In this article, Joshua Correia interviews different generations of healthcare professionals to gain an insight into the experiences of racism and discrimination in the NHS. He considers: how far have we come in tackling the issues and what support is available today?
When we look at how much of an impact racial inequality had on the inner workings of our society during the mid to late 1900s, it’s easy to make a distinction between the world of today and how things used to be. Currently, there is an overwhelming emphasis on the importance of equal opportunity for all individuals in employment regardless of race, gender, sexual orientation, socio-economic status or disability. Particularly over the past decade, any evidence of institutional racism and unconscious bias within the workplace is taken far more seriously; the implementation of the Equality Act in 2010 and other safeguards (such as unions) is supposed to ensure that employees are given adequate protection and support in any instance of racial discrimination or misconduct
On the surface level it seems that we’ve made good progress in creating a fairer society that commits itself to challenging inequality. Nevertheless, upon closer inspection there is still much room for improvement, especially when it comes to our National Health Service. The issue of racial inequality for doctors and nurses from BAME (Black, Asian and minority ethnic) backgrounds is a recurring one, even more so in light of the COVID-19 pandemic.
Regarding the pandemic and unequal access to personal protection equipment (PPE), a report published by the National Institute for Health and Care Research (NIHR) claimed that there was a lack of care and consideration for NHS staff from minority backgrounds. It stated: “The NHS advised that all high-risk workers should have a personal risk assessment to minimise the risks they faced. However, some felt that risk assessments and recommendations were not taken seriously. Research found that those from ethnic minorities felt the risks more keenly than their White colleagues.”1
This is further supported by an RCN member survey carried out during the height of the pandemic in 2020. Of all the BAME respondents working in high-risk environments, it found that:
- Only 43% had adequate equipment for eye and face protection, in contrast to two-thirds (66%) of White British nursing staff.
- 37% did not have enough fluid-repellent gowns to use during their shift, compared with 19% of White British staff.
- More than half (53%) had been asked to re-use single-use PPE compared with 42% of White British respondents.2
More worryingly, in a survey carried out by the Royal College of Nursing, there was a startlingly clear contrast between NHS nurses from BAME backgrounds and White British nurses when it came to fit testing for filtering face piece respirators: “There was a substantial difference when exploring ethnicity; only half of BAME respondents (49%) said they had been adequately fit-tested for the filtering face piece respirators (FFP3 or FFP2/N95), whereas almost three-quarters of White British respondents had been adequately fit-tested (74%).”3
These findings illustrate the undeniable inequality and lack of consideration for NHS workers from BAME backgrounds who work in high-risk environments, despite them being at a higher risk from more serious COVID–19 health problems.
These extracts are just the tip of the iceberg when highlighting instances of racism within the NHS and the issue isn’t exclusive to the amount of access BAME workers have to adequate PPE. Moving beyond the pandemic, one of the main focuses of this article is to examine how doctors and nurses are subjected to incidents of racial abuse, bullying and discrimination – either by patients or even their own co-workers.
In a survey conducted last year, by the British Medical Association (BMA), covering more than 2,000 doctors and medical students, over 90% of Black and Asian respondents said they believed racism to be an issue within the medical profession. It should come as no surprise that almost 60% of doctors reported that such incidents of racist bullying had negatively affected their wellbeing including causing depression, anxiety, and increased stress levels.
