Facing the uncomfortable possibility that healthcare is discriminatory

When Covid struck and BAME patients died disproportionately, students of heath inequalities were not surprised

As the first Covid wave hit, it quickly became clear that people from black and ethnic minority backgrounds were dying in disproportionate numbers.

The immediacy and visibility of these deaths was shocking and revealed a disparity so clear-cut that some wondered if the explanation could be genetic. But those who have spent a lifetime studying health inequalities were less surprised. People from black, Asian and minority ethnic (BAME) backgrounds do worse across a wide range of health outcomes.

Black women in the UK remain four times more likely to die in pregnancy and childbirth than white women. Black and ethnic minority patients are less likely to be prescribed newer medication for type 2 diabetes and are more likely to suffer retinopathy, a side-effect of the disease that can lead to blindness. The revelations that black and Asian people have to wait longer for a cancer diagnosis is another stark example.

When trying to understand the causes of health inequalities, there has too often been a complacent tendency to look at factors that set minority groups apart, rather than face the more uncomfortable possibility that the healthcare system itself is discriminatory.

If a group of people are genetically vulnerable to a disease, for example, the NHS can hardly be blamed for worse outcomes (genetic factors are rarely a major contributor to health inequalities). Socio-economic factors can play a substantial role in health outcomes, but this problem is mostly beyond the remit of healthcare leaders. Academic papers refer to “healthcare-seeking behaviour”, a phrase that seems to subtly place responsibility for poor outcomes on patients who failed to attend the doctors in a timely fashion. In fact, a recent report from the NHS Race and Health Observatory concluded that many people from ethnic minorities may delay or avoid seeking help because they fear racist treatment from NHS professionals.

The differences in diagnosis wait times for black and Asian people compared with white people provides clear evidence that health inequalities can – and often do – result from inequalities in the healthcare system. These were all people who attended their GP surgery with symptoms. Underlying risk factors such as diet and lifestyle cannot have played a role.

More work is needed to understand the factors at play. One possibility is that GPs are more likely to downplay the seriousness of cancer symptoms in black and Asian patients. Another possibility is that black and Asian patients are more likely to live near hospitals with longer waiting times. The NHS needs to make collecting data on patient ethnicity a priority so that health inequalities can be more fully understood and remedied.

“Everyone counts” is a core value, written into the NHS constitution, but it is hard to avoid the conclusion that in 2022, from maternity wards to oncology clinics, not everyone receives equal treatment.