TWO PANDEMICS, NOT ONE: HOW “RACIST” NHS IS FAILING ITS STAFF OF COLOUR

• NHS has been slow and disjointed in recognising and responding to disproportionate deaths amongst its Black and Brown staff members.
• Staff of colour report having to take PPE from Intensive Care Units due to shortages; in one Essex hospital, management gave out expired masks to medical staff.
• Conflicting NHS and Public Health England guidelines left many staff of colour treating suspected COVID patients without even wearing surgical masks, leaving them vulnerable to infection.
• POC staff feel under-protected, and under-supported by an organisation that is “institutionally racist”.

The twin pandemics of COVID-19 and institutional racism have been roaring through the NHS at once. Much has been reported on how People of Colour (POC) have been disproportionately affected by the Coronavirus. Government reports and reviews have been ordered but little has been done to interrogate the racism at the heart of the NHS.

What this investigation reveals is that the NHS’ was woefully disjointed, and slow in recognising that People of colour, and particularly Black communities, were dying at a disproportionate rate, and consequently were slow at taking action. This potentially has unnecessarily cost yet more lives to the virus.

Testimonials from tens of Black and Asian nurses and doctors reveal distressing stories of racist bullying, unwelcoming and unsupportive management, and a complaints procedure that is uninviting. What these testimonials further underpin is a systemic issue of racism that permeates at “all levels”, according to a senior member of one London NHS Trust who preferred to remain anonymous. They also put to serious question both NHS HQ and individual Trusts’ responses to the disproportionate number of Black, Asian and People of Colour dying from the Coronavirus.

Requests for information about risk assessments were sent to dozens of NHS Trusts and were largely ignored. The requests that were answered reveal a disjointed and inadequate attempt to prioritise the safety of high-risk Staff of Colour. 25 NHS Trusts with some of the highest non-white populations in the UK were contacted and asked a plethora of questions, one being whether they had sent risk assessments for their staff of colour to complete. Of those 25 that were contacted, just 2 replied: The Central and North West London NHS Foundation Trust, and Barts Health NHS Trust (the latter being responsible for hospitals in the two of the worst affected local authorities in the UK, Tower Hamlets, and Newham).

Barts Health NHS Trust did not provide any answers to the questions pertaining to when Staff of Colour were sent risk assessments, nor to what other steps the trust had taken to protect Staff of Colour. Their response was: “As recommended by NHS England on 29 April Barts Health is risk assessing all staff at potentially greater risk in line with NHS Employers guidance.”

Central and North West London NHS Foundation Trust responded saying that risk assessments were sent out to Staff of Colour on the 7th of May, with the CEO having written to “BAME staff on the 29th of April”.

Source 1: A screengrab of part of the reply from the Central and North West London NHS Trust.

They also showed the responses of staff of colour to a survey that reveals that many felt “scared and frightened but feel [they] have to put on a brave face” for fear of being labelled “troublesome”. The reply also shows that POC staff “do not feel appreciated, listened to and understood.” These responses reflect the experiences of many staff that spoke to me.

The data

The statistics that have emerged from this coronavirus crisis paint a depressing picture for people of colour in the UK. According to the Office for National Statistics (ONS), the mortality rate involving Covid -19 was lowest among white men at 87 deaths per 100,000 while highest among black men, at a considerable 255 deaths per 100,000 people. For Bangladeshi and Pakistani men the death rate stands at 191 per 100,000 people, and for Indian men it is 157.6.

The figures become even more alarming when compared to the make-up of these ethnic groups in the general population. White people make up 80.6% of the population, while the next single biggest ethnic group are Asians who make up 7.5% of the population. Indians, the largest Asian group, account for 2.5% of the general population, whilst Bangladeshis account for just 0.8%. Despite being the larger ethnic group, Indians have a considerably lower death rate compared to Bangladeshis. Black people account for a total of 3.3% of the population, and their death rate is by far the most disproportionately high.

When looking at the average household wealth averages across ethnic groups, ONS statistics reveal that the average white British household earns 63% more than Black British households. The ONS also show how top income groups were less likely to have had exposure to the virus.

