review
.
www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review/fair-society-healthy-lives-full-report-pdf.pdf
(accessed 27th October 2022)
West, M., Dawson, J. and Kaur, M. (2015) Making the difference. Diversity and inclusion in the NHS.
www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Making-the-difference-summary-Kings-Fund-Dec-2015.pdf
(accessed 26th October 2022)
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