The Sewell Report: Why public health is an unlevel playing field
Hector Smethurst of Appt Health reflects on how the Sewell Report on institutionalised racism misses the mark in one of its main areas — Health.
In May 2020 the murder of George Floyd triggered Black Lives Matter protests in the US and across the world. In the UK, increasing concerns about institutionalised racism led to the formation by the government of the Commission on Race and Ethnic Disparities. Then, in April this year, nearly a year after George Floyd’s murder, the Sewell Report was published. In essence, the report found that there was no evidence of institutional racism in Britain. It went so far as to suggest that the UK was a ‘model to the world’ on diversity.
A month has passed since the report was published, which has given people from across the political spectrum the time to collect their thoughts and respond to the report and its findings. Almost universally, the response from those who are committed to social justice and anti-racism has been critical.
I founded Appt in 2017 while I was a fellow on the Year Here programme. Appt is a social enterprise working to make call and recall more effective and more inclusive. Call and recall is an underappreciated part of primary care that is responsible for creating public participation in preventive healthcare and health promotion activity. During my Year Here frontline placement, I saw the challenges of delivering healthcare in communities that experience high rates of deprivation and inequality.
I founded Appt to fight back against the worrying trend where the members of the public who were most likely to benefit from preventive healthcare and health promotion activity, appointments like immunisations, health checks and cancer screening, were the same people who were most likely to find accessing this kind of care the hardest. Black and minority ethnic (BME) people are more likely to be found in that ‘hard to reach’ group. And, a lot of the time, it is the processes that are followed in the health service that can help create this disadvantage. It was this sense of unfairness — that a person’s circumstances can have a bigger effect on their ability to access care, than their need — that still motivates me to grow Appt today.
But this sense of unfairness was not immediately obvious to me. It was something that I was patiently guided towards by my colleagues in the practice, who have spent their careers working within the health service to improve health outcomes for their community. They introduced me to concepts like the social determinants of health, like health inequality. They were experts in this stuff because they dealt with their consequences every day.
How racism gets under the skin
The Steven Lawrence Inquiry, published in 1999 after his murder in 1993 and the Brixton riots of the 1980s, described institutionalised racism as “the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness, and racist stereotyping which disadvantage minority ethnic people.”
The academic literature is pretty clear on how institutional racism can get under the skin. Racism can leave its victims feeling like they are being singled out, and negatively judged by others in society. This can lead to what researchers call ‘social-evaluative threat’ which can cause stress and increase the release of stress hormones. Stress hormones can be a healthy part of a fight or flight response, but only when they are temporary. When stress persists in the long term, it can damage your cardiovascular system and lead to the unhealthy accumulation of body fat — creating a causal path for institutional racism to lead to worse health outcomes.
The Sewell report rejected the view “that ethnic minorities have universally worse health outcomes compared with white people, the picture is much more variable.” It recommended the creation of an independent office for health disparities which would target differences in health experiences and outcomes across the UK — effectively saying that more evidence was required. There is no denying that this is a complex issue, but given the strength of the evidence for the social determinants of health and the disproportionate likelihood of BME people to experience deprivation, it makes me wonder how much more evidence is needed?
The missing pandemic: COVID-19
For a report published one year into a global pandemic, the impact of COVID-19 was conspicuous in its absence. If it had been mentioned, it must surely have mentioned the impact of COVID-19 on BME communities, which Halima Begum, CEO of the Runnymede Trust, described as “devastatingly disproportionate”. The Office of National Statistics found that black people are 4.2 times more likely to die from COVID-19 — and this is a finding which continues even after deprivation and health is accounted for.
Professor Ajit Lalvani, Epidemiologist and Chair of the Bromley by Bow Centre explained that the pandemic was highlighting the faults in our society. He said, “COVID has been a torch, shining a light on inequalities, but it has also been a wedge, forcing those inequalities wider”.
Institutionalised racism undermines the resilience of all communities, but the effect is greatest on the most vulnerable. So, when a major crisis like COVID hits, those communities have less to fall back on.
An unlevel playing field: the NHS itself
But unequal health outcomes are not the only evidence of institutionalised racism in the health sector. Baron Simon Woolley, founder of Operation Black Vote and member of the House of Lords, suggests we take a look at the NHS itself: over 40% of the health service’s staff are BME but, if you look up the ladder, only 2% of the NHS’s senior leadership are. “Whether it comes to trying to enter the executive suite or to being stopped and searched, black people are at a disadvantage.”
The NHS is not standing still on this issue, though. In 2015, NHS England introduced the Workforce Race Equality Standard (WRES) to increase BME representation at a senior level. And, it’s working. Since the formation of the WRES, the proportion of BME senior managers in the NHS has increased by 30%.
Progress is possible
The formation of WRES is just one sign that progress driven from within the NHS, is possible. Over the last ten years reducing health inequalities — and all its causes — has been a growing priority for the health service. And this momentum is strengthening over time as both a top-down and a bottom-up movement. It was this movement that I was swept into on my front-line placement with Year Here and which continues to influence Appt today.
But, it’s important to realise that preventing ill health and improving health outcomes for all should be a universal priority. This can’t be something that is pushed only from inside the health service; it must be backed by policy. And if this happens, we will all benefit: healthier communities and a more sustainable health service, where we aren’t spending billions on treating avoidable illness, will create positive returns for us all.
We all share the responsibility to build a fairer society. Simon Wooley explained the need for a common purpose: “We have to have a conversation that says: what is good for black and minority ethnic communities is good for wider society too… it’s not a zero-sum game. My win is your win too, we’re in this together”. I know from my time working in a practice that my colleagues share this view. As long as NHS staff continue to work towards better, more equitable outcomes for their communities, we will see progress.