Source 2: COVID Male Death rate vs Average Household Income

Source 3: COVID Female Deaths vs Household Income Average (source: ONS)

However, the reality is that doctors earn above the median British income, yet even amongst doctors, Black and Asian colleagues remain far more likely to die from the virus than their White counterparts, suggesting that institutional racism has a part to play. For context, all but one of the 17 doctors who are known to have died from COVID-19 are of Colour.

Source 4: London Local Authority Death Rates vs Average Income

(Source 4, above, shows COVID death rate per 100,000 in each London local authority. The darker the colour, the higher the Death rate. Newham, the most ethnically diverse local authority in the UK has the highest death rate in London. Richer and less ethnically diverse areas trend with lower death rates.)

Some NHS workers recall their frustration with PPE shortages, and changing guidelines that meant staff were not permitted to wear filter masks even when aerosol-generating procedures were carried out. They reveal a worryingly low level of trust in the complaints system, as well as countless experiences of racism from patients, white colleagues, and managers.

The realities for NHS Staff of Colour and particularly Black staff are not pleasant. In a 2019 NHS report, it was revealed that Staff of colour were considerably more likely to be formally disciplined than white staff. The statistics reveal that “BME staff were relatively more likely to enter the formal disciplinary process in 64.8% of NHS trusts.”

The complete lack of a cohesive response in attempting to address the issue of Staff of Colour being disproportionately affected by COVID is laid bare by the experiences of NHS staff of colour. Amber Rajan, 27, who works at Kings College Hospital, London, says that she has not yet “received any risk assessments” to complete. “Not one of my BAME colleagues that I’ve spoken to has received a risk assessment either.”

“At the beginning of the epidemic around March, there were so many times where me and other doctors were directly exposed to patients experiencing COVID symptoms but Occupational Health said we couldn’t wear masks.” Amber additionally recalls how “difficult” it was to access testing, and all the while there was “no clear guidance and there was no uniform guidance regarding what we could and couldn’t wear.”

She also highlights the lack of Personal Protective Equipment (PPE) that appears to have been a common issue at a considerable number of hospitals across the country: “If you worked in ITU (intensive care unit) COVID areas you had PPE but if you were working in surgery there was initially a lack of protection.”

Amber complains of a guideline focused approach taken by senior doctors and nurses in her ward that in her opinion did not work practically or appropriately to the required needs of patients coming in with symptoms. “One of the biggest problems is that because people were so concerned about following guidelines, patients with some but not all of the symptoms were being told they didn’t qualify for testing, and because they weren’t getting tested we weren’t allowed to wear protection when treating them. [The guideline heavy culture during COVID] has been very ineffective and very protocol based rather than common sense”.

“In A&E for example, they’re very guideline heavy. We had a patient of colour who was very unwell. I was asking the nurse to oxygenate him and the white A&E registrar said ‘but do we need to give it to this patient’ since his condition did not meet the guidelines.” Amber stresses how the guideline over common-sense culture is compounded by a hierarchical system of staffing that flared up in this situation. “The white ED registrar was coming at me in a way that was ‘I’m at this level and you’re at this level so you had better listen to what I am saying’. My more senior colleague, who is a black woman and is a registrar had to intervene and say ‘actually I’m more senior than you and I want this patient to be oxygenated and taken to theatre now’. The white doctor kept persisting though which I really doubt would’ve happened if she had been white. In the end he stormed off really angrily which I thought was very unprofessional.”

Amber adds that “unfortunately this is not the first time something similar to this has happened.” Several other staff tell me that the hierarchical nature of staffing within the NHS is not conducive to a healthy working environment between staff, and can exacerbate existing racial biases.

NHS data reveals that while white and black staff make up 50.1% and 7.2% of trainee junior doctors, this shifts dramatically to 60.7% of senior consultants being white and 2.9% being black. As Mariella Fortune-Ely, a black junior doctor working at the Royal Free Hospital notes, “there’s diversity amongst me and my junior doctor colleagues, but the senior consultants on my ward are all white. There isn’t a single black consultant in the ITU ward but most of the patients there are black.” This stark difference between the make-up of consultants and the patients that they are treating, especially in such an ethnically diverse global capital like London is worrying to some including to Rita* who works in Human Resources at the NHS.

