Dr Chaand Nagpaul CBE, NHS Race and Health Observatory Board Member, GP North London, Chair of the BMA Forum for Racial and Ethnic Equality and former chair BMA Council (2017-22)
I came to the UK when my family moved from Kenya in 1968. It was a time when racism was overt in society, with signage in windows of flats to let openly stating “no blacks” and racial attacks such as “paki-bashing” were commonplace.
On this backdrop, the NHS epitomised to me the antithesis of such discriminatory behaviour, with its laudable founding value that all patients should be treated equally, based on clinical need, regardless of who they are or their background.
It is therefore all the more regrettable that the NHS is manifestly failing to deliver on this defining principle with regards to its own workforce, where staff from ethnic minorities face unequal treatment and poorer experience in their daily lives.
My first-hand experience relates to the medical profession, in which 42% of doctors are from ethnic minorities and whom I’ve represented for over 30 years at both a local and national level.
The reality of racism in medicine
Racial inequalities begin from the onset of entering medical school, with medical students from ethnic minorities four times more likely to report “often” experiencing bullying or harassment than their white peers. This is a shameful statistic upon embarking on a career which is rooted in the principle of treating people fairly. The BMA has as a result produced a Racial Harassment Charter which is now in operation in the majority of medical schools in the UK.
A major BMA survey study that I led in 2018 further showed that ethnic minority doctors continue to suffer bullying and harassment at twice the rate of their white colleagues. They were also less confident to raise concerns about patient safety, worried that they would instead themselves be blamed for systemic shortcomings.
International medical graduates (IMGs) face further disadvantage. In addition to the rigours of settling in a new country – often isolated away from their family – they have to adjust to an unfamiliar and challenging UK healthcare culture and a system under exceptional pressure with record backlogs of care. Apart from a half day “Welcome to the UK” GMC programme there is no national standardised induction– with many working in busy on-call rotas soon after arriving in the UK. This lack of adequate induction and support is cited by IMGs as a major factor impeding their performance at work and with consequent employment related difficulties.
Ethnic minority doctors face poorer career progression. They are less likely to pass postgraduate examinations – termed “differential attainment”. This is worse for international medical graduates. But what’s particularly striking is that even UK trained ethnic minority doctors have 2.5 times higher odds of failing exams compared with their white peers. This defies face validity, given that ethnic minority doctors are just as industrious, capable and with a strong work ethic. Independent analysis supports that this disparity is not due to lack of academic ability, but due to a negative learning environment, with lack of inclusivity and support given that learning is a social construct.
A study by the Royal College of Physicians showed that ethnic minority doctors are less likely to be shortlisted, and less likely to be offered senior consultant positions. A study in 2021 showed that black doctors were six times less likely to get a job in London, and Asian doctors four times less likely than white applicants.
Inevitably, this results in an ethnicity pay gap estimated at nearly £5000 difference between ethnic minority and white British doctors.
One of the most distressing experiences for any healthcare professional is to suffer complaints or disciplinary procedures. Ethnic minority doctors are twice as likely to referred to the medical regulator (GMC) and international medical graduates three times more likely. That this is due to racial bias is demonstrated by a recent study showing that anonymising cases together with scrutiny by an independent panel before a formal referral to the GMC reduces this disproportionality.
Further, once a doctor has been referred to the GMC, they are likely to suffer further racial disadvantage in their treatment and outcome, evidenced by a recent landmark employment tribunal ruling against the GMC for race discrimination.
The reality of racial inequalities amongst doctors was alarmingly epitomised during the Covid pandemic, after the first 10 doctors who died were all from ethnic minorities. Over 90% of doctors who lost their lives from Covid in the first wave were also from ethnic minorities. These stark figures defy statistical variation and are inevitably rooted in structural factors that disadvantaged ethnic minority doctors.
Weeks into the pandemic, I publicly demanded a government enquiry and urgent action to mitigate risk to ethnic minority and vulnerable doctors. Sadly, the government’s race disparity report published some months later was silent on the issue of the disproportionate deaths of healthcare workers from Covid.