More specifically, the survey investigates instances of derogatory comments, social exclusion, bullying, and physical attacks or threats of violence. The survey makes for difficult reading, at times, and illustrates the on-going disparity between NHS workers of colour and their White British counterparts. Specifically with regards to bullying within the workplace, the survey states that: “Many respondents experienced bullying in their workplace due to their ethnicity; 37% of respondents from Black backgrounds, 37% from Asian backgrounds, 34% from other backgrounds, 22% from Mixed backgrounds, 22% from White non-British backgrounds, and 5% from White British backgrounds reported this. Bullying was most often perpetrated by senior doctors, with 68% of those who had been bullied reporting that they had been bullied by senior doctor.”4
To support these findings, the report goes as far as to include testimonies from junior doctors who have been at the receiving end of such treatment. In particular, one junior doctor recounted that: “At times the tone of senior colleagues would be so rude that I would cry in the washroom. Fellow junior colleagues who were locally from the UK would notice this and also be rude (…). This would make me feel isolated and hesitate to ask for help.”5
A separate testimony from another junior doctor describes being “constantly harassed and bullied” by a patient who had made inappropriate remarks and racist comments about the doctor’s place of birth, name and appearance. Concerning the emotional and professional repercussions of these incidents, BMA council chair, Chaand Nagpaul, stated: “The findings highlight the negative impact that racist experiences have on doctor retention, well-being, and career progression – an indisputable rebuttal to the Government’s claims in its Sewell report that the NHS is a success story for ethnic minority doctors.”6
eyond the poor treatment BAME workers experience within the medical profession, racism also has its influence on career progression and promotional opportunities. An RCN employment report, published in June 2022, found that there was a very clear distinction between ethnic groups when it came to securing a promotion at work: ‘While 66% of White and 64% of respondents from mixed ethnic backgrounds in this age group said they’d been promoted, this dropped to just 38% of Asian and 35% of Black respondents.’7 Indeed, such instances of structural racism prevents perfectly qualified healthcare workers from being able to put their knowledge into practice, stunting their development within the profession and further preventing doctors from fulfilling their full potential.
To help give some scope on what has or hasn’t changed within the NHS over the years regarding racism, it was important for me to interview BAME healthcare professionals from different time periods – both past and present. These individuals have all asked to remain anonymous. My first interview was with a woman I shall refer to as ‘Jane’. Jane was part of a much older generation of nurses, who originally arrived from the West Indies to tackle the shortage of staff and aid in Britain’s recovery following the Second World War.
Jane first started working for the NHS in July 1965. She initially worked as a registered nurse, then as a midwife (she trained at Lewisham Hospital for that role), and then finally as a health visitor
Speaking on the racism she experienced throughout the course of her career, Jane recalls a specific incident of racial abuse she sustained from a White patient while at work: “I remember once I was working on the ward a long time ago and an elderly gentlemen looked at me and said ‘oh, it’s a jungle bunny!’ I couldn’t help but look at him and think to myself what a fool he was.”
Considering that racism was especially rampant during this time, it wasn’t at all surprising to hear from Jane that some patients had even gone as far as to claim that Black nurses had “monkey tails curled up under their clothes”.
Although she was perfectly qualified to do her job, Jane observed that some patients regarded her as less educated and qualified than White doctors and nurses, so patients would often refuse to be attended by a clinician of colour. It wasn’t until Black nurses demonstrated that they were in fact just as capable and attentive as White nurses that people began to change their attitude towards BAME healthcare workers in general. Worse still, there was a clear animosity from some White colleagues towards Jane whenever they stepped outside into the corridors, despite working and spending time together earlier in the day: “Some White nurses would actually talk to you when you were in the wards, but when you were out in the corridors it was like they’d never seen you before.”
Another interviewee, a consultant, describes a particular incident of discrimination whereby a senior member of staff made a comment about her head scarf in the presence of other workers after she was asked what her hair looked like underneath: “She said that: ‘In the morning when you’re changing to go back home, I’m going to burn your headscarf so then you have no choice but to leave the changing room without your headscarf and then you have to show us your hair.’ I was very taken aback by that and everyone else just sort of laughed.”
The experience had upset her deeply, as she recalls crying once she got back home later that day. After bringing this to the attention of her supervisor, the offender was reprimanded for what she had said but it wasn’t taken any further because they didn’t want to ‘damage someone’s reputation and years of hard work’.
When I asked Jane how she herself handled poor treatment from colleagues and patients, Jane said that she simply chose to ignore it. She didn’t have confidence in management or other members of staff from senior positions to take her concerns further, as many of them also exhibited similar subtleties of racism and discrimination.
Another possible reason many healthcare professionals feel reluctant to speak up was illustrated in an observation made by my third and final interviewee, who currently works for the NHS as a dermatologist: “People do take things more seriously today than they did ten years ago, but there is a very negative whistleblowing culture in the NHS that traditionally has shot down the messengers. And you hear about that causing so many problems with patient management, patient care and various enquiries, so there has definitely been a culture of dismissal of concerns and also attacking people who are willing to open their mouths.”
