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How systemic racism affects general practice


systemic racism


systemic racism

Covid and the Black Lives Matter movement have shone a light on the ivory towers in general practice. Nicola Merrifield and Emily Stearn investigate

‘We no longer see a Britain where the system is deliberately rigged against ethnic minorities. The impediments and disparities do exist, they are varied, and ironically very few of them are directly to do with racism.’

This statement comes from the controversial Government-commissioned Sewell report1, whose remit was to investigate race and ethnic disparities in the UK in the wake of Black Lives Matter protests. Its publication in March led to widespread alarm, including among health leaders and campaigners.

‘There is clearly an attempt to diminish the impact of racism,’ says Manchester GP Professor Aneez Esmail, a leading expert on racism in the NHS.

The statement, from report chair Tony Sewell, looks even more poorly judged in the light of the pandemic. GPs have seen a disproportionately high number of patients and colleagues from black, Asian and minority backgrounds die from Covid-19.

The Office for National Statistics found that in England and Wales, males of black African ethnic background had the highest rate of death involving Covid-19 – 2.7 times higher than white males. All ethnic minority groups other than Chinese had a higher rate than the white ethnic population, for both males and females.2

Tragically, 16 practising GPs have died with Covid – all but three of them from a BAME background.

These health outcomes may be down to a mix of structural and biological reasons and it is likely to take years to develop a full picture.

But for BAME GPs, it is simply more evidence that they face greater disadvantages than their white colleagues.

Speaking in a personal capacity, Sheffield GP Dr Krishna Kasaraneni, who is also on the BMA’s GP Committee executive team, says: ‘The significant difference in outcomes, both in hospitalisations and mortality rates, shows there is a problem.’

Pulse looked at the issue of racial bias in medicine three years ago, in the wake of the Dr Hadiza Bawa-Garba case. Sadly, there has been little improvement – ethnic minority doctors still face worse outcomes in terms of investigations, exams, and CQC inspections.

The NHS Race and Health Observatory acknowledges this in its response3 to the Sewell report: ‘The evidence is clear: institutional racism exists in this country, it exists in the organisations that make up our health and care system, and it exists across wider public establishments.’

Structural – or systemic, institutional – racism was elevated into the public consciousness with the 1999 Lord Macpherson report into the Stephen Lawrence murder. It concluded that ‘processes, attitudes and behaviours’ create discrimination. 

Lord Macpherson’s definition of institutional racism

‘The collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racial stereotyping.’

Yorkshire GP and RCGP Council member Dr Margaret Ikpoh points to indications of systemic racism in general practice: ‘It manifests in myriad ways: a lack of career progression or opportunity; bullying and harassment; a lack of diversity at management or senior board level; and ethnicity pay gaps.’

Of course, the catch-all terms ‘BAME’ and ‘minority ethnic’ can be problematic. They may not reflect the way people refer to their race, or the differing problems for different ethnic minority groups. But there is no doubt that outcomes are worse for GPs in all non-white ethnic groups than for their white colleagues.

The reasons are complex and exist at the societal level. There is a will to understand the problem from the organisations involved – the GMC, the RCGP and the CQC have all commissioned work to get to the bottom of the differential outcomes.

However, there are clear factors that lead to non-white GPs facing different challenges. For example, BAME GPs are more likely to work in singlehanded practices, and in deprived areas4 with a high proportion of BAME patients.

These factors need not be disadvantageous in themselves. But the metrics used to judge general practice are more often than not based on a model of larger practice sizes, in less deprived areas with a predominantly white patient population.

Smaller-scale general practice

Roger Kline, an expert on race issues in the NHS, says BAME GPs are more likely to work in smaller practices because of historical recruitment drives attracting overseas GPs: ‘They landed with little practices at a time when these were more common… and they felt it was extraordinarily difficult to join larger practices that had a majority of white partners. So they kept going in little practices.’

But in recent years, there has been an increase in the shift towards large-scale practice. NHS England has been upfront about this aim, which has culminated in the formation of primary care networks.

Dr Vijay Kumar, co-clinical director of North Doncaster PCN, says: ‘Smaller practices do fare worse within PCNs. They lose out because these days there is so much non-clinical work, and many are merging with medium-sized practices.’

Smaller practices are also likely to see worse outcomes from CQC inspections. Dr Kumar says: ‘Many are unable to have training contracts because the buildings are small, it is difficult to recruit staff and funding is less than adequate because of the [relatively] poor health of the people there.’

But, although small practices might struggle to meet the criteria used by the CQC, they are likely to be stronger in other respects – which are less emphasised during inspections.