Revealingly, in a Zoom chat held by management about the high number of deaths attaining to people of colour from coronavirus, Mariella alleges that “white ICU consultants said [they] might not be taking symptoms of POC as seriously as we would have [with white patients].” The issue becomes even more prescient given that during the peak period of COVID arrivals, management together with the ICU consultants at the Royal Free decided to lower the danger limit of oxygen in the blood from 94% to 90% which was a move Mariella states her and most other doctors were “not comfortable with.”

A senior member of NHS staff who preferred to remain anonymous but who works as Inclusion and Diversity Rep at a South London NHS trust highlighted the way in which the organisation is too focused on waiting times and budgets at the expense of wanting to make any “serious push to achieve a more equitable culture”. “The people at the top of the NHS are all elite, white and upper middle class and there is absolutely no desire to change that. What happens because of this is that decisions that affect ethnic minority staff members who are much lower paid are taken without much thought about how it is going to affect them.”

This is a point that Rita* articulates further. “Before I joined my Trust, every time the department wanted to order more equipment or get more money for anything my colleagues would have to sit in front of a finance panel who would scrutinise everything. There is a real hostility towards spending more money in the NHS; the culture is very pro- cost cutting. A colleague told me it took ages for the finance team to agree to buying more oxygen masks for the Trust”.

The perceived and pronounced disconnect between staff of colour and the largely white senior management staff is seen as an issue by both Rita and Moya* that contributes to a culture that is overall hostile to POC and their concerns. Rita recalls an uncomfortable memory where one of the white senior management at her Trust which has a very high BAME population made an “arrogant and uneducated” complaint about how so few immigrant nurses were getting vaccinated against the Influenza (flu) virus and how this was “stupid”. “This type of comment didn’t get challenged but it should have been. It comes from a place of privilege and a complete lack of understanding of the real cultural sensitivities that some communities have around vaccinations.”

On how class operates in the NHS, Moya* continues, “There’s a massive class factor in the structure of the organisation and the patient outcomes reflect that. You have white middle class doctors working in hospitals in deprived London areas and they’re treating black and brown working class patients. Inevitably this creates negative outcomes for those patients as there’s a lack of trust on part of the patients and an empathy gap on part of those doctors. White doctors may not even be aware of the fact that there are different health outcomes for different ethnic groups so even if they’re supposedly treating everyone the same regardless of colour, there’s still that to consider. Lots of important things can get missed because of lack of perception and awareness.” She points out how Black women are perceived to tolerate pain easier than white women and how this explains an historic higher mortality rate for Black women in labour.

The hierarchical nature of the NHS is problematic, she agrees, “it’s very archaic and it exacerbates issues with discrimination and makes it harder for people that have been victims of racism to speak up against it as they feel those with the senior roles will be heard and respected over them.”

“Speaking up about abuse within the NHS is a very hard thing to do and unions aren’t that helpful either in this regard. The uncomfortable narrative within the NHS is that you’re going to lose your jobs and you’re going to be the bad guy so why would you report and whistleblow if it doesn’t have a positive outcome? They’ve [the NHS} created the policies that are meant to safeguard whistleblowers but people don’t feel safe still because the consequences of speaking up are still detrimental.” Moya continues, “you’ve also got to realise that the majority of those experiencing racism are going to be those in lower paid, more junior roles. They simply can’t afford to lose out on pay and that is one of the consequences of speaking out.”

As part of her role in Human Resources, Rita was made responsible for launching and running a coffee drop in session for staff at the Trust, where they were encouraged to talk about and raise any issues they were experiencing with management. “Most of the people that would come were female nurses who didn’t speak English as their first language. They would come to us and say this service manager is bullying me, that service manager is abusive to me. They said they don’t trust the management and they have concerns about reporting their experiences because they’d rather stay anonymous or just brush it off.”