Aside from having a lack of faith in management to help tackle racism from both ends, it was also apparent to Jane that there weren’t many Black health visitors in the force to begin with, as pointed out by one of her patients whom she came to visit. However, Jane said that an effort was made by the colleges to take more Black nurses in for training.
Indeed, such efforts are still being made to diversify the healthcare workforce. In a message to the profession, Carrie MacEwen, chair of the General Medical Council (GMC), observed that, in 2021, more international medical graduates joined the medical register than UK graduates, and just under half of all trainees were from ethnic minority backgrounds. Unfortunately, as the following data soon illustrates, indicators of inclusion and equality generally “remain stubbornly fixed”
In a study conducted by the GMC on Tackling disadvantage in medical education (published March 2023), some key findings showed that:
- UK graduates of Black/Black British heritage have lower pass rates in specialty exams (62%) than UK White (79%), Asian (68%) and mixed heritage trainees (74%). Other factors such as socio-economic status compound the poorer outcomes. For example, the most affluent UK Black trainees had a pass rate of 67%, whereas the least affluent UK Black trainees had a pass rate of 59%
- A larger proportion of UK Black/Black British trainees (5.3%) have had their training programme extended than UK White trainees (2.6%)
- A smaller proportion of UK Black/Black British trainees receive an offer when applying to specialty training than other UK qualified groups (75% offer rate compared to 82% for UK White trainees).
- There is no evidence, yet, that the attainment gap between doctors of different ethnicities is significantly narrowing over time.8
While it is disheartening to see such marginal differences in change, it is equally just as encouraging to see that additional efforts are being made to combat discrimination in the workforce. In an article published by the BMJ, earlier this year, it is stated that the NHS had published a five-point action plan to tackle racism within the organisation. The aim of this initiative is to ensure that employees from ethnic minority backgrounds are given equal access to career opportunities and receive fair treatment at work. Exploring the action plan and its five domains in more detail, the article proceeds to outline its key areas and objectives:
“The first domain aims to improve consistency in decision making and reduce the disproportionate use of local disciplinary and regulatory processes for ethnic minority and international medical graduate doctors (…). The second domain focuses on increasing diversity in senior medical leadership positions, including recommendations that panels appointing senior staff have at least one senior independent member from an ethnic minority background (…). The other domains cover diversity in the Royal Colleges, support for international medical graduates, and parity for specialty and associate specialist (SAS) doctors.”9
The implementation of this action plan is part of a response to the increasing number of patients on waiting lists, which puts significant pressure on health services that are already struggling to meet demand. It also comes at a crucial point in time where disparities between White British NHS workers and those of colour have contributed to a shortfall in the workforce, for as stated in the article: “Ethnic minority doctors and international medical graduates have a crucial role in meeting NHS workforce demand. Failure to attract and retain staff is an existential threat that inequality exacerbates.”
Additionally, support is available for healthcare workers from BAME backgrounds to help aid conversation and implement change where possible. Among them, the NHS Employers website contains a list of online resources for healthcare workers to access, all of which explore solutions such as providing guidance on setting up staff networks for peer support, a BME leadership network that aims to improve the number of leaders from BAME backgrounds in the workplace, and a series of blog pages which encourage and explore diversity in the profession.10
Elsewhere, the NHS has produced an antiracism resource called Combatting racial discrimination against minority ethnic nurses, midwives and nursing associates. Made in partnership with NHS Confederation and the NMC, this resource is designed for nursing and midwifery professionals who experience or witness incidents of racism within the profession. It includes practical examples and tools for healthcare professionals to recognise and challenge racism in its many forms (discrimination, abuse, harassment, etc) safely and with confidence.11
There is also a support group called ‘Equality 4 Black Nurses’, an organisation that commits itself to empowering Black nurses to stand up against racism within the health service. As outlined on their website:
“Our aim is to bring about positive change by lobbying employers and Government to reduce and eradicate racial discrimination in the healthcare sector. Our nurse-led organisation (…) has been developed in light of the George Floyd incident, the Black Lives Matter movement, COVID-19 and the way it disproportionately and adversely affects Black healthcare staff in the UK due to racism and discrimination in the workplace.”12
The website has its own blog, online forum, and a weekly Zoom meeting for nurses every Tuesday at 9pm. The blog page, in particular, is very useful as it explores a range of issues Black nurses commonly face in their field of work, and includes testimonies from Black healthcare workers who have experienced varying forms of racial inequality or abuse. Overall, this support group is invaluable for Black nurses seeking additional peer support and consolation.
