Several reports describe structural racism in the NHS. Why are people still denying this?
by Dr Rathi Guhadasan
Dr Guhadasan is Vice-Chair of the SHA, however the views represented in this piece are those of the author and do not necessarily represent the views of the SHA.
Who were the Windrush generation?
On 22nd June 1948, HMT Empire Windrush docked at Tilbury, Essex. Over 800 of her 1027 passengers were from the Caribbean, and others gave their countries of residence as India, Kenya, Pakistan and South Africa. The Windrush ship came to symbolise not only its own passengers but everyone who emigrated from the Caribbean to the U.K. between then and the 1971 Immigration Act, which gave all Commonwealth citizens who were living in the U.K. at that time the permanent right to live and work here.
Photo credit: https://microform.digital/boa/posts/category/notable-days/785/windrush-day-2024
What was the Windrush scandal?
In 2018, the U.K. Home Office admitted that it had kept no records of those given permanent residency under the 1971 Immigration Act. They had been given no paperwork to enable them to prove their status. Moreover, in 2010, the Home Office destroyed landing cards belonging to Windrush migrants. This led to many people being threatened with deportation or actually deported, despite having lived here since childhood and considering the U.K. their only home. People have also been subjected to NHS charges for treatment.
The government responded by launching a public enquiry and official compensation scheme. However, as Home Secretary, Suella Braverman dropped some of the commitments recommended by the enquiry, and the compensation scheme has been heavily criticised by claimants and campaigners, including Human Rights Watch1.
The fight for justice goes on.
We called and they came – Windrush and the NHS
On July 5th, just two weeks after the arrival of HMT Empire Windrush, the NHS was born.
76 years on, these two histories remain inextricably linked. From its inception, the NHS had thousands of nursing and other vacancies and looked to the Commonwealth for recruits. The Caribbean was an important source of recruitment then and remains so today. The NHS continues to employ children and grandchildren of Windrush, as well as thousands of other healthcare workers from around the world. Almost one-fifth of NHS staff report a non-British nationality2.
From the beginning, these workers displayed incredible compassion and resilience, in the face of extensive racism and discrimination, both in the community and within the NHS3. Our Labour movement was not exempt from this. Just 2 days after the arrival of the Windrush, 11 Labour MP’s wrote the following to Prime Minister Clement Attlee: “An influx of coloured people domiciled here is likely to impair the harmony, strength and cohesion of our public and social life and to cause discord and unhappiness among all concerned.”
Within the NHS, in addition to overt racism and microaggressions, structural discrimination affected people’s working conditions and prospects for career progression. Nurses from the West Indies were often sent to unpopular specialties, such as psychiatric nursing or working with people with learning disabilities – areas still referred to today as “Cinderella services”. They were more likely to be referred for State Enrolled Nursing, which was a lower and less transferable qualification than State Registered Nursing, leading to fewer opportunities for career development.
That structural racism which was baked into the foundations of the NHS continues to thrive today. Despite enjoying a diverse workforce for 76 years, and with almost a quarter (24.2%) of its staff coming from ethnic minority backgrounds, the Kings Fund4 reported last year that only 10.3% of very senior managers and 13.2% of board members are from ethnic minorities. Additionally,
- white applicants are 1.54 times more likely to attain jobs that they have been shortlisted for,
- staff from ethnic minority backgrounds report a lack of equal opportunities for career progression or promotion, and
- staff from ethnic minority backgrounds are 2.5 times more likely to report discrimination at work compared to white staff.
Between 2017-2020, the number of black and ethnic minority doctors increased by 21%, in comparison to a 2.4% increase in the number of white doctors; yet the former remain under-represented in consultant grade and academic positions and paid less than their white colleagues5. This discrimination starts on application to medical school, where they are less likely to gain a place, and follows them throughout their careers. Black and ethnic minority doctors do worse in examinations, Annual Review of Competence Progression, revalidation and referrals to the GMC5.
