Talk on Racism in the NHS by Dr Aneez Esmail to Greater Manchester SHA 2000
When asked to speak about racism in the NHS I find it difficult to understand the organisation that I work in. I will explain why by describing two examples that impacted on me as a doctor working in the NHS.
About a year ago I received a letter from a hospital consultant about the death of a young Somali patient from liver failure. The letter described how the case presented and the attempts that the hospital made to try and help this unfortunate young man. He had been in this country only a few months and had arrived as a refugee from Somalia. He had family in England and settled in Manchester. Soon after arriving in Manchester he became ill and after a series of investigations that were done in primary care he was referred to hospital where it became quickly established that he was suffering from a serious liver disorder. He was given the full range of treatment, which was available to any NHS patient, by some of the top experts in the country. He was even put on the liver transplant waiting list as an urgent priority but sadly his condition deteriorated to such an extent that he died. What impressed me most about this case was the fact that he was a refugee newly arrived in this country and yet it did not affect one single bit the sort of care that he received. He was treated as a human being with a health problem and he got the best treatment that the NHS had to offer. Sadly he died but I was most impressed with the treatment he received. No one asked or considered whether he should get this treatment because he was a refugee, whether he was entitled to it or not. His needs were assessed and he was given everything that we had to offer.
The other case is the case of a young Bengali patient of mine who lived in Rusholme. She was only 26 years old and had a young child who was 4 years old. Following her first pregnancy she had difficulty conceiving and had a series of investigations carried out to determine why she was having difficulty getting pregnant the second time. As part of that investigation she was listed for a routine day surgery case called a laparoscopic examination. This involved putting a telescope into her lower abdomen to assess the state of her ovaries and her womb. It is a routine procedure and is carried out hundreds of times every day in the NHS. There is a slight risk associated with the procedure but this is well known and there are good systems in place for monitoring patients who have this procedure. This young Bengali woman was listed for such a procedure and went in as a day case to have this investigation. She did not speak very good English, nor did her husband, but she knew enough to understand what was being done and why it was being done. On the day of her day case surgery she dropped the child to school and went in for the procedure which to all accounts was uneventful. As is normal procedure she remained on the ward for a few hours and because everything was fine she was sent home with instructions on what to do if there were problems. Soon after arriving home she began to complain of quite severe stomach pain. That is the point where things started to go wrong. As instructed she rang the hospital for advice and was told that it was not unusual for people to experience this pain and she was given advice to take peppermint water and wait and see what happened. The pain did not get better and two or three hours later her husband rang again saying that his wife was very distressed and again was told not to worry and given advice what to do. Her husband was so worried that he rang her brother who lived in Rugby and who spoke much better English. I assume he thought that if someone could actually explain to the nursing staff how severe the problem was then they would perhaps take more notice of his concern. The brother caught the last train from Rugby and arrived in Manchester the same night. He rang the hospital and pleaded with them to do something about this, and yet again he was told that there was no cause for concern. Finally after pleading that his sister was really ill the hospital agreed to see her. She was admitted to hospital early in the morning and according to what the family told me was really left alone. She continued to suffer from severe pain but her examination was cursory and people as far as the relatives were concerned did not seem to take her concern seriously. This continued throughout the whole day until the evening when she collapsed suddenly and people began to take more notice of what was wrong. She was assessed by a consultant who realised the seriousness of the situation and rushed her to the operating theatre. Unfortunately she was so ill at that time that she died on the operating table. When her family was recounting the story to me when I visited them on the day that she died they said to me that even an animal would not have been treated the way she had been treated.
This is the problem I have you see. On the one hand we have the NHS dealing with a Somali refugee where the colour of his skin did not matter to anyone and he was given the best treatment available. In the same hospital we have another patient who dies in terrible circumstances. She receives an appalling level of care which I contend she received because she was Bengali. I know for a fact that if she had been an articulate white middle class patient she would never have had that treatment and she would still be alive today. So which is the NHS that I really work in?
I have spent a lot of my working life researching racial discrimination in the NHS and it is partly based on my own experience. I went to University in this country and I graduated in 1982. In my year there were about 10 ethnic minority students and to be honest we did not really think that there was going to be a problem of racism once we qualified. We were all very idealistic – the world was our oyster and we thought that we would progress and our skills would be taken into account whenever jobs were advertised and that we would have no problem reaching the top of our profession. That was our aspiration. It soon became clear to us that things were not quite so simple. The most obvious was that almost all of us had difficulty getting hospital jobs and we began to think that the real reason was to do with discrimination rather than our abilities. I knew for a fact that for every 10 jobs that my white colleagues applied for when they were wanting a junior hospital post I was having to apply for 100. And they were getting jobs much quicker than I was. I soon worked out that the best way of getting on that all important short-list was to actually go and visit the hospital, speak to the consultant face to face and say look – it’s me – I speak good English and I am applying for this job. Make sure you look at my CV. I did that because I had this notion that the reason I was not being short-listed was because that people had been looking at my name and making assumptions about whether I should or should not be short-listed.
