Time to rethink our approach to racial discrimination in the NHS:
The next big idea
by Rajan Madhok
Racial discrimination is a fact of life in the NHS. The occasional glimpse of a breakthrough – like BAME (Black and Minority Ethnic) people reaching senior positions – does not mean that the system has become a merit-based level playing field. Numerous enquiries and initiatives, such as WRES (Workforce Race Equality Standard), have failed to address the underlying problems. The resulting frustration of BAME communities is justified, real and palpable.
But does it have to be this way? What can and should be done? Let us start with exploring the current situation.
What, where and how big is the problem?
My understanding is that many ‘old’ issues have been addressed; systems have been introduced to limit bias in medical school admissions or training or substantive appointments, and are working. Even issues around some leadership positions have been addressed. Where there is limited representation of BAME individuals, then perhaps another factor could also be at play – for example socio-economic class.
A new way forward may be to acknowledge the (albeit limited) progress, without giving up the quest for equality, and by reviewing the narratives. You may be familiar with the oft-quoted Esmail and Everington study, where identical CVs were sent under different names (1). This study is useful as a reminder of where we have come from, but may not reflect current reality. Why do we often repeat and re-live these past experiences? My father struggled, but did I? Can I see the friendliness implied in a shortened or ‘nick’ name- since it is a common practice in the British culture?
There is also the tendency to create more labels and divisions – what started as White vs Non-whites debate, became BME (now BAME) and then split even further into Afro-Carribeans and South Asians etc. I was particularly intrigued by South Asian Heritage Month festival – what unites this broad group apart from the historical fact of being ruled by the British. Such refinements are useful in some contexts, but may not be very effective in positive system/cultural change.
The whole racial situation is compounded by general and noisy polarisations in society and increasingly adversarial approaches to problem solving. We’ve seen complaining, campaigning, enquiries and discrete initiatives. But doing more of the same is not enough; we need a rethink. I am particularly looking at the younger generations of clinicians, who are facing different challenges to those that affected my generation of immigrants, and they have new opportunities too. Let us remind ourselves of the Hippocratic Principle of First, Do No Harm- and stop adding to the problem.
So is there a way forward? What is the new big idea to address racial discrimination?
Actually what I have is not new, more a reminder but maybe the time has finally come for these. In particular I want to highlight two, overlapping, things: firstly, to draw parallels with medicine we can borrow from Geoffrey Rose’s Big Idea: Changing the population distribution of a risk factor is better than targeting people at high risk (2). Secondly, I want to draw from the Zen and the Art of Motorcycle Maintenance – almost the ‘Bible’ for my generation (even though its lessons are universal in all religions, and exemplified by Gandhi, King and Mandela); and this is what the protagonist had to say: “I think if we are going to reform the world, and make it a better place to live in, the way to do it is not with talk about relationships of a political nature… The place to improve the world is first in one’s own heart and head and hands, and then work outward from there.”(3) So learn, and practise, connection at the human level – before we are white or BAME (or indeed women or men or of different sexual orientation) we are human beings and need to observe some basic humanistic principles and practise appropriate behaviours of respect, tolerance, support, etc. By all means let us be proud of our heritages and remember history but not with a view to creating the ‘other’ or for holding onto grudges. Let us explore what unites us – the love of the NHS – and celebrate successes. Let us complain less but be assertive (not aggressive). With increasing divisions, there is a danger of turning on each other – ‘Black on Black’ discrimination used to upset me more than the ‘White on Black’ discrimination. We need to become Inclusive not Exclusive.
In closing let me ask: Do you have a view on what success would look like? The ‘Snowy White Peaks’ (4) can come down- but be careful as they can be like erupted volcanoes when all that is left is devastation. Create a new vision and pursue it, by setting an example yourself – do not fight the old battles, it’s a new world. The NHS needs all races to win the race especially during this pandemic.
About the author
Rajan Madhok, originally from India, worked as a director of public health and medical director in the NHS until his retirement from active service in 2012. Since then he has been working, in both paid and voluntary roles, to promote leadership development with focus on professionalism and ethics and in capacity building. See https://www.peoples-uni.org/content/trustees for further details and his last article on the subject of race is at https://www.hsj.co.uk/comment/treatment-of-foreign-and-bme-staff-exposes-the-erosion-of-nhs-values/5072572.article
Declaration: I was on the WRES Steering Group but resigned after the initial meetings.
1. Esmail A, Everington S. Racial discrimination against doctors from ethnic minorities. BMJ 1993;306:691-2. (accessed on 05/10/2020 https://www.bmj.com/content/306/6879/691
2. Hofman A, Vandenbroucke JP. Geoffrey Rose’s Big Idea. BMJ 1992; 305: 1519-20. (accessed on 05/10/2020 https://www.bmj.com/content/305/6868/1519)
3. Pirsig R M. Zen and the art of motorcycle maintenance. 1974
4. Kline R. The snowy white peaks of the NHS, 2014. (accessed on 05/10/2020 https://www.england.nhs.uk/wp-content/uploads/2014/08/edc7-0514.pdf )