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How Covid-19 exposed existing ethnic inequalities – including for GPs

The conclusion of Public Health England’s final review into the risks of Covid was stark: ‘Risk of dying among those diagnosed with Covid-19 was higher in those in black, Asian and minority ethnic groups than in white ethnic groups.’

People of Bangladeshi origin are most at risk of dying from Covid-19, while people from black ethnic groups are most likely to be diagnosed with the disease, the report found.

This might not have come as a surprise to many, least of all to the stakeholders consulted by PHE for its review. These stakeholders, many of whom represented BAME groups, put forward another conclusion: that the factors behind the figures might be socioeconomic and racism-related, rather than biological.

The report summed up their views: ‘Covid-19 did not create health inequalities, but rather the pandemic exposed and exacerbated longstanding inequalities affecting BAME groups.’

Many GPs working in areas with a high proportion of minority ethnic patients have been saying this for years.

British International Doctors’ Association chair and Stoke GP Dr Chandra Kanneganti says: ‘Problems with inequalities have been going a long time. With Covid, I’ve had patients who may have asthma or another condition and they are scared go to work, but fear if they tell their bosses that they will be seen as someone who doesn’t want to work and they may lose their job.’

Multiple risk factors

The PHE report found that many BAME households were intergenerational and overcrowded, making it harder to follow rules on distancing and isolation.

At the same time, it states minority ethnic people are more likely to use public transport – heightening the probability of contracting the disease – and to work in public-facing jobs with a higher risk of exposure.

The report highlights the stakeholders’ view that the ‘poorer socioeconomic circumstances’ faced by BAME groups are ‘strongly associated with the prevalence of smoking, obesity, diabetes, hypertension and their cardio-metabolic complications, which all increase the risk of disease severity’.

And GPs are not immune to many of these factors, despite their relatively higher economic status. So far, 11 of the 12 GPs who have died from Covid-19 have been from BAME backgrounds.

We often have to support families back home, so at times have to work less desirable shifts

Dr Adwoa Danso

Dr Adwoa Danso, a locum GP based in Essex and London and executive member of the Ghanaian Doctors and Dentists Association UK, says: ‘Some of the patients I see in these groups – black African, black Caribbean, Asian – we often have to support not just families in the UK but those back home, so they will at times have to work less desirable shifts or jobs to obtain the same amount of money due to the race pay gap which exists in the NHS.’

The report found discrimination plays a part in Covid-related inequalities, even within the NHS. PHE says BAME people may have experienced racism in the NHS, including poorer access: ‘This may mean they are less likely to seek care when needed or, as NHS staff, less likely to speak up when they have concerns about PPE or testing.’

Dr Sapna Agrawal, a GP trainee in the West Midlands and member of the GP forum at the British Association of Physicians of Indian Origin, says she is already noticing this: ‘As a trainee, it’s evident in the enthusiasm with which you are trained or given opportunities. It feels more of a tick-box exercise. If a BAME doctor makes a mistake, the patience isn’t there, or the chance to repeat training might not be given.

If a BAME doctor makes a mistake the chance to repeat training might not be given

Dr Sapna Agrawal

‘As a GP trainee you’re supposed to have tutorials weekly but I’ve worked in practices where I’ve only had one in six months. When I complained I was made out to be a troublemaker.’

Dr Kanneganti has seen how easily NHS staff can put themselves at risk. Two of his patients, who work for the NHS as nurses, felt unable to raise concerns.

‘They were being asked to do more shifts in Covid zones because the hospital sometimes has shortages, and they felt they were potentially asked because they wouldn’t speak up or say no – so they are probably taken for granted.’

NHS discrimination

The first version of PHE’s report, published at the start of June, failed to include first-hand experiences or views from stakeholders – or any recommendations to address the problems it highlighted. This led to a backlash, with accusations that a key section of the report – including stakeholder feedback thought to suggest that discriminatory decisions in the NHS were partly to blame – had been omitted.

Dr Kanneganti says the final report, published a few weeks later, is an improvement but adds that what happens next is more important: ‘There are some good recommendations that would solve a number of problems – and they should be brought in without delay.’

There are some good recommendations – they should be brought in without delay

Dr Chandra Kanneganti 

These include: a targeted campaign aimed at BAME groups to promote healthy weight, smoking cessation, mental wellbeing and management of chronic conditions; education campaigns to reinforce how households can reduce the risk of catching the virus; and a proposal to ‘rebuild trust with and uptake of routine clinical services’.

Perhaps most importantly, it recommends the development of occupational risk assessment tools – especially for key workers. Pulse revealed last month that many practices had been forced to develop their own.

Summary of PHE’s seven key recommendations

  • Mandate comprehensive and quality ethnicity data collection and recording as part of routine NHS and social care data collection systems, including the mandatory collection of ethnicity data at death certification
  • Support community participatory research, in which researchers and community stakeholders engage as equal partners
  • Improve access, experiences and outcomes of NHS, local government and integrated care systems commissioned services by BAME communities including regular equity audits, use of health impact assessments and good representation of black and minority ethnic communities among staff at all levels
  • Accelerate the development of culturally competent occupational risk assessment tools that can be used to reduce the risk of employee exposure to and acquisition of Covid-19, especially for key workers
  • Fund, develop and implement culturally competent Covid-19 education and prevention campaigns, working in partnership with local BAME and faith communities to reinforce individual and household risk reduction strategies, and rebuild trust with and uptake of routine clinical services
  • Accelerate efforts to target culturally competent health promotion and disease prevention programmes for non-communicable diseases promoting healthy weight, physical activity, smoking cessation, mental wellbeing and effective management of chronic conditions
  • Ensure that Covid-19 recovery strategies actively reduce inequalities caused by the wider determinants of health to create long term sustainable change. Fully funded, sustained and meaningful approaches to tackling ethnic inequalities must be prioritised

Source: Public Health England, 2020: Beyond the data: Understanding the impact of COVID-19 on BAME groups.

The Government says the equalities minister is taking the recommendations forward, reporting to the health secretary and Prime Minister every three months. But there are already calls from a Government adviser to begin the NHS Health Checks programme from the age of 25 for minority ethnic groups.

Professor Kamlesh Khunti, a Department of Health and Social Care adviser, told MPs last month: ‘We have an NHS Health Check for people aged 40 to 74, but I think for the BAME groups, who get these conditions earlier, we should extend that to age 25 and onwards.’

Dr Danso says GPs need specific recommendations for individual ethnic groups to keep people safe during the pandemic: ‘“BAME” refers to a huge group of people with varying risks and completely different ethnicities. Even among the black community, the genetics vary drastically.

‘We need more specific data and better recording of it so we can deduce more to formulate risk assessments that are individualised – especially if we have a second wave, to protect ourselves.’

But she warned rebuilding trust with BAME communities will not be easy.

‘There is such a huge distrust in these communities. Even discussing with black work colleagues about being potentially vaccinated first against Covid-19 – people feel we may be used as guinea pigs.’

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