Radical action is needed urgently to tackle “overwhelming” minority ethnic health inequalities in the NHS, leading experts have said, after a damning study found the “vast” and “widespread” inequity in every aspect of healthcare it reviewed was harming the health of millions of patients.
Racism, racial discrimination, barriers to accessing healthcare and woeful ethnicity data collection have “negatively impacted” the health of black, Asian and minority ethnic people in England for years, according to the review, commissioned by the NHS Race and Health Observatory, which reveals the true scale of health inequalities faced by ethnic minorities for the first time.
“Ethnic inequalities in health outcomes are evident at every stage throughout the life course, from birth to death,” says the review, the largest of its kind. Yet despite “clear”, “convincing” and “persistent” evidence that ethnic minorities are being failed, and repeated pledges of action, no “significant change” has yet been made in the NHS, it adds.
The 166-page report, seen by the Guardian, is due to be published in full this week.
From mental health to maternity care, the sweeping review led by the University of Manchester paints a devastating picture of a healthcare system still failing minority ethnic patients despite concerns previously raised about the harm being caused.
“By drawing together the evidence, and plugging the gaps where we find them, we have made a clear and overwhelming case for radical action on race inequity in our healthcare system,” said Habib Naqvi, the director of the NHS Race and Health Observatory, an independent body established by the NHS in 2020 to investigate health inequalities in England.
The Covid pandemic has taken a disproportionate toll on ethnic minorities, prompting fresh questions about inequalities that permeate the practice of medicine. The observatory ordered the review last year to synthesise the evidence, translate it into “actionable policy” and “challenge leaders to act”.
“This report is the first of its kind to analyse the overwhelming evidence of ethnic health inequality through the lens of racism,” said Naqvi.
Its findings are shocking. The review concludes that inequalities in access to, experiences of, and outcomes of healthcare in the NHS “are rooted in experiences of structural, institutional and interpersonal racism”. For “too many years”, it adds, the health of minority ethnic people in England has been “negatively impacted” by a lack of appropriate treatment, poor quality or discriminatory treatment by NHS staff, missing ethnicity data from NHS systems, and delays in seeking help for health issues “due to fear of racist treatment from NHS healthcare professionals”.
The year-long review, which examined 13,000 papers and interviewed policy experts, NHS staff and patients, was led by Dharmi Kapadia, an investigator at the Centre on the Dynamics of Ethnicity, the UK’s leading research centre into minority ethnic, racial and religious inequalities. Kapadia, a sociology lecturer at the University of Manchester, said she and her co-authors had uncovered “crucial” evidence of persistent health inequalities that were harming the health of patients on a daily basis.
“The evidence on the poor healthcare outcomes for many ethnic minority groups across a range of services is overwhelming, and convincing,” she said.
The report is littered with striking examples and evidence of inequity in the NHS. In mental healthcare, for example, the review found minority ethnic patients faced “clear inequalities” in regard to Improving Access to Psychological Therapies (IAPT), a flagship NHS programme set up in 2008 to transform the treatment of anxiety and depression in England.
Minority ethnic groups were less likely to be referred to IAPT by GPs than white people, the report said. Minority ethnic patients who do get a referral are less likely than white British patients to receive an assessment. Minority ethnic people with psychosis are also less likely to be referred for cognitive behavioural therapy (CBT).
The review found “strong evidence” of “clear, very large and persisting ethnic inequalities” in compulsory admission to psychiatric wards, particularly affecting black people. It uncovered evidence of harsher treatment for black patients, who were “more likely to be restrained in the prone position or put into seclusion”.
Minority ethnic parents reported their children faced the same barriers to accessing health services as they did. Black children are 10 times more likely to be referred to children and adolescent mental health services (CAMHS) via social services – rather than through their GP – compared with white children, the report says.
Maternity services were also found lacking. The review found evidence of negative interactions, stereotyping, disrespect, discrimination and cultural insensitivity, leading to some minority ethnic women feeling “othered”, unwelcome, and poorly cared for. Some women whose first language was not English were denied access to quality interpreting services, the report adds.
“Our review shows the role of structural barriers – including racism and experiences of racial discrimination – in patterning stark ethnic inequalities in healthcare,” said its co-author Laia Bécares, a senior lecturer in applied social science at the University of Sussex.
The review found a lack of research in specific areas. Despite screening 10 years’ of research, the review team found only one study that examined health inequalities in the care of newborn babies.
It showed Asian babies are over-represented in admissions to neonatal units from home for jaundice. Visual estimation of jaundice in babies “may be particularly unreliable” for babies with darker skin tones, the review said, raising the possibility that “routine postnatal care practices may systematically disadvantage non-white babies by delaying access to care”.
The researchers also said any efforts to improve health outcomes among minority ethnic patients were being thwarted by the shambolic collection of health information by NHS staff and organisations.
Racism within the NHS workforce persisted, they said, and the report found evidence of an pay gap affecting black, Asian, mixed and other groups. The review also uncovered minority ethnic health inequalities in areas as diverse as digital access to healthcare, genetic testing and genomic medicine.
“Persistent inequalities in the healthcare and health outcomes between ethnic groups remain, despite past commitments to address the issue,” said its co-author Sarah Salway, a professor of public health at the University of Sheffield.
“As a nation we are proud of our NHS. It is one of the few healthcare services worldwide that enjoys a reputation for quality care that is free at the point of access, so it can be difficult to discuss how things may be failing. This report, however, gives us the opportunity to identify how we can do things better, for a healthier and fairer society.”