‘[Singlehanded GPs] have been harassed and penalised for simple tickbox problems, mainly about appearance and other minor issues, without ensuring access to proper resources.

‘This ignores the areas where smaller practices excel – such as providing personalised care and continuity,’ says Dr Ramesh Mehta, president of the British Association of Physicians of Indian Origin (BAPIO).  

Deprived areas

A disproportionate number of BAME GPs work in deprived areas.4 The historical recruitment drive cited by Roger Kline could also explain why overseas-trained GPs ended up in hard-to-recruit regions around 30 years ago, but UK-trained BAME GPs were often also brought up in those communities, and tended to be more likely to settle and practise there than GPs from elsewhere.

But the various regulatory approaches tend not to give enough weight to the challenges associated with deprivation.

Practices in deprived areas contend with the inverse care law: in regions of greater healthcare need, there are fewer resources. There has been ongoing controversy over inadequate weighting for deprivation in the Carr Hill Formula, which determines GP practice funding in England. It also fails to consider the number of languages spoken in a practice.

Bristol GP and Pulse columnist Dr Shaba Nabi says: ‘There’s a triple whammy in practices like mine: one, deprivation; two, language access; and three, cultural differences in health-seeking behaviour. I explained all this to the then PCT but we got no extra funding, resulting in the partnership handing back its contract.’

Dr Kumar says the CQC also ‘fails to take into consideration the deprivation index of BAME-led practices… It’s comparing apples with pears.’

Non-white populations

The more deprived areas tend to have higher rates of BAME population5, meaning their patients are more likely to face different societal and health problems. Cultural norms and different health issues mean this job will differ from that of a GP in, say, rural Oxfordshire. While this is to be expected, the yardsticks used for general practice are often white populations.

Take, for example, the RCGP’s clinical skills assessment. One controversy behind its uneven scores was that the actors tended to be from a white, middle-class background with presentations that trainees working predominantly with BAME patients might be less comfortable with.

Any doubts about the differences of working in predominantly non-white areas have been swept away as the pandemic has thrown differential health outcomes into stark focus.

The government response has been criticised by many BAME GPs. Despite their worse outcomes, BAME people were not prioritised for vaccination until the QCovid tool was introduced in February, says Dr Kasaraneni.

‘Race is almost an afterthought every single time – whether it’s an impact on the profession or the wider population.’

Grassroots lead the response

Dr Ikpoh says: ‘We now need to try to move beyond questioning whether systemic racism exists – it exists – and start questioning how we all intend to address it.’ She points to the RCGP’s ‘listening exercises’ for GPs from ethnically diverse communities, instigated by past presidents.

In January, the BMA set up its first dedicated BAME forum, while BAPIO is midway through a year-long project looking at tackling differential attainment in healthcare professions – from education and career progression to human resources matters.

Meanwhile, BAME doctors within the RCGP put forward a successful motion to council in March.

It must also not be forgotten that general practice is ahead of the curve in terms of BAME people in leadership positions, while a third of GPs are from BAME backgrounds. That said, more can always be done. There is a notable lack of black leaders in general practice.

Essex GP Dr Adwoa Danso, who is an executive at the Ghanaian Doctors and Dentists Association UK, wants more tangible changes: ‘We could look at the Rooney Rule in the US, where American NFL teams have to interview an ethnic minority person for any [senior] role.’

She adds: ‘I want to see someone who looks like me, who has the same experiences as me.’

Systemic racism is a fixture in general practice. But any successful efforts to start correcting this will undoubtedly come from the grassroots up.

References

1 Report of the Commission on Race and Ethnic Disparities, 2020. tinyurl.com/Report-CRED.

2 Office for National Statistics, 2020. Ethnic contrasts in deaths involving the coronavirus. tinyurl.com/ONS-ethnic-covid

3 NHS Race & Health Observatory, 2020. Response to the report of the Commission on Race and Ethnic Disparities. tinyurl.com/NHRO-CRED

4 GMC, 2019. Fair to Refer? tinyurl.com/GMC-fair2refer

5 People living in deprived neighbourhoods, June 2020. tinyurl.com/uk-deprived

READERS' COMMENTS [9]

Dave Haddock 1 May, 2021 3:58 pm

White males markedly under-represented in GP training; victims of race and gender discrimination?

