Towards the end of 2019, China reported a new virus infection. This spread exponentially to different nations and is still carrying on. In the UK, the first cases were confirmed on January 31 2020. The UK government initially started with hospital quarantine and later with home quarantine for travellers from certain countries. With the spread of the illness, it asked the nation to “stay at home” from March 23. This was initially for three weeks, but later it extended lockdown to “save the NHS”.

Hospitals were reaching full capacity in certain areas and the death toll was increasing day by day. As more Covid-19 patients were admitted to hospitals, staff began to become affected. Yet, there was a variation in the hospital staff getting affected.

With the easing of lockdown measures in the UK, the fear of a second wave of Covid-19 is a matter of concern for the population and health authorities alike. One of the observations of the pandemic thus far, is the increased susceptibility of the ethnic minority population and Covid-19 outcomes. This has been explored in the Public Health England report on “Disparities in the risk and outcomes of COVID-19”.1

The report showed that 34% of the patients admitted to UK intensive care units with Covid-19 were of BAME background. Considering that BAME people account for just 17% of the UK population, this is disproportionate.2 Indian and Black Caribbean groups showed the largest total number of deaths (492 and 460 deaths respectively).3

Healthcare workers from ethnic minorities also seem to be disproportionately affected. Of the NHS staff who have sadly died from Covid-19, 63% were from BAME background. This included 71% of the nurses and midwives, 94% of doctors and dentists, 56% of the healthcare support staff and 29% of other healthcare personnel, who died.3

Further reading: Communication challenges with DNA-CPR discussions 

Further reading: Looking beyond lockdown

The PHE report highlighted some of the speculated reasons for increased susceptibility to Covid-19 in ethnic minority groups. These disparities are set against a higher prevalence of numerous health conditions, including diabetes, cardiovascular disease, and mental ill health in ethnic minority populations in the UK.4

Addressing and mitigating the vulnerability of BAME healthcare staff

Research has shown differential attainment by ethnicity in the medical workforce across all measures of career progression.5 They also find it difficult to voice their concerns and grievances which makes it worse.

Hence, it is clear that addressing and mitigating the vulnerability of all healthcare staff, especially those of BAME background, is of paramount importance in the event of a second wave of Covid-19 infections. 

With this in mind an online survey was initiated to report on current attitudes of BAME healthcare staff towards working on the frontline. This was then sent across the UK to different health staff in various posts to get their opinion and concerns.

The aim was to obtain insights about the concerns and risks BAME health professionals faced during the ‘first phase’ of Covid-19. Also, we thought of collecting the views on remedial measures/support, which would give them confidence in continuing to work.

Method

We tried to capture the views of healthcare professionals by doing an online survey from a wide spectrum of staff. This online survey of 10 questions was posted on social media groups on 24th of May 2020. It took around three minutes to complete with an option for participants to enter their views on how they felt and also to comment on support from their employers and various unions. Participants were also asked for their comments on the best way of supporting staff by various organisations. Respondents were asked to select as many options as relevant to a given question, and had the option to leave additional comments at the end of the questionnaire. Results were collected on 1st June 2020.

Results

221 responses were received. Respondents included doctors, nurses, healthcare assistants as well as domestic and other ancillary staff.  It is worth noting that 97% of responses were from BAME staff of Asian or Asian British background.

 BAME and Covid-19 image 1

Figure 1

 

64% of respondents were doctors, 29% were nurses and the remaining were healthcare assistants and other ancillary staff (See Figure 1). Figures 2 and 3 show how concerned respondents felt about working on the frontline, and how much of this was related to ethnicity.

 

BAME and Covid 19 Figure 2

 Figure 2

 

Interestingly nurses were more concerned than doctors (78% and 57% respectively.)  86% of the nurses and 90% of the doctors said that this level of concern was related either partly or entirely to ethnicity.

 BAME and Covid 19 Figure3

Figure 3

 

When asked what they felt was contributing to the increased susceptibility to Covid-19 among ethnic minorities, 60% of respondents felt that BAME staff being overrepresented in the NHS frontline was a significant factor (Figure 4). 58% said lack of adequate PPE was important and 52% felt that comorbidities also played a role. Socioeconomic factors and genetic predisposition were felt to be equally responsible. Low Vitamin-D levels were also expressed as a potential contributing factor.

 BAME and Covid 19 Figure 4

Figure 4

 

The British Medical Association and Royal College of Nursing are said to be engaging in various services to support BAME staff working on the frontline. Guidelines and advice for employers and staff have been issued, including risk assessment and PPE. However, only 48% of respondents received support from trusts through email, while 37% received no support. 29% of respondents received support from trade unions through email, while 61% received no support.

The questionnaire revealed that only 38% of respondents had been risk stratified (see Figure 5). This represented 32% of doctors and 44% of nurses. This suggests that frontline BAME staff are not being adequately supported.

Inadequate risk stratification was emphasised by many respondents.

