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Race inequality in health and care. Who’s responsible?

Our report Safer care for all  launched at a Parliamentary reception on 6 September 2022. It highlights some of the biggest challenges affecting the quality and safety of health and social care across the UK today.

With the publication of Safer care for all, we started a debate on the issues highlighted in the report and the recommendations we put forward. As part of this debate, we are publishing a series of guest blogs written by stakeholders from across the sector. This blog is from Sam Rodger, Assistant Director, Policy and Strategy at the NHS Race and Health Observatory.

The NHS is for everyone, we are told. This is the promise of our most treasured national institution. The very first principle of the NHS constitution sets out a commitment to provide a comprehensive service, available to all, irrespective of a person’s protected characteristics. More than that, the NHS constitution outlines a “wider social duty to promote equality” through the services it provides. So, whose job is it to make this a reality?


Everybody’s job

The answer we often hear is that it’s everyone’s job. We’re told that considerations about racial and ethnic equality should be a ‘golden thread’ embedded in all discussions about healthcare. We are told that every policy decision should be underwritten by an Equality Impact Assessment. We are told that every member of staff in the NHS, from the CEO to each and every clinician, should be mindful of potential health inequalities, and should work to eliminate them where they find them.

This means each GP and practice manager should be thinking about ethnic health inequalities in their local population, and that individual nurses, receptionists, allied health professionals, and other members of staff should be culturally competent. It means that commissioners should be allocating funds according to the needs of our most marginalised communities, ensuring that nobody is left out of the great promise of an NHS for all.

More recently, we are told that the newly established Integrated Care Boards will have responsibility for taking a place-based population health approach to delivering services in an equitable way. The hope is that, by joining up the NHS with Local Authorities and other providers of essential services, we will make it impossible for the needs of marginalised communities to fall through the cracks, as has so often been the case in the past.

Nobody’s job

But what is happening on the ground? Is it realistic to expect NHS leaders to give their limited time and resources to race equity when they are under significantly more pressure to cut costs and reduce waiting times? Is it reasonable to expect members of staff – usually from ethnic minority communities themselves – to give their free time to the cause of achieving race equity?

As the old saying goes, when it’s everybody’s job, it’s nobody’s job. Across the system, we see a phenomenon whereby everyone thinks someone else should be responsible for making a difference. There’s not enough money, our leaders might say, to fund the extra community engagement required to properly cater services to our most vulnerable marginalised communities. I recently met a GP who claimed they would love to spend more time out in their local community fostering trust, but that they were already struggling to keep on top of the rising demand for consultations. And perhaps there wouldn’t be such a need to build this trust at a local level if cultural competence were considered at the outset of public health campaigns.

Part of the issue is accountability. Is anyone really held to account for delivering on race equity in the NHS? It is currently possible for a trust with among the lowest scores on the NHS Workforce Race Equality Standard (WRES) to still be rated ‘Outstanding’ by the Care Quality Commission (CQC). What message does this send to Black, Asian and ethnic minority members of NHS staff? What message does it send to members of the public when leaders are not held to account for the continued poorer outcomes experienced by these communities?

In a similar fashion, the NHS announced in 2020 that each provider organisation in the NHS (including both trusts and ICSs) was required to appoint a board-level accountable lead for health inequalities. In our research on these appointments, we found a huge variation in the levels of support available to these leads, and in the amount of power they felt they had to effect change. Moreover, at a national level, it remains unclear who is responsible for ensuring that these appointments have been made, or who is responsible for holding them to account. This is particularly concerning given the lack of representation among ICS Chairs and Chief Executives.

Most concerningly of all, we have recently seen that the NHS has dropped targets in its planning guidance aimed at ensuring an organisation’s leadership reflected the racial diversity of its workforce.

Moving towards an equity culture

As we have seen repeatedly in the past, we are reaching a point where the NHS is under such significant strain that considerations about equity are becoming an afterthought. When targets around equity are forgotten, so too is the dream of an NHS that serves everyone equally and with dignity.  Exacerbating this is an increasing tendency for efforts to promote equity to be dismissed as ‘wokery’ by some media outlets and politicians.

In truth, equity should be everyone’s responsibility. It should be a fundamental tenet of every job description, policy document and target that the health sector produces. But if equity is ever to be more than a tick-box exercise, it must be embedded in a holistic framework of accountability.

For regulators, this likely means considering their internal processes first – ensuring that their fitness to practise procedures and their role in clinical education are free of bias. Then, it means considering how members of the health and care workforce are encouraged and supported to champion equity in their work, but also how they are held accountable for doing so. What, for example, is the role of revalidation and appraisal in making a difference?

Most importantly of all, we must all look beyond our individual roles and consider how each of us can contribute to a culture of equity. A culture is not just carefully chosen words, or a list of generic ‘values’ on a corporate website. A culture is formed of human interactions and behaviours. A culture is formed when people ask questions, when they listen to the views of others, when they speak out in a meeting, when they recognise their lived experience – privileged or not – may be at polar opposites from others in the room.

Accountability is the start of a journey towards health equity. But an equity culture must be the shared ambition of everyone in our health and care sector if we are to move forward.

Find out more

Read our full report Safer care for all - solutions from professional regulation and beyond  or through chapter 1 -  No more excuses - tackling inequalities. There are also shorter versions available, including the executive summary, you can download these versions here.

Find out more about the NHS Race and Health Observatory here

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Please note the views expressed in these blogs are those of the individual bloggers and do not necessarily reflect those of the Professional Standards Authority.