Concerns amongst ethnic minority nurses at the so-called ‘coffee and chat’ sessions about NHS managements’ ability and willingness to properly handle complaints of abuse stemmed from previous poor experiences they had had. In one case, Rita says, a member of the nursing staff had written a whole report detailing her experiences of being bullied by a manager that was ignored, and when it was re-raised, the said manager was “given a warning but allowed to continue working.”

For Rita, the stories she’s heard working in HR demonstrate how the infrastructure in the NHS is not suitable nor accommodating to staff of colour that feel victimised or bullied. “The experience itself showed how poorly people were treated and governance was not built around the safety and wellbeing of staff, especially female staff of colour. They [Staff of colour] feel that nothing will get done, and they just don’t feel supported. There are so many white people in managing positions that aren’t friendly so how are you really going to feel reporting that stuff anyway?”.

“He’s nice but a bit of a Nazi” : A culture of failure to protect NHS Staff of Colour

The uncomfortable and unenviable situation that Isabella describes is one that countless people of colour face when working in the NHS and also one that medical student Duaa Musa, 21, can relate to. Duaa is mid-way through her medical degree at the University of St Andrews, and for her, the racism she experienced was while undertaking trainee doctor placements at a Fife hospital in Scotland.

“It’s always been a specific way that people treated me”, she recalls, “whether it is other NHS staff or patients. In many cases, the person I am in contact with will always assume that I am an international student — which is not a bad thing — but they will always automatically assume I will not understand the work I will be given.” She was particularly aggrieved when while the doctor responsible for supervising her GP placement in Cupar, Fife, acted in a “racist” manner towards her. “At first glance he assumed I was an international student due to me wearing a headscarf and the colour of my skin. Because of this he immediately treated me like I had no understanding of the way the medical field worked. He was meant to spend the time explaining stuff to me but he mostly ignored me between shifts. Even when I tried to talk to him he kept giving me the cold shoulder.”

The doctor in question continued to ignore her throughout the shift, she says, until he found out that her father was a doctor when she mentioned it during a consultation with a patient. “At this point I realised that the doctor had only seen me better due to my dad’s career and if it wasn’t for that, I would’ve spent the whole placement having been ignored. This may seem like not a big thing but when you are in a place of education and the main educator refuses to teach you anything because they don’t see you as important as them. Whether it’s due to differences in skin colour or religion, you are set back.”

“I’m sure this doctor was not like that with my fellow white colleagues. In fact none of my white coursemates that also did the placement told me they had a remotely similar experience”, she says.

On the topic of making a complaint, Dua is adamant that had she put one through, “they [management/HR] wouldn’t take it seriously especially since the doctor [who mistreated her] is of such a high position. And they could easily say that he is busy or overthinking it. The problem is that it’s not just one or two doctors. It’s a large number of them. They will always favour white colleagues.”

Raksha Naik, who also undertook a medical placement at the same hospital in Cupar, Fife, experienced racial antagonisms while working. “I’ve gotten the question ‘where are you from?’ from a doctor who was meant to be teaching me, to which I answered Glasgow and then got ‘oh so you’ll be familiar with the language then.’” She additionally recalls another doctor suggesting that if she did have patients who were racist to “just let it slide.”

Teniola Dowie, who is black, has had to deal with outright anti-blackness while on her placement. “I’ll never forget my first or second week on placement where a very senior member of staff told me to be careful when I was performing basic life support on a colleague because in their words it ‘looked like I was thieving’. I’d literally just started the placement,” she recalls.

“I’ve also had cases on placement where patients have made racially insensitive comments towards me and it’s hard to deal with sometimes. For example, on one placement I was left alone with a patient who asked me where I was from and I said ‘Manchester’, and she said, ‘No you’re from abroad. Africa? Maybe not.’ I’m used to people asking me where I’m from, but she later asked if I liked Scotland to which I replied ‘yes’ and she said ‘Good, you can stay then’.” Further demonstrating the lack of proper safeguarding available for medical staff of colour and lack of consideration for them by white members of staff, Teniola describes an incident where a clinician simply warned her that a patient was ‘nice but a bit of a Nazi’ before leaving her alone with them. “These were just a handful of incidents to name a few”, she tells me.