Beyond simply gathering testimonies from the interviewees who have experienced racism while working for the NHS, a couple of them also presented to me their personal thoughts on dealing with and overcoming this discrimination in the workplace. One of them (the dermatologist) offers a suggestion: “If you don’t (want to) say what you experience, you can talk about your experience without actually accusing anyone of anything; you can just say how you feel. If people say how they feel rather than try to hide how they feel, I think people of minority backgrounds can make a difference.”
Separately, the other consultant, aforementioned in this article, expresses and supports the choice to speak up, but she also highlights the inaction which is so often the case regarding such incidents: “There’s a part of me that wants to say ‘make your voice heard, raise your concerns, escalate it to the appropriate people’, but then having seen very little action and very little movement in any of this over twenty years of training, another part of me is like ‘should I just put my head down and get on with the work?’”
Ultimately, racism within the NHS is clearly an on-going issue that is yet to be properly resolved. While notable progress has been made to diminish the inequality between BAME healthcare workers and their White British counterparts, research proves that racism not only continues to play a key factor in the form of unfair treatment and career progression,
Beyond that, it is also clear that such disparity between workers contributes to the shortfall of staff, increasing the strain on healthcare services. For any of this to change, the NHS needs to prioritise the safeguarding of its workforce; a thorough investigation and on-going commitment to tackling racism in its many forms (unconscious bias, bullying and abuse, disproportionate allocation of work) must be sustained to ensure that this inequality isn’t allowed to propagate. In the meantime, it is important for nurses and doctors of ethnic minorities to support and empower one another to stand against the injustice many of them face in their professional working lives.
1. Healthcare workers from ethnic minorities felt unsafe during the pandemic, The NIHR, December 2022. Accessed at: https://evidence. nihr.ac.uk/alert/healthcare-workers-fromethnic-minorities-felt-unsafe-during-thepandemic/
2. Jones-Berry, S, COVID-19: PPE Harder to access for BAME nurses, Nursing Standard, May 2020. Accessed at: https://rcni.com/nursingstandard/newsroom/news/covid-19-ppeharder-to-access-bame-nurses-161386
3. Second Personal Protective Equipment Survey of UK Nursing Staff Report: Use and availability of PPE during the COVID-19 pandemic, RCN, May 2020. Accessed at: https://www.rcn.org.uk/ Professional-Development/publications/rcnsecond-ppe-survey-covid-19-pub009269
4. Racism in Medicine, BMA, June 2022. Accessed at: https://www.bma.org.uk/media/5746/ bma-racism-in-medicine-survey-report-15- june-2022.pdf
6. Tonkin, T, Racism an issue in NHS, finds survey, BMA, February 2022, accessed at: https://www. bma.org.uk/news-and-opinion/racism-anissue-in-nhs-finds-survey
7. Mcllory, R, and Maynard, E, Employment Survey 2021: Workforce diversity and employment experiences, RCN, June 2022. Accessed at: https://www.rcn.org.uk/ProfessionalDevelopment/publications/employmentsurvey-report-2021-uk-pub-010-216
8. General Medical Council, Tackling disadvantage in medical education; analysis of postgraduate outcomes by ethnicity and the interplay with other personal characteristics. Accessed at: https://www.gmc-uk.org/-/media/ documents/96887270_tackling-disadvantagein-medical-education-020323.pdf
9. Reynolds, C, and L’Esperance, V, Tackling race inequality in the medical workforce, BMJ, February 2023. Accessed at: https://www.bmj. com/content/380/bmj.p149
10. NHS Employers, Access resources to tackle racism and discrimination, June 2021. Accessed at: https://www.nhsemployers.org/news/ access-resources-tackle-racism-anddiscrimination
11. Dame Ruth May, et al, Combatting racial discrimination against minority ethnic nurses, midwives and associates, November 2022. Accessed at: https://www.england.nhs.uk/ long-read/combatting-racial-discriminationagainst-minority-ethnic-nurses-midwives-andnursing-associates/
12. Accessed at: https://www. equality4blacknurses.com.