Stuart Buchanan 3 May, 2021 9:17 pm

Unfortunately this article isn’t very convincing. BAME GPS make up 30% of UK general practice. This is over-representation compared to the ethnic proportions of the UK population. Dr Nikita Kanani, anybody heard of her? I take not…..I would like the authors of and contributors to this article to ask why if the NHS is so racist which country would they prefer to work in, and why don’t they relocate there, rather than staying on such an ‘overtly racist’ system and complaining about it. Can they please explain if the UK is such a racist institution why are so many doctors from overseas still choosing to go there? Haven’t they heard the warnings about how bad it is there? I didn’t hear any mention of the under-representation of whites within medicine from any of the contributors as perhaps part of an overall problem, perhaps an inconvenient truth. Also, whites are under represented in UK Universities Generally, UK Medical school is now 41% BAME. There is a complaint about lack of access to higher paid jobs, what is the ethnicity of the highest paid GP in Britain? (Its a tabloid favourite) I am open to the concept of ‘people born with advantages’ being alive and well in the UK and EVERY country, people who are born and bred there, like in ANY country, will have a better network than those newly arrived, and hence more likely to land top jobs due to familiarity bias….. look at the OxBridge brigade- but thats not Racism – its Nepotism. Thats a different beast. Any immigrant is unlikely to do as well as a native when relocating from one country to another. That is not racism – its to do with familiarity and support mechanisms. I relocated to Australia, its harder for me than the local graduates, but hey ho, I choose to go. So I don’t complain about it but enjoy the advantages that Australian Practice brings. Its just a fact of life. Relatively well paid GPs from a BAME background that overachieve in Medicine , driving around in their Mercedes, publicly complaining that they are not well enough paid, don’t get enough top jobs, and are discriminated against is unlikely to go down well in poor white communities, where there is academic underachievement, particularly in males. Some of these contributors I am sure were shocked by the ‘Whitelash’ in America when Donald Trump got voted in. but Donald Trump (Much as I detest the man) tapped into resentment in the white underclass and stoked up the tensions and now everyone is worse off over there. The danger with articles and attitudes like this is that it can create resentment by moderate whites who feel they are constantly accused of somehow being racist. Dr Nabi raises language as an issue. Is it any surprise that people who choose not to learn the language, i.e. English, but then go to the UK regardless, will not do as well as the locals? Thats not a surprise. Its an inevitability. But its down to the actions or inactions of that individual, not an inbuilt racism within the structure. The question is why the UK accepts migrants who refuse to learn the language. Is it ethical that the NHS should divert money away from other services to provide interpreters for those who choose not to learn English? In Australia you HAVE to learn english to be accepted for immigration. I don’t see what wrong with that, as it results in better integration, easier access to resources, better job prospects, and you are less likely to be the victim of racism and can tell the difference between a local shouting either racist comment or ‘Look out for the car’ when they might be trying to save your life. My observation is that there is more discrimination against UK born Deaf people in the UK, than against the immigrant populations. I’d be happy for the authors to look at the health outcomes for our deaf community and compare. They have very poor job prospects, and poor access to healthcare. I am an immigrant in Australia, I don’t have the same rights and access to healthcare for the first 5 yrs, I don’t have my extended family available for childcare, I am not ‘in the know’, I didn’t go to school with the people who can influence my career, I had to pay an extra 5000 AUD just to be able to buy a house, My Visas cost a fortune, but I choose to go, I am aware that I don’t get the same treatment, but its not racism, and I am free to return to the UK any time I want. The systems in place ensure that those coming to Australia will make a positive contribution and are able to look after themselves. I think thats sensible. If I complained over here the locals would ask me why if I don’t like it I don’t go home again? I can see their point of view. If you are moving to another country for economic reasons and you end up better off than where you came from, then its a trade off against loss of family and social support, and not having being born into an influential circle. You pick, you choose, but its still freedom of choice, and I still think the UK and the NHS are great with many more freedoms and benefits than most other countries. With your qualifications you are fee to move to other countries as I did. For most deaf people, they don’t have that luxury. And oh, yes I am still subject to racist taunts in Australia, particularly from the Indigenous population who call me white C***… and they mean it. I understand why they are angry, and rightly feel their lands have been invaded. Do I feel offended…….no….. at the end of the day we choose to be offended…. its part and parcel of freely choosing to practice in rural and remote Australia.

Stuart Buchanan 4 May, 2021 9:33 am

If a white patient stated that “I want to see someone who looks like me, who has the same experiences as me” when requesting a GP at the reception desk, would you view them as a racist?