On the issue of patient care, Dua maintains that she “truly [doesn’t] think patients of colour are given the same level of care as others.” “I don’t know whether it’s because NHS staff believe that the patient has a lower level of understanding or that they are too lazy to ensure the patient and received and understood all the information. I’ve seen this impact many first generation immigrants, who have the ability to speak English but the doctor will just assume that they will have difficulty [speaking and understanding English]. In the end they get limited care.”

Dua additionally has personal experience of seeing her own mother fall victim to perceived racial biases from NHS staff which has meant that her “GP or hospital staff have not provided her with the correct care resulting in the deterioration of her medical condition.”

A Junior surgical doctor working at an Essex Hospital who requested to be anonymous reiterates an uncomfortable line that many others told me in regards to what it was like working during the peak infection period: “We were like lambs going to the slaughterhouse”.

They were impressed by the state of preparations at their workplace. “You’d never send soldiers to war without armour, you need to give them the protection they need. The same should have been done for us.”

“When the FFPE (filter masks) arrived, the matron had put a label to cover a label that showed they were all actually expired. Can you imagine being given expired masks?”. They tell me that one of the most frustrating periods while working during the peak period in March and April was how the level of risk for different wards would change on a day to day basis. “It would cause me so much anxiety, not knowing if I’d be putting myself at risk on the surgical ward or not. The reality is I was.”

Long waits for test swabs to return added to the anxiety. “It took weeks to get swabs back at one point; in March the average wait was over seven days.” Around patients that hadn’t had their results yet confirmed, medical staff were not allowed to wear FFP3 (filter) masks.

Frustrations were hard to keep at bay for the surgical doctor and they would regularly complain about the poor protections in place. They offer another stark example of how dire the situation became in March: “during the peak period, we were told to wear a plastic visor when taking bloods or when generally treating a confirmed positive case in our ward. We still weren’t given PPE because it was limited to the Intensive Care Unit.”

At the same time, they say the “majority” of the patients that got “really, really unwell” in the Essex hospital were of colour. For added context, in the 2011 census, 90.8% of respondents defined themselves as ‘White’ in Essex.

“We were around two weeks behind London’s wave. We had enough PPE in the high risk designated areas like ITU but they weren’t distributed in the right areas,” they continue. They decided to take matters into their own hands by secretly taking masks from ITU to treat patients exhibiting symptoms that were nonetheless kept in ‘low-risk’ areas. “It wasn’t just me. A lot of people were carrying extra ones in their bags because we just weren’t being protected. We were covered by PPE eventually but it was just too late.”

Despite going above and beyond the guidelines enforced by their management, and NHS England, the surgical doctor still got infected with COVID, as did 30 of their colleagues — most of them being of colour. No special protections were granted nor did management express any recognition of the fact that Black and Asian staff were more at risk than others, they say.

Jazmin Ahmet, a newly-qualified cardiac nurse working in Nottingham, shares many of those same concerns and experiences. “The first few weeks were so hectic. There were so many admissions.” She wasn’t encouraged to wear a mask so in the first few weeks, she treated somebody while not wearing any protection. “A few days after I’d treated him I was told he had tested positive and had become really unwell,” she recalls. The patient passed away a few weeks later.

Jazmin talks of another traumatic experience, when after looking after a man with chest pain who despite having tested negative, still passed away from COVID. Jazmin was never required nor encouraged by management to wear PPE, yet at one point just “one box” of surgical masks were left — which meant she and her colleagues were often not wearing any protection while treating potentially infectious patients.

Protection at Jazmin’s Nottingham hospital was running low extremely often throughout March and April. She recalls a moment when she and her colleagues couldn’t find any visors ahead of an aerosol generating procedure. “We went looking in the other wards and couldn’t find any there either. People had to share a couple visors per ward.”