This was confirmed to me in fact when I was doing a hospital job in Yorkshire. I got talking to the consultant one evening, when his guard was down probably, and I said to him Tell me how do you decide who you short-list for a job? and he said Oh its very simple Aneez he said I put all the foreign applications in one pile and all the English applications in another pile and I look at the English applications first and only if I do not find any suitable candidates I look at the list with the foreign names. He explained to me that I was only short-listed because I came to see him otherwise I would have been in the other pile. So it was as simple and as crude as that. This was in 1985. I have to admit that to my shame I did not do anything about it and I just carried on as normal, sort of grinning and bearing it type approach. In the meantime most of the people that graduated with me had already left the country because they felt that they were not being recognised and thought that they would stand a better chance elsewhere and in fact they almost certainly did. So the NHS lost. They trained all these doctors and they emigrated to America and Canada where they are all in quite senior positions now. They left because of the racism that operates in our system.
As for me, I became a Public Health physician and I decided that we had to do something about this. It helped that I was an active member of the Medical Practitioners Union. We devised a project that would try and actually determine whether discrimination was real or was it just that I had a chip on my shoulder. It was a very simple experiment. What we did is that we took two sets of application forms, CVs in effect, one with an Asian name and one with an English name. We constructed these CVs so that they were almost exactly the same. They were the same in terms of the age of the applicant, in terms of where the applicant qualified, in terms of their experience. The only thing that differed was the name of the applicant. We made sure that these CVs were the same because we then blocked out the name and asked independent consultants to look at them. We asked them to tell us if there was any difference between these candidates. They told us that they were exactly the same and that there was no problem or difference between them. So what we did then was we looked in the classified ads where they advertise junior hospital doctor posts and for every job that was advertised we sent one application with an English name and one with an Asian name. Of course the names were false and it was our intention that as soon as we were informed that this particular applicant had been short-listed, we would ring the hospital and say thank you very much but we do not want the job. I did this research with a colleague of mine, Sam Everington. He was the English applicant and I was the Asian applicant. Because it was an experiment we thought we would pilot it first and so we only sent off application forms to about 30 advertised posts.
Not surprisingly we found that the white applicant was twice as likely to be short-listed as the Asian applicant. Me and Sam were so cock-a-hoop about the success of our pilot that we decided that we would extend it. I took a half day off work and went home early to craft some more job applications. It was quite time consuming because every application had to be hand-written by each of us and then the typed CV was sent. I was in the process of doing the next batch of 50 when I got a phone call from Sam and he said You won’t believe what has happened – I have just been contacted by the police – they came to my front door. We can’t carry on with the study any more. I was completely dumbfounded. To cut a long story, what had happened was that someone had made a complaint against us. Because the names on the applications were false someone in their over-zealousness had decided to ask for a reference for one of these applicants, had rung up the hospital only to be told there was no such doctor working there. Apparently alarm bells began to ring and the police were informed. Soon there was a major investigation under way talking about bogus doctors trying to get jobs in the NHS. Shortly afterwards I received a phone call from the police. I of course explained to them that this was all part of a research project and it was quite bona fide and they really did not have to worry about it. However the police were not happy with that and said that they believed that we had broken the law and that they wanted to question us. I remember it very well because when I said that I would refuse to come in for questioning he just told me that I had a choice, either he would come to my home and arrest me in front of my family or I could come voluntarily. It was at that point that I realised that this was serious. Fortunately I had a very good friend who was a solicitor who put me in touch with a good firm of criminal lawyers. To cut a long story short, me and Sam were taken to the police station where we were formally arrested by a police officer and taken in for questioning in the presence of our solicitor. It was quite a harrowing experience, though, when I look back at it now I certainly can see the funnier side of it. The police believed that we had broken the law because by making fraudulent applications we were in effect denying someone else a job. This was quite amusing because our solicitor pointed out to the police officer that in fact because I was the Asian applicant I was never short-listed so I could not possibly have deprived anyone of the opportunity of getting a job! We were subsequently charged and discharged on our own bail. Four weeks later the Crown Prosecution Service felt that it was not in the public interest to prosecute us and so the case was dropped. I remember having the interview with the Chief Constable at the time and he explained to us that we were not being cautioned and we were not being charged. However if in future we were doing research of this sort we should perhaps inform the police so that they could take suitable precautions. He also told us directly that he would not be contacting the GMC since he considered the case closed. Soon after the police investigation I wrote up the paper and sent if off to the BMJ which agreed to publish it.