 

BAME and Covid-19 Figure 5

 Figure 5       

 

BAME and Covid-19 figure 6

 

Figure 6

 

When asked what would give them confidence to continue to work on the frontline, 78% of respondents felt provision of adequate PPE was significant. 63% felt urgent research into the causes for increased susceptibility needed to be undertaken. Only 19% were in favour of being withdrawn from the frontline.

 

BAME and Covid-19 Figure 7

Figure 7

 

Lack of adequate PPE was also reiterated. In addition to the above responses, an overwhelming number of respondents reported a feeling of institutional apathy among the NHS and management.

 

BAME and Covid-19 Figure 8

Figure 8

 

Discussion

The results have given an insight into the general morale of BAME staff and have suggested a general lack of support and robust guidance for BAME staff working on the frontline. Many of the risk assessment tools used nationally do mention risk stratification, however it is vital to note that there is still lack of effective risk stratification and provision of adequate PPE. Addressing these issues will be vital to ensuring that BAME staff are supported and feel sufficiently protected to continue their work.

Even after the disproportionate increase in BAME staff being unfortunately affected by Covid-19, the response in the survey was that the majority of BAME staff still want to work in the frontline serving the NHS and the UK people as long there is adequate protection (both in support and equipment).

It seems that these issues are not exclusive to the Covid-19 period and exist as systemic flaws within the healthcare system. The survey has also raised questions on institutional bullying and racism. On comment was: “The main issue is that BAME staff are going through mental bullying from those in charge or coworkers who are of white background.”

There were calls and suggestions to request various organisations to raise voice against these indifferences to BAME staff. Another comment said: “Investigate vigorously institutional racism in NHS trusts. Also push back against culture of complaints against BAME staff which are in part due to cultural differences in approach.”

BAME healthcare workers continue to be insufficiently supported, with their concerns systematically dismissed. “The trust is not proactive in recognising the risk to staff.” Even after a BAME member of staff feels let down and concerned about the treatment they receive from their employers and managers, they still find it difficult to raise their concerns. “[BAME staff] fear that if they say no to such unreasonable requests, they will lose their jobs and face uncertainty in this country.”

In addition to the above responses, an overwhelming number of respondents reported a feeling of institutional apathy among the NHS and management. “It would be great if frontline BAME staff are not coerced into frontline positions by colleagues who then are not participating equitably in frontline tasks.”

Issues included a lack of representation among decision-making teams, with many feeling excluded by the management. “Very few BAME staff are part of the management boards of the trust, more representation of BAME staff in management boards is an absolute must”.

Many staff have continued their requests to have proportionate representation in the management and decision making groups. Many of the trusts/organisations have a good proportion or even majority of staff from  BAME backgrounds, but the management of these organisations and trusts still have more white staff.

They feel that the management or board are then not able to understand the culture or needs of their staff. Not only does this make them feel let down, but the survey found that BAME staff do not often feel confident to raise their concerns within the organisation. Understandably, this will affect the productivity of the organisation and the quality of service to the patients. 

Another point reiterated by many was the culture of coercion towards ethnic minority staff, preventing equitable delegation of frontline tasks and in high risk areas. “Auditing work pattern of BAME staff. Not making them work more than their fair share in the red areas”. “Frontline duties should be equally distributed.”

Research confirms that the extent to which an organisation values its minority staff is a good barometer of how well patients are likely to feel cared for.A NHS Race and Health Observatory report agreed with this recently and additional funding for the Workforce Race Equality Standard (WRES) mentioned in the NHS long term plan 2019 may be a step in the right direction, but there needs to more acknowledgement and action before it is too late.

Also there needs to be proportional representation of BAME staff in NHS management. BAME representatives locally who can feed to WRES should be another option considered. Tackling the above issues will be vital to ensuring that BAME staff are not only properly equipped and supported to work in the event of a second wave of infection, but also that they are valued and respected for their service to our healthcare system for the future.

 

For more information on older patients and Covid-19 go to our Covid-19 section

 


Dr Manoj Rajagopal, Consultant in Psychiatry (Old Age), Associate Medical Director (R&R), Executive Member, Royal College of Psychiatrists   

Radhika Kaimal, Year 12, Clitheroe royal grammar school

Dr Sunil Nedungayil, Clinical Lead & GPwSI, Musculoskeletal Medicine

manoj.rajagopal@lancashirecare.nhs.uk

  


References

  1. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/890258/disparities_review.pdf
  2. https://www.hsj.co.uk/exclusive-deaths-of-nhs-staff-from-covid-19-analysed/7027471.article
  3. https://wellcomeopenresearch.org/articles/5-88
  4. StevensonJRao M. Explaining levels of wellbeing in black and minority ethnic populations in England. University of East London, 2014. 
  5. LintonSTaking the difference out of attainment. BMJ2020;368:m438. doi:1136/bmj.m438.
  6. Racism in medicine: why equality matters to everyone A race equality observatory is needed to provide leadership and data. BMJ 2020;368:m530 doi: 10.1136/bmj.m530