One of the hottest topics right now is health inequality in the NHS, particularly amongst BAME communities which make up over 14% of the population of England. BAME communities refer to the Black, Asian and Ethnic Minority population who unfortunately have poorer health outcomes and are underrepresented at management positions within the NHS.
These are big issues that aspiring and current medical students should be aware of and could well be asked about at interview. We will therefore cover it in depth to give you a complete, rounded understanding of the matter which will be invaluable when answering a few of the potential medical school interview questions listed at the end of the blog.
When thinking about why a group of people may have better or worse health outcomes in the NHS we need to think about the determinants of health. We can divide these into four core categories:
These categories are by no means separate but are interlinked. The significance of genetics, lifestyle and nutrition has received a lot of attention historically, but we are now also beginning to realise the the non-medical factors that affect health.
These are called the social determinants of health, and may include the following factors:
Research is starting to show that the social determinants of health may be the root cause of half of all health outcomes, making it potentially more influential to our overall health than the lifestyle choices we make.
It was identified by the Marmow review in 2010 that there are ethnic disparities in health and that something needed to be done. For example, South Asian's are 6 times more likely to be diagnosed with Type 2 diabetes compared to the White population, and have a 50% higher risk of dying from heart disease and strokes. It is naive to think that the reasons for these ethnic disparities is due to genetics alone; it is a mixture of genes, lifestyle factors and the social determinants of health that play a role.
Below, we've outlined 3 reasons why ethnic minorities have poorer health: deprivation, access to healthcare and racism.
Ethnic minorities are more likely to experience deprivation, and this is associated with poorer health outcomes. Statistics show ethnic minority groups make up a significant proportion of the most deprived areas within England. Overall, 15% of people from Asian and Black communities live in the most deprived 10% of neighbourhoods in the country compared to 9% amongst White British people. This statistic is even more alarming amongst the Pakistani and Bangladeshi communities, of whom 30% and 20% respectively live in the most deprived neighbourhoods in the nation. This shows there is a strong correlation between ethnic minority groups and deprivation within society. But how does this relate to health outcomes?
One simple measure of health is life expectancy. This is the number of years a person can expect to live. Whilst the average life expectancy of a child born in 2018 UK is 79.6 years for males and 83.2 years for females, there is massive variation depending on where you live. For example, in the North-East of England there is a 13-year difference in life expectancy between the most and least deprived areas. Furthermore, another measure of health is the healthy life expectancy, which predicts how long we spend in ‘healthy’ and ‘ill’ states. The same pattern presents here, where in deprived areas habitants spend around 30% of their life in ill health compared to 15% in the least deprived areas. Putting these together, we can see that deprivation not only reduces life expectancy but also reduces a person's quality of life as they spend more of their life unwell.
So how exactly does deprivation translate to poor health? Deprivation can affect someone's health in a number of ways. For example, people who receive a low income are less likely to be able to afford healthier food options and gym memberships. They may work multiple jobs and unsocial hours leaving them little time to meal prep, exercise or visit the GP if they're unwell. Their job itself may require more manual labour which may take its toll on their physical health. The stress of their financial situation may damage their mental health or push them to turn to alcohol or smoking as an escape. All of these chronic stressors combined contribute to the development of long-term mental and physical disease which just accentuates the situation further resulting in a vicious cycle of stress and deteriorating health.
Access to healthcare is also a huge factor due to barriers such as communication and culture amongst ethnic minorities. Being a multicultural society with many different languages, living styles, and beliefs is a difficult challenge for the NHS to overcome.
As a result, patients may:
The inability of both the NHS and Government to cope with a multi-cultured society has led to poor access to health for patients from minority ethnic groups which has a huge bearing upon their health outcomes.
We know that compared to the White population, patients from ethnic minorities are unfortunately less likely to:
Racism continues to exist in our society and is affecting the ability of ethnic minorities to succeed and attain high-earning jobs. Naturally, this is likely to lead to deprivation. However, a less obvious impact of racism is the effect that racial abuse can have on mental health and the stress it can cause. Racism contributes to the several stressors that are already prevalent amongst the ethnic minority communities as a result of deprivation such as child poverty, lack of education, inadequate housing, and food insecurities. As aforementioned, it is the combination of all these chronic stressors that research has shown increases the risk of long-term conditions such as diabetes, inflammatory diseases, and psychiatric illnesses. Communal racism also stretches to NHS care itself, which we will touch on later, with 78% of Black women in a large survey believing that their health isn’t as well protected compared to white people in the NHS.