“Racism is a stain on the NHS. It damages mental health and makes existing mental illness worse. It destroys the lives of patients and colleagues.”
Adrian James, Royal College of Psychiatrists
Added to this is the strain of facing daily microaggressions, harassment and bullying at work. The outgoing president of the Royal College of Psychiatrists, Adrian James, said last year, “Institutional racism is rife in society and the NHS is not immune. We see its pernicious effects on colleagues who are leaving the NHS in droves.”6 An independent report published earlier this year and comprising data from significant tribunals and a survey of over 1300 staff from black and minority ethnic backgrounds, found that 41.8% of respondents had left jobs as a result of racism and discrimination7.
The Royal College of Psychiatrists have reported that 59% of respondents experienced racism at work. 29% of those who experienced racism at work reported impacts on their health and 41% said that it had impacted patients or carers6. When staff do report concerns around race discrimination, only about 5% are likely to find a satisfactory resolution7.
Ultimately, structural racism kills. 85% of the doctors who died from COVID-19 were from ethnic minority backgrounds8. While shocking, this is unsurprising to many who have firsthand experience of working in the NHS. A BMA study8 conducted during the pandemic reported that doctors from ethnic minority backgrounds were more likely to feel pressured to work without adequate PPE and were more fearful of recriminations for raising safety concerns.
From a public health perspective, black and ethnic minority communities still experience high mortality and morbidity rates in a range of areas, including maternal health, cardiovascular disease, diabetes and mental health. If we can’t get it right for the staff delivering the health care, how can we hope to do so for its recipients?
We owe an immeasurable debt to the Windrush generation and their children, and to all overseas workers and their descendants, who have contributed so greatly to the NHS.
Starting at governmental level, we need to see definitive measures to reduce inequalities for staff in the NHS as well as in allied institutions such as Royal Colleges and medical schools; and to reduce ethnic disparities in health and in health care. We need to see robust reporting structures where staff can feel safe to report concerns and confident that these will be acted upon. We need COVID justice for all, but in particular, we need to ensure that no minoritised staff groups or individuals take on a disproportionate burden of risk ever again.
How will the next Labour government tackle these challenges? Any credible NHS workforce plan will need to address these issues.
References
- “Who were the Windrush generation and what is Windrush Day?” BBC https://www.bbc.co.uk/news/uk-43782241
- “NHS from overseas: statistics.” Carl Baker, House of Commons Library. 2023. https://researchbriefings.files.parliament.uk/documents/CBP-7783/CBP-7783.pdf
- “You called and we came – Windrush and the NHS”. The Kings Fund. 2022. https://features.kingsfund.org.uk/windrush-and-the-nhs/
- “How it started…how it’s going: the experiences of migrants and people from ethnic minority backgrounds working in the NHS.” The Kings Fund. 2023. https://www.kingsfund.org.uk/insight-and-analysis/blogs/how-it-started-how-its-going-windrush-75
- NHS Medical Workforce Race Equality Standard 2020 (published 2021). https://www.england.nhs.uk/wp-content/uploads/2021/07/MWRES-DIGITAL-2020_FINAL.pdf
- “Racism is a “stain on the NHS” and is driving out staff, warns top psychiatrist.” Elisabeth Mahase. BMJ 2023;382:p1595 doi: https://doi.org/10.1136/bmj.p1595
- “Too hot to handle. Why concerns about racism are not heard…or acted on.” brap and Roger Kline. 2024. https://27aa994b-a128-4a85-b7e6-634fb830ed15.usrfiles.com/ugd/27aa99_4d4e620e6889408d926dad142839c0f3.pdf
- “Race inequalities and ethnic disparities in healthcare.” BMA. 2021. https://www.bma.org.uk/advice-and-support/equality-and-diversity-guidance/race-equality-in-medicine/race-inequalities-and-ethnic-disparities-in-healthcare