Around this time both Sam and I got a letter from the General Medical Council which was quite threatening. It said that they had received a complaint and that in their view they felt that we might have been responsible for behaviour which was unbecoming of the profession. After taking advice me and Sam decided we were not going to respond to them and anyway shortly after our paper was published in the BMJ and there was an almighty outcry because not only had the police stopped the first investigation but now the GMC had decided that there might be a case to answer against us. The point was made to them that of course what we were exposing was illegal activity by hospital consultants because they were discriminating against ethnic minority applicants. This did not seem to cut much ice with the GMC. The paper that we published was of course the first documented evidence that discrimination did exist in the NHS and I think that it certainly had a massive impact on this whole debate. Because of the external pressure the GMC subsequently dropped all charges against us though it did say that our names would be kept on file in case a further allegation was made against us.
It is fair to say that the GMC’s action did not endear us to them nor them to us and we decided that the next avenue for investigation should be the GMC. We had receive anecdotal evidence that ethnic minority doctors were more likely to be disciplined compared to white doctors. Of course no one kept any information on this so we decided with the help of the BBC to investigate the GMC complaints procedure. We looked back over ten years of records and identified all the cases that had come before their Professional Conduct Committee. What we found was quite amazing. Ethnic minority doctors were six times more likely to be brought before the Professional Conduct Committee of the GMC than white doctors. When we published our findings the GMC’s position was that this was nothing to do with them, that all they did was act as a clearing house for complaints. There was of course an incredible outcry about this and because of our investigation they were forced to hold an internal inquiry into the whole issue of complaints. Not only did our investigation find that there was a disproportionate number of ethnic minority doctors brought before the GMC but there are some very interesting differences in the actual charges that were laid against those doctors. That research was published in the BMJ as well and I don’t want to go into too much detail about that work, but suffice to say that the case against the GMC was quite damning as was their response to this finding. The subsequent enquiry that was headed by an academic researcher called Isobel Allen concluded that the GMC’s procedures were archaic, and that whilst the charge of racial discrimination could not be levelled against them it could also not be disproved. The GMC has now had a complete overhaul of its procedures and has agreed to ethnic monitoring of its complaints procedures. Interestingly one of the criticisms made by the GMC against us was that it wasn’t their problem because they just dealt with complaints. In fact the independent inquiry found that in terms of complaints there were no more complaints against ethnic minority doctors than there were against white doctors. The problem was that the GMC seemed to take the complaints made against ethnic minority doctors much more seriously which is why so many more cases appeared before the Professional Conduct Committee. This is important because I have also maintained that it is not the problem that the doctors that are brought before the GMC are in some ways mis-tried, it is just that I believe a lot more doctors should be brought before the GMC. My conclusion is that if you are white you have more chance of getting away with misdemeanours than if you were an ethnic minority doctor.
There are two other areas of racial discrimination that I want to highlight and in which we have carried out research. Entry into medical school is said to be one of the most difficult University degrees to get accepted into. There has been concern for some time that ethnic minority applicants are disadvantaged when applying for medical school because statistics which were released by the University and Colleges Central Admission Service showed that overall ethnic minority candidates were less likely to get accepted for a medical school place than white candidates. Of course the statistics were never provided in any meaningful way and certainly not by medical school. When we approached UCAS for these statistics we were told that they were the property of medical schools and therefore they could not release them to us. We then approached the medical schools and were told by them they were the property of UCAS and they could not release them to us. At the time Sam Everington worked for the Shadow Health team so he used their good offices to write to the medical schools. Of course they all agreed to release the data that we were asking for! One school did not so we wrote to them to say that everyone else had agreed and it was obvious who they were so they also agreed then to release that information to us. It pays to have friends in high places doesn’t it!