A statistic that has become a headline recently (and rightly so!) is the remarkable increased death rate amongst Black mothers during childbirth. Maternal deaths during childbirth has reduced markedly in the last few decades with statistics showing that on average maternal mortality occurs in fewer than 10 deaths in every 100,000 pregnancies but again, this is an average figure. When we look at stats for particular ethnicities, they are alarming:
Shockingly, the maternal death rate is over FIVE times higher in Black mothers compared to White mothers. But why is this? We don’t know the definitive reason but the BMJ have an inkling that there is some institutional racism in the form of conscious and unconscious bias which is influencing the quality of antenatal, labour and postnatal care Black mothers are receiving. For example, healthcare professionals may believe that Black people have a higher pain threshold, and therefore may not give them enough pain medication when they need it. There is also an argument about the lack of ethnic diversity within clinical trials which means that guidelines and treatments are largely based on what works for White mothers only.
Statistics show that people from ethnic minorities have the highest COVID death rates in the UK. In the first wave, Black males were 2.7 times more likely to die from COVID than White males. Similarly, Bangladeshi and Pakistani males were 2.5 and 1.8 times more likely, respectively.
Other significant statistics during the first wave include:
This is clear evidence of health inequality against ethnic minorities in the Covid pandemic. However, the pandemic has not created health inequalities but exposed them. We know that the severity of Covid is increased in patients with co-morbidities such as high blood pressure and diabetes as discussed earlier, but remember again, these co-morbidities themselves are partially due to health inequality itself.
Alongside an increased risk of dying from Covid, ethnic minorities are also at a higher risk of catching Covid. These communities are more likely to have frontline occupations, live in overcrowded conditions, and use public transport – which all increase the risk. The ONS has concluded that the cause of Covid being so threatening in minority groups is largely based on demographic, geographical, and socioeconomic backgrounds with a large emphasis on occupation and living conditions.
You can read more about this topic and practice interview questions in our newsfeed article here.
Away from the impact that being from a minority ethnic group may have on health in the NHS, it also influences NHS jobs. Ethnic minorities make up 21% of NHS staff in England, and 44.9% in London. However, despite this wide representation in the general NHS it was reported in 2020 that only 8.4% of leadership boards in NHS trusts are made up of staff from ethnic minority backgrounds. As well as this, 15% of ethnic minority staff have reported discrimination in the workplace compared to 6.6% of White staff members. Furthermore, in 2016 it was shown that healthcare workers from ethnic minority groups were 1.56 more likely to be accused of malpractice and enter the formal disciplinary process compared to White healthcare workers. In London, they are twice as likely. Have a think about the case of Dr Bawa Garba, and reflect on whether you think racism played a role in her situation.
The only reasonable explanation for all three of these statistics is racial discrimination. To see an element of institutional racism in the NHS is heart-breaking. The NHS is built upon the values of fairness and equity to both its patients and staff. If these core values are not upheld then it will affect the health of our healthcare workers, our patients and ultimately the health of the nation. In 2016, the NHS introduced the workforce race equality standard (WRES) to help increase fairness amongst NHS employees which is having an impact in slowly decreasing the disparity in management jobs between White and Ethnic minority NHS staff but a lot of work still needs to be done. If we are able to close this gap and have more people from ethnic minorities in positions of influence in the NHS, then hopefully this will have a knock-on effect on the way patients from ethnic minorities experience healthcare.
As a future healthcare professional, it's important for you to be aware of the reality of healthcare in the NHS. In a multicultural nation, minority ethnic groups are being marginalised as a victim of austerity and bias which is compromising their health. It is a combination of deprivation, poor access to health, discrimination and genetics that all play a role in how ethnic minority communities are receiving poorer health outcomes. The system is failing a huge proportion of the population, and by being aware of this, you can be part of the solution, not the problem.
So how may this topic crop up in an interview? Not all questions will directly ask about this topic, however, showcasing your knowledge of it anywhere you think it could be relevant will really impress the interviewer.
Potential questions where you could bring it up include:
Author: Dhillon Hirani
Editor: Latifa Haque