In sharp contrast to Zana, Jazmin did receive an email from her management acknowledging how the virus was affecting Black and Minority Ethnic people a lot more than white people. However, this email wasn’t sent until May, which highlights the slowness and overall disjointed nature of NHS England’s communication on the matter.

Jazmin describes a hectic working environment, where the primary priority for herself and her colleagues is to ensure that beds are held for as little a time as possible so that patients can be moved in and out of wards as quickly as possible. “As soon as swabs get back, we’re moving that patient to either a COVID ward or a low-risk ward. The problem is that there are frequently times when there are too many people to move in or out so some wards have become mixed like mine, where COVID patients are housed with non-COVID patients.”

Krizsti Szanto, a junior doctor working in Brighton, expresses a familiar experience working on wards that were overflowing with COVID patients, running low on PPE, and grappling with conflicting and ever-changing guidelines.

“No one had any idea what PPE to be using until the 2nd of April because we weren’t being told clearly. I treated a cardiac patient without wearing any PPE because I didn’t know whether he was positive or not.”

She was frustrated at the testing limitations. “It was abysmal that we couldn’t test until patients actually had all the three major symptoms. A lot of consultants tested their patients anyway though.”

The perpetually changing and oftentimes confusing messaging that NHS’ managements, and NHS England were sending to staff is because the “people who make the decisions in the NHS are so, so far removed from the hospital experience”, Moya* tells me. “It’s very difficult for staff to know what to do. There’s a lack of decision making and because everything is so centrally controlled, a lot of lackeys are just waiting around for others to tell them what to do.”

“You have to directly compare the NHS’ own mismanagement of the epidemic with that of the Government’s: the two [bodies] are very closely related. Just look at who runs the NHS in England [Sir Simon Stevens] — he’s really good university friends with Boris Johnson. There’s less accountability the higher up you go.”

While 40% of NHS doctors are of colour, just 5.5% of the NHS executive board is not white. This is the material consequence of a culture and system, Moya* tells me, that is structurally racist. “You’ve got just three members of the top board consisting of 20+ people that are of colour — and only one is actually an executive. None are black. People say the NHS is culturally left-wing. The truth is that as an institution it is no different from all the other institutions in the UK, in that it is racist by default.”

“You will not reach high up as a person of colour in the NHS unless you do and say what the white people at the top want you to do. Hence why Trevor Phillips is running the report into BAME deaths”, she says. Trevor Phillips, a black man, has been widely condemned by anti-racist activists for historic Islamophobic remarks, and views on institutional racism. It has since been uncovered however that he played little role in the review. Boris Johnson has however announced a further review into racism by a trusted Tory advisor Munira Mirza, who has made public statements casting doubt on the very existence of institutional racism.

What’s more, the report into the disproportionate COVID deaths by ethnicity itself has been vociferously attacked for failing to not “discuss the overwhelming role structural racism and inequality has on mortality rates” by Harun Khan, the secretary general of the Muslim Council of Britain, “whilst simultaneously providing no recommendations or an action plan, despite this being the central purpose of the review.”

It took until the 28th of May, for a page detailing guidance for NHS organisations on how to enhance their risk assessments for at-risk groups to be posted on nhsemployers.org. The page outlines the following guidelines:

• Organisations should ensure that line managers are supported to have sensitive and comprehensive conversations with their BME staff, recognising the long-standing context of the poorer experience of BME in all parts of the NHS.
• Most importantly, the conversations should also, on an ongoing basis, consider the feelings of BME colleagues, particularly regarding both their physical safety, their psychological safety, and their mental health.

The page also outlines a list of ten adjustments that should be made in the case that any staff are identified as being at greater risk of serious ill-health from COVID. These include “avoiding public transport through adjustments to work hours”, “redeploying staff to a lower risk area”, and “providing surgical masks for staff members for all interactions with patients or specimens.”

What the realities show is that many NHS members of staff feel interventions have not helped staff of colour feel more secure, and they’ve likely come too little late to make a material difference. What’s clear is that the coronavirus has laid bare the other pandemic that has scourged the NHS for decades: racism, and there appears to be little appetite from the top to eradicate it.

*Names have been changed to protect anonymity of sources.