Jonathan Heatley 4 May, 2021 6:18 pm

what a depressing article

Stuart Buchanan 4 May, 2021 11:54 pm

The use of Coronavirus mortality variation as indication of systemic racism is also absurd. I haven’t heard anyone talking about diabetes being racist yet, is that next on the cards? White people get more skin cancer…. does that make skin cancer racist???? Or is it simply the variation in genetics between different ethnic groups that makes the different groups susceptible to different diseases??? If smaller practices have more difficulties meeting the CQC criteria, which given the absurd amount of admin that they look for, I can see that being very difficult to achieve, then the problem isn’t racism per-se, its a mismatch between the ability of that practice to meet the CQC criteria and the expectations of the examining CQC. There are two outcomes here, either the CQC has a point and safety was an issue, or there wasn’t, and the tick boxing exercise was just more evidence of GP-bashing. The reader would need to be shown what has been ‘clamped down on’. This article doesn’t provide any detailed evidence to allow the reader to form their own opinion either way as to whether or not the CQC decisions were reasonable or not, another weakness of this article. Most colleagues I know are CQC cynical, it would have been nice to have had some specific examples provided that we could have used as ammunition to lambast the CQC with. The Bawa-Garba case in contrast, united doctors as everyone was able to see the very difficult situation that she had been placed in and there was pretty much universal agreement that the regulatory bodies were unreasonable. On this note whilst the commentators commented on the negative aspects of this case, I didn’t see anyone comment on the positive aspect of this, how the rank-and-file doctors of all races rallied behind her in an act of unity and support. It was this response that gives a truer picture of the values of the colleagues I have worked with over the years. General Practice is rotting in the UK, but its not because of racism. Turning on each other with accusations and denials of racism I am sure will help distract us from the real issues of wealth inequality and underfunding of general practice. Hancock must be loving this….. further fuel for the pyre when the Daily Mail goes in for the kill again…. “wonder why you can’t get into see your GP during the Covid crisis? Is it PPE they are wearing or a KKK clan hood?”

Sunil Limaye 4 May, 2021 11:55 pm

Not as depressing as some of the comments

Kosta MANIS 6 May, 2021 10:14 am

A comprehensive report written by two well-meaning authors, painting a picture of racism that does not reflect accurately what I have experienced in my forty years as GP. Undeniably there is racism in general practice. But it is much more widespread and it is not restricted just to White v Coloured as the article asserts.
Three days ago, Sir Anish Kapoor wrote in The Times an article under the heading, “Covid must force India to face up to its secret shame”.
Here are some extracts.
“There is a reality about India that remains wilfully undeclared. It is that India today is the most unequal society there has ever been. Sixty per cent of the population — 800 million people — live, or more accurately survive, in abject poverty and are forced into invisibility. The harshness of caste boundaries and endemic social segregation means they are the downtrodden of the earth and it matters not if they live or die…. foolish insistence on Hindu superiority is to be seen as reinforcing an age-old disregard for those among his own people who were born “inferior” … lack of concern about the spread of Covid-19 is linked to the perceived racial superiority of high-caste Indians who will survive the crisis relatively unscathed, while the poor and low caste are left to fend for themselves with little or no help or medical assistance…” It was one of the most distressing pieces I have ever read and I mention it only because I have witnessed over the years this sense of superiority exhibited by upper caste colleagues to their “inferiors”. Originally from Southern Peloponnese, easily the most classless society in the world where any claims of superiority are considered as hubris attracting instant nemesis, I found it shocking that some recipients of such discriminatory behaviour accepted it passively.
PULSE has repeatedly shown that it respects Free Speech, the fundamental principle of Democracy. It may consider emulating The Times and offer an open forum to its readers where members of various races and religions are allowed to speak openly about their treatment by other races and religions, not in their country of origin but in democratic Britain.
It is time general practice faces up to its own secret shame.

John Evans 13 May, 2021 12:32 pm

1. It is in no way clear that the adverse outcomes are due to racism instead of numerous other factors.
2. Do they consider country of qualification or language skills rather than ethnicity?
3. I am convinced that poverty is the determinant. Immigration was often to fill poorly paid employment with immigrants starting from scratch living in postwar city housing developments. Poorer children faced a greater challenge. It is commendable that such a high proportion have achieved. The figures for white males from poor background are a disgrace that we continue to accept.
4. Attribution to racism without more analysis of compounding factors leads to resentment and division.

A non 22 July, 2021 9:04 pm

If you are white and working as a GP in my area (a very large UK metropolitan area) you are very much in the minority. Despite most definitely not being a minority in either the workforce or population BAME Drs here get offered extra free CPD through BAME network meetings, nothing similar exists for their non BAME colleges, (although apparently we are allowed to attend – which is very nice obviously). I still cant quite get my head around the idea that more than half the educational events in my area are explicitly arranged around racial lines. From the perspective of this non BAME identifying Dr this place is run by and for BAME Drs. I don’t see these kind of realities reflected honestly anywhere and certainly not in this lazy and cliched article.