In my two previous posts this week I’ve tried to explain the genesis of the Government’s new independent political line on race equality in this country. So, what should the NHS do about it?
Nothing. Ignore it.
The Government wants a long loud row to defend its belief that discrimination is about economic and social circumstances against those arguing for diverse identity politics.
Let’s not give them that row.
The NHS is an organisation engaged in practice. A million consultations every 36 hours. It does not need to pick political fights for their own sake. Especially if that is what the opposition in that fight wants.
In contrast to ignoring the Government’s new independent political line on race – here is another question. What should the NHS do to improve race equality in health care outputs and health outcomes?
A great deal more than they are doing at the moment.
Starting with the organisation of the NHS itself. The leadership of most of its constituent parts does not reflect the diversity of its staff. Recent efforts to improve this situation have had minimal impact.
(And incidentally if discrimination is all about socio-economic background how do you explain a such a predominance of white leadership in the NHS?)
There are more black and minority ethnic highly qualified staff, who in class terms have ‘made it’ in the NHS, than any other organisation. Senior experienced clinicians from diverse backgrounds work in every corner of the NHS. Yet very few of them reach the Board of their organisations. Is that down to the higher class of the white people who get on to the Board?
Of course not.
It’s because of systemic racism.
Since the NHS wants to change the diversity of its leadership it has to get on with the extremely hard yards of dismantling the way in which race and disadvantage work together throughout its workforce and promotion culture. It means moving way beyond kind words and policy to working through every single moment of the way in which staff are recruited and managed. As we do this, we uncover the ways in which these NHS institutions, that we love, have systemically failed to provide equal opportunities for all. I would never underestimate how painful this is.
But equally I would never underestimate the awful pain experienced by black and minority staff who have not had the leadership opportunities of their white colleagues.
Beyond the NHS as an organisation, to the people it serves, the necessary changes are even greater. Let’s separate out two issues. Health care outputs, over which the NHS has a lot of control, and health outcomes over which it has less (but still about 20%).
It is key to both of these issues that the NHS understands how its current practice fails to relate as strongly as it should to the diverse nature of its patients’ ethnic backgrounds.
The Government ‘independent’ report on race makes much of the problem of the acronym BAME. It’s wrong to treat everybody who comes from the hundreds of different ethnic communities in the UK as if they were the same. If that’s wrong (and it is) then it would be even more wrong to treat everyone who comes from those various communities as if they were white.
It’s wrong to create a single category of patients with an ethnicity called ‘BAME’. In terms of health, they are NOT all the same.
It’s even more wrong to create a single category of patients called ‘British’. In terms of health, we are not all the same.
NHS practice needs to be clear about the different propensities of its diverse population to get various illnesses and treat them as different.
To provide an equitable service for different people, it is vital to treat them as different.
If, as we know, people whose ethnicity derives from the heritage of the Indian sub-continent are 6 times more likely to develop diabetes, then if the NHS really believes in equity health care inputs must recognise that propensity.
If the NHS wants to provide equitable health care outputs to a population that has different propensities to certain diseases, it will have to match different heath care inputs to these different groups.
If we want more equality in health care outputs, we will need much greater understanding of the health differentiation that comes with ethnicity. And that must mean greater differentiation of inputs.
Treating people as if they are the same will not create greater equality in health care outputs.
Improving equality in health outcomes takes much bigger canvas but also needs differentiation. Those factors external to the NHS – economic, housing, education, and environment – that we all recognise as having a much greater impact on health outcomes need to be addressed.
And this is where he Government’s independent report on race is much less vocal. Given the core of their argument is that it’s all about socio-economic circumstances – and not about race – you would expect that there would be a range of policy recommendations to sort this out.
There are a multitude of ways to get more money into the pockets of those from poor economic backgrounds. Increase the minimum wage; increase universal credit – both increases way above inflation. Remove the insecurity of the gig economy. Double the number of large social housing dwellings built every year so that those living in mufti-generational housing can have better homes.
This would have an influence on the socio-economic background issues that impact health outcomes. And, with its newly discovered understanding of class as the determinant of unequal health outcomes, I look forward with eager anticipation to a Conservative Government implementing these policies.
As I have discussed in previous posts, this Government is committed to bringing in legislation that gives the Secretary of State the right to give direction to the NHS. It hopes to have this power from April 2022.
It’s also the case that over the coming year the Government may provide further power into its new political line on race. It may begin to impose that line on the public services it controls.
And from April 2022 it plans to control the NHS.
This means that the Government may, from April 2022, be in a position to try and impose on the NHS the political line that argues for race having a smaller impact on health care outputs and health outcomes than we know that it does.
Good luck with trying to impose that on the one million consultations every 36 hours.
That’s when the real battle starts.