Is the NHS institutionally racist?

The explanation for the disproportionate number of black and minority ethnic (BAME) doctors being referred to the General Medical Council (GMC) for fitness to practise concerns may be the result of poor induction, inadequate support, and unhelpful feedback, according to a recent GMC report.

Between 2012 and 2017, 1.1% of BAME doctors were referred to the GMC compared with 0.5% of white doctors. Doctors who qualified outside the UK are 2.5 times more likely to be referred to the GMC compared with UK graduates (1.2% compared with 0.5%).

The ‘Fair to Refer’ report is based on interviews and focus groups, with 262 people including GPs, locums, specialty and associate specialist doctors, and consultants from different ethnic backgrounds – including a mixture of those from overseas and the UK.

The report, commissioned by the GMC, found a combination of factors could explain the disproportionate referrals of BAME doctors. Some doctors who are new to the UK or the NHS have inadequate induction or lack support when they first arrive. Another problem is that BAME doctors – whether new to the NHS or not – do not always get effective, honest, or timely feedback which could have helped to prevent subsequent problems. The report says some clinical and non-clinical managers avoid or defer difficult conversations, particularly if they are of a different ethnic group to the doctor.

The report also says that some working and contractual patterns leave doctors isolated, meaning they lack exposure to learning experiences and resources. In addition, some groups of doctors are treated as ‘outsiders’, which creates barriers to opportunities and makes them less favoured than ‘insiders’ who experience greater privileges and support.

The report also says that some organisations have a culture that looks to find an individual to blame when something goes wrong, rather than investigating the system in which he or she works, or trying to learn from the mistake so it doesn’t happen again.

Charlie Massey, Chief Executive of the GMC, said: ‘We want to avoid doctors being referred to us for problems that can be resolved earlier locally. We want patients to get the best possible care, which is best delivered by doctors working in supportive and inclusive surroundings.’

The report makes four key recommendations:

  • Improve support for doctors new to the UK or the NHS, or whose role is likely to isolate them;
  • Ensure engaged and positive leadership more consistently across the NHS; 
  • Create working environments that focus on learning, rather than blame, when something goes wrong; 
  • Develop UK-wide mechanisms to ensure delivery of these recommendations.

What are your views? Do you believe that there are significant elements of institutional racism embedded within the NHS? If so then what should be done?

Comments (5) Add yours ↓
  1. Krishna Patil Consultany Urologist

    ” Fair to refer” report is fair in many respects! It clearly recognises that there is a problem in referring Doctors to the GMC. It also identifies that disproportionate numbers of black, asian and minority ethnic (BAME) doctors are referred to the GMC. The report tries to search the possible reasons for this disproportionate numbers. The report also makes four robust recommendations.

    Self awareness gives one to learn from mistakes as well as successes. It allows one to progress. System awareness is bigger picture of self awareness. It allows the system to learn from its mistakes and successes.
    Now that we know where the fault lies we should focus on those weakness. We should also identify the reasons as to why White/Uk trained doctors are less likely to be referred. Learn from their practice.
    One to one mentoring of the BAME and overseas doctors will be very helpful for developing Non-technical skills in overseas doctors in which they lack.
    Implementing the recommendations of the ” The Fair to Refer” report UK-wide will be the key.
    All the medical professional bodies like Royal colleges, RSM, BMA and BAUS should work together towards a good cause.

    July 2, 2019 Reply
  2. David Sellu Hon Consultant Surgeon

    When Sir William McPherson published his seminal report in 1998 into the death of the black teenager Stephen Lawrence, who was murdered by racists in Eltham in 1993, he branded the police and the Crown Prosecution Service (CPS) as institutionally racist(1). “The investigation (of the death) was marred by a combination of professional incompetence, institutional racism and a failure of leadership by senior officers,” Sir William concluded. It was hoped that the 70 or more recommendations he made would signal the end of a pervasive and pernicious culture in one of our major public services. Sadly there is no evidence that I know of that is the case today.

    Those of us subjected to racism on a day-to-day basis knew it was not just the police and the CPS that were institutionally racist. It has come as no surprise therefore that another major public service, healthcare, has now also been branded as being just that, in a major report commissioned by the GMC 21 years later. Professor Roger Kirby’s excellent blog summarises the key findings of this enquiry and its main recommendations. One obvious question arises: Why did it take so long for the GMC to launch this enquiry, when we have been calling for it for as long as I have been in Medicine in the last 40 years?

    While we all welcome the recommendations of this GMC report, we know that several other questions remain. This report looks at institutional racism in healthcare resulting in among other things, the disproportionate referral of black and minority ethnic (BAME) workers to regulators and to the law. Sadly, it stopped short of following on to investigate what happens when these individuals reach the regulator. Are they still disproportionately punished for the same misdemeanours as their white colleagues? The GMC denies that this is the case but it would have been reassuring to extend the remit of the investigation to answer this very important question independently.

    Are there plans to ensure that the recommendations of this report are implemented, and when and how do we measure the outcomes?

    I, for one, a black surgeon, have been a victim of the very racism referred to by McPherson and by the present report. The way I was treated by the private hospital where a patient died under my care in 2010 and subsequently by the police, the CPS and by the courts and the penal system gives me little optimism for the future. It was disconcerting to read a report only last month declaring that the NHS drive to promote diversity in key jobs ‘is going backwards.’(2) The task ahead is made all the more difficult by the fact that the starting point appears to be receding. Which other public body is going to be under scrutiny for institutional racism in 21 years time? Whoever comes under that spotlight, the results are predictable.

    1.https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/277111/4262.pdf

    2. https://www.theguardian.com/society/2019/jun/07/nhs-drive-for-diversity-in-key-roles-going-backwards?CMP=share_btn_link

    David Sellu FRCS
    Hon Consultant Surgeon
    St Mark’s Hospital, London

    July 2, 2019 Reply
  3. Roger Kirby Professor of Urology

    Thank you David – readers do listen to David’s recent podcast: https://www.theguardian.com/news/audio/2019/jul/03/should-doctors-face-jail-when-treatment-goes-wrong-podcast
    Also check out his new book “Did he Save Lives?” to be published this month and reviewed in the forthcoming issue of Trends.

    July 3, 2019 Reply
  4. Hannah Warren Miss

    The figures presented here are disappointing and depressing but I have absolutely no doubt they are true. It would be interesting to know the breakdown for UK-trained doctors, removing the issue of adjusting to work in the NHS – although I suspect the picture is the same. One only needs to look as far as the cases of David Sellu and Hadiza Bawa-Garba for an illustration of how BAME doctors are treated in our healthcare system. I commend Trends for bringing this issue into the spotlight. We are all responsible for systematic racism that pervades our workplace and society, and the first step is to aknowledge it exists. The following are excellent reads, and I would recommend them to anybody be who wants to explore this topic more: ‘Why I’m no longer talking to white people about race’ by Reni Eddo Lodge and ‘Brit(ish)’ by Afua Hirsch. Eye opening!

    July 4, 2019 Reply
  5. Roger Kirby Professor of Urology

    Black and ethnic minority staff working in the NHS are more likely to report being bullied or harassed than their white colleagues, the first national review by NHS England has suggested.
    The report, which covers all NHS trusts in England, calls for attitudes and behaviour to change.
    NHS England chief executive Simon Stevens said the results were “deeply concerning and a clear call to action”.
    The NHS has said it is investing £2m over two years to tackle the issue.
    Joan Saddler, who co-chairs the NHS equality and diversity council (EDC), said although trusts had traditionally collected data on staff experiences through local surveys, they had “generally failed to act” on them.

    July 8, 2019 Reply

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