What we found in our analysis was that despite having the same grades as a white candidate ethnic minority applicants were half as likely to get accepted for a medical school place compared to white candidates. Previously we had been told that the reason that there was a difference between ethnic minority applicants and white applicants was that ethnic minority applicants were applying inappropriately. We were told they were pressured by their parents, didn’t get good enough grades and therefore it was obvious that not many would be accepted. Our research for the first time debunked that idea and more importantly, it produced a league table which showed that there was a huge variation between medical schools So for example at St Andrew’s in Scotland and Belfast University you were ten times more likely to be accepted for a place if you were white than if from an ethnic minority, compared, to a place like Manchester, where there was some equality. We then started out campaign to insist that this information was put out in the public domain on a yearly basis, and it was incredibly difficult. I don’t want to personalise this talk but the amount of pressure that I came under to back off was quite immense. We used all the political influence that we had as a trade union to force the medical schools to release this data and I think in the end it became obvious to the Council of Deans that they could no longer resist the legitimate concerns of people and that they would have no choice but to put that data in the public domain. They therefore commissioned their own report and released the data into the public domain. Not surprisingly their own commissioned report in fact confirmed our findings. Their own report was published in November 1998 whereas our report was published in 1995. It took three years of arguing and cajoling before they were prepared to take action. In fairness to them they have moved, and every Dean of every medical school in the country got a personal letter from the Chairman of the Commission for Racial Equality telling them to get their house in order or else they would be subject to an investigation. It was an important learning experience for us in Manchester because in fact we found that there was a possibility that we were perhaps discriminating against ethnic minority candidates. The important thing is that the whole process of looking at our admissions process, aiming to learn from the data that we collected routinely, has in fact been quite cathartic for the organisation and has made us review the whole admissions process. It is fair to say that because of this we have in fact probably made the process much more fairer and open which will only benefit all candidates and not just ethnic minority candidates.
The final area that I want to describe is our research on distinction awards. Most people don’t know that NHS consultants after an minimum of five years service are entitled to be considered for a distinction award. Aneurin Bevan set these up at the creation of the NHS. What it means is that through a process of internal review an NHS consultant is entitled to an award of up to £60,000 per annum which would bring his or her salary up to £120,000 a year for meritorious service. Don’t ask me how meritorious is defined but inevitably in such a system it is very much determined by the old boy network. And I mean boy. The end result is that about 10% of consultants receive an award, which can range from about £12,000 to about £70,000 a year, which is given for life for a contribution to the NHS over and above what, would normally be expected. Of course there are concerns in any such system about how equitable they are. People have known for some time that women consultants and ethnic minority consultants are disadvantaged when it comes to obtaining merit awards. We carried out research, again using officially produced data. It always amazes me how much data is collected and how little use is made of it. But we carried out our own investigation which showed in fact that in some specialities white consultants were over four or five times more likely to receive a merit award compared to ethnic minority consultants. This of course was political dynamite and it has brought the whole system into disrepute. I am pleased to say that following our research report, which was again published in the BMJ, the Government instituted a fundamental review of the merit award system and I think that it will no longer exist in the form that it is presently conceived. There are number other examples that I can give. I have appeared in court cases for consultants who have been given discretionary points on a pay scale because they are ethnic minority consultants and they have won their case. I have published research on showing how there is a distribution of general practitioners which means that all the plum areas where general practice is practised, for example the Home Counties and Avon and Somerset are packed full of white GPs whereas all the difficult areas like inner city Manchester, are packed with Asian doctors. This is not saying that Asian doctors do not want to practise in the Home Counties or in Avon & Somerset it is just that they do not have a chance of getting a job there. But I don’t really have time to go into all these areas.
To summarise, what I want to show you is, a picture where racism is endemic in the NHS. You can almost paint a life story from a young student who wants to do medicine filling in an application form for University and finding that he is half as likely to get a place in medical school compared to his white colleague simply because he is from the ethnic minority. Then having qualified he will find that he will be less likely to get a job. Once he is in practice he is more likely to be brought before the GMC, and even if he succeeds in getting to consultant status he will not get due reward for his work compared to his white colleague. So the picture I paint is one of racism which I think is endemic and sadly is still present in the NHS. So I come back to my two examples of the NHS – one dealing with the Somali refugee and how he got the best treatment, and the other with this poor Bengali woman who died because she received such sub-standard care. Which is the NHS I work in? Sadly I think we have a problem with institutionalised racism and it is only by confronting it and accepting that it exists will we be in a position to actually tackle it, because tackle it we must. Something like 20% of all the doctors in the NHS are from ethnic minorities. If you look at nursing and health visiting there was a time in the early 50’s when about 12-15% of the staff were from ethnic minorities. If you look now it is down to about 2 or 3%. It is down to that level because black and ethnic minority staff are voting with their feet and saying that we will not work in such an organisation. So when it is important for the NHS to recruit and make sure that people stay in the service these sort of issues have to be dealt with because if they are not dealt with then people who are good and committed to the NHS are not giving their all to that organisation. So I think we have a significant problem in this organisation and we have a long way to go before we can truly say that we have dealt with and got rid of the problem of racism.