open space

Despite years of equal opportunities policies, the NHS has failed to promote racial equality effectively. Naaz Coker asks what the NHS can do to counter its institutional racism

Is the NHS institutionally racist? I believe it is if we accept the definition Sir William Macpherson used in the report of the Stephen Lawrence inquiry; that is, its attitudes and behaviour amount to 'discrimination through unwitting prejudice, ignorance, thoughtlessness and racial stereotyping'.

There is plenty of evidence of that discrimination in the health service, whether it is anecdotal, or qualitative or quantitative research. A survey published last year by Professor Chris McManus of University College London, for example, found that 18 of the country's 27 medical schools had 'disadvantaged' applicants from ethnic minority backgrounds.1 In some cases, black and Asian students were three times less likely than white students to gain a place.

But the problem does not end there. Research by Dr Sam Everington and Aneez Esmail revealed that if you have an Asian-sounding name, you are half as likely to get an interview for an NHS post.2

Even supposing they manage to get in, doctors from ethnic minorities are disadvantaged at every stage of their careers, as well as in their representative medical bodies and the Department of Health, according to the research findings. In a press release issued by the Royal Society of Medicine, Dr Everington points out that racial discrimination and prejudice is 'epidemic' at all levels in the NHS.3

Despite years of equal opportunities policies, there has been a collective failure by the NHS to promote racial equality effectively, both in employment and in service delivery. In fact, those equal opportunities policies themselves have failed. There are a number of complex reasons for this, but one of the most important factors in that failure has been a lack of involvement and commitment by senior and middle managers. This commitment is paramount if institutional racism is to be eradicated.

But the NHS must critically examine the whole of its human resources policies, starting with recruitment and selection. It must pay attention to how job descriptions and job specifications are written, to ensure that the language used is not exclusive. It must look at how shortlisting is done and how and where jobs are advertised.

Placing an advertisement in the ethnic minority press sends people from the ethnic minorities a signal that you are serious about employing them.

A non-English sounding name can result in discrimination at the shortlisting stage. A way to prevent this would be to have nameless applications. And it should be compulsory for people sitting on interview panels to have received training in fair selection procedures.

Once staff have entered the service, discrimination continues in terms of career prospects - black nurses, for example, tend to be concentrated largely in the lower grades. One difficulty is that people's differences are not appreciated, and once they enter the service they have to conform to the organisational norm, which is white.

We now need positive action, such as the London black and ethnic leadership development programme, to develop the skills of ethnic minority staff. Half of the people who participated in this programme, which was run by the King's Fund, have taken on new, more responsible, roles. But committing time and resources to ethnic minorities in this way could cause resentment among their white colleagues. Their resistance must be managed as part of any bid to tackle institutional racism and this will involve a huge amount of ethnic minority awareness training for staff at all levels.

On the service delivery front, services must be culturally sensitive. Only by respecting patients' cultural backgrounds can we hope to offer a truly holistic health service. Broadmoor Hospital, for example, has an Afro-Caribbean hairdresser who visits once a week, and its shops stock cosmetics and general items used by the Afro-Caribbean population. These may be small things, but they can make a great difference to people's well-being.

A commitment to providing a culturally sensitive service, and how this could be done, should be written down in a racial equality strategy, to be adopted by all NHS bodies. And, in London and the metropolitan areas in particular, NHS managers need to set targets for improvement. These should not be seen as quotas, but as achievable goals towards which organisations can strive over a period of time.


1 McManus C. Factors affecting likelihood of applicants being offered a place in medical schools in the UK in 1996 and 1997: retrospective study. Br Med J 1998; 317 (7166): 1111-1116.

2 Esmail A, Everington S. Racial discrimination against doctors from ethnic minorities. Br Med J 1993 (6879): 306: 691-692.

3 Press release, Royal Society of Medicine. Racial discrimination and prejudice epidemic at all levels of the NHS.2 September 1998.