However, the BMA’s pandemic tracker surveys revealed probable reasons for this disparity. Doctors from ethnic minorities were twice as likely to say they were not provided with adequate PPE in the first wave, and also twice as likely to say they felt pressured to see patients without adequate protection. There were also less likely to challenge their employer, for fear of recrimination or that it would affect their career progression. After covid risk assessments were introduced, BMA surveys showed that doctors from ethnic minorities felt less satisfied with the assessments, or that appropriate adjustments had been made.
A negative workplace culture affecting patient care
These findings depict a negative culture affecting ethnic minority doctors in the workplace. This was graphically illustrated in the BMA’s racism in medicine survey report earlier this year, with over seven in 10 doctors reporting experiencing racist incidents last two years.
Going under the bonnet, 54% of black and 46% of Asian doctors reported feeling that their clinical ability or professionalism was being doubted, compared to 6% of white British. Nearly half of black doctors and 44% of Asian doctors felt that their work was unfairly scrutinised, compared to 4% of white British. 58% of black doctors and 48% of Asian doctors reported being assumed to be in a more junior role compared to 7% of white British. Over half of black doctors and 44% of Asian doctors reported receiving derogatory comments or behaviours, compared to just 7% of white British colleagues. Over half of black doctors and 44% of Asian doctors reported feeling ignored or socially excluded at work, compared to 5% of white British.
While racism affects people of all backgrounds, these findings show that black doctors are the worst affected.
These demeaning interpersonal micro-experiences naturally take a cumulative toll on doctors, and unsurprisingly 60% reported that racist incidents had negatively impacted on their well-being, ranging from affecting their physical health to anxiety and depression.
Particularly disturbing is that more than seven in 10 respondents stated they did not report racist incidents, citing reasons that nothing would be done, that they would be considered a troublemaker or worried that their career progression would suffer. As a result, the true extent of racism is neither exposed nor tackled, and worse, doctors suffer in silence, perpetuating further deterioration in their wellbeing.
Additionally racism in medicine impacts adversely on patient care. There is evidence that incivility causes an average 61% reduction in cognitive ability and an increase in diagnostic and procedural errors. A simulated surgical scenario showed that rudeness reduced the performance of anaesthetists by almost 33%.
Racism is also directly impacting on the workforce, at a time of acute doctor shortages. 9% of doctors reported having left their jobs due to racist experiences, with 23% considering leaving. 16% reported taking sick leave or time off work. This reduction in workforce capacity will undoubtedly be jeopardising patient services and the ability of the NHS to tackle the current record backlogs of care.
What needs to change
In conclusion, there is no doubt that racism in medicine is wrecking doctors’ lives and damaging the NHS’s ability to care for patients. It should be an explicit government priority to tackle this with an action plan cascaded to every management and leadership tier in the health service, with it being a running agenda item on the boards of integrated care systems and providers.
It’s vital that there is racial literacy among all staff, recognising the structural factors that result in discrimination, inequalities, and poor experience, and the impact this has both to individuals and the organisation. It also needs compassionate and inclusive leadership – leaders who positively embrace diversity and equality, and support healthcare workers to speak out and be supported when they experience racism.
Change also requires accountability of those in senior responsible positions, from government officials through to NHS managers, health leaders and policymakers. This must be underpinned by objective measures of change, such as supportive standardised inductions for all IMGs, elimination of the ethnicity pay gap and the disparity in referrals for disciplinary processes and also ending differential attainment of ethnic minority doctors. The proposed NHS England Medical Workforce Race Equality Standards are a promising first step.
On a positive note, some NHS providers have introduced anti-racist policies, and created positive cultures of inclusion. There should be dissemination and shared learning of best practice, and systematic evaluation of training and interventions to create environments of equality and equal opportunity. We need to move to a position where we don’t only eradicate racism as a wrong—but celebrate diversity as a good and value the immense contribution ethnic minority doctors bring to our health service.
Ultimately, tackling racism in medicine is, to me, about the NHS being true to itself and abiding by its own founding principle of equality for all.