Tackling ethnic minority inequality in the workforce: priorities for primary care

Professor Mayur Lakhani explains how the COVID-19 pandemic has cruelly exposed health and workforce inequalities in the NHS

Research has shown a disproportionate impact on both patients and staff from black and minority ethnic groups (BAME) with an increased risk of SARS-CoV-2 infection and worse clinical outcomes. The issue has been discussed extensively, but this has tended to focus on hospitals. What then are the implications of this stark finding for general practice and primary care, where 90% of patient contacts occur? What should leaders and managers in primary care do? 

2021: now is the time

2021 is a brilliant opportunity to define the post-COVID world and ‘reset’ general practice. I urge all readers of Practice Business to forge a new normal by embracing the pandemic’s learning, including the fairness agenda. It is a time of opportunity, but we must engage, wholeheartedly, with health and workforce inequalities. As chairman of the Faculty of Medical Leadership and Management (FMLM), let me state, unequivocally, the importance of practice managers in leading and driving fairness and equality for both patients and staff.  

The problem

This quest begins with accepting that there is a problem. All the research points to poorer health outcomes for patients and demonstrates differential attainment by ethnicity in the NHS workforce across all career progression measures. Ethnic minority staff are more likely to be bullied and harassed in the workplace, to be investigated and sanctioned, and have lower pay.  They are more likely to be found in lower pay bands in NHS Agenda For Change scales. There is underrepresentation at senior, and very senior, levels.

The reasons for these differences are likely to be systemic. Race in medicine is a toxic and polarising issue. It isn’t easy to talk about. People become defensive and see it as a personal attack on them or their institutions – but we have to talk more about race and be open about it by learning more about ourselves and each other. It is more than just attending ‘tick box’ training, or sending people on courses, critical though this is; it is about being ‘deliberate’, and requires a  mindset change.

What is your culture in your practice/PCN like?

First, ask yourself what your culture is like in your GP practice, federation, or primary care network. The FMLM states that effective (medical) leaders: 

  • ‘Support a diverse workforce and understand the value diversity brings to patient care.’
  • ‘Are robust defenders of fairness and justice, and constantly strive to create an optimal environment for colleagues to give of their best.’
  • ‘Actively manage poor behaviour’, not accept it.

These values are vital for all healthcare professionals, and core to being a leader and manager in primary care. As a start, can your practice, PCN or federation adopt these standards, debate and discuss them, and find ways of implementing them, to make them real?

Watch out for complacency and cynicism

Racism and good leadership are incompatible. We have to guard against complacency and cynicism – these are our number one enemies.  How often do you hear the following – and sometimes from senior leaders?: ‘We don’t have a problem. We are not racist. We have an equality and diversity lead, so we are fine. We have done the courses. We always appoint by merit; if someone is good enough they will succeed.’

Or that it is someone else’s problem to solve. Or that it only exists in cities or large organisations or that somehow primary care is immune?

People have told me of everyday examples of micro and macro aggression in general practice, such as ‘Where are you really from?’ stereotyping, giving  anglicised names for apparently complicated names rather than learning proper pronunciation, or a patient refusing to see a brown doctor – or a black doctor mistaken for cleaner.

But let us also celebrate progress

Historically, migrants have not been treated with the equality we now strive for; our society has not always got it right. This is true in the NHS as well; there are lessons to be learned and some way to go. But we have made progress. I am writing this as the son of immigrants who could not speak English who went on to be the elected president of Britain’s largest medical royal college. And there are there are many such examples – there are more senior BAME leaders in the NHS. We must talk about the good things but also recognise that there is much more to do. I do not see many black leaders on my zoom calls.

What can be done?

There is need for action and leadership at national, regional and local level. Some of the planned initiatives will go a long way to promoting fairness – such as a data-driven approach through the newly founded race observatory. The introduction of an appropriate workforce race equality standard, designed and owned by primary care, will be an important milestone for the English NHS. Examples like the Athena Swan initiative – which has been successful in improving the progress of women in academia – is an exemplar that can be adopted and which also addresses intersectionality.

Call to action

Practice managers should encourage coaching and mentoring using the many free opportunities currently available during the pandemic; this includes reverse mentoring. Racial equality education, and practice leadership, will make the biggest difference. Mind-set change through anti-racist education and training is a key strategy. Relying on staff to make their own move may not be enough, so spot, ‘sponsor’, and support talent.

Despite the serious problems we face, and the huge amount of work that needs to be done, recent research has shown that, whatever our backgrounds, we have more in common. My vision is that whatever your start in life, you will have unrivalled opportunities in the anchor institution that is the NHS and that primary care in the UK is one of the best sectors to be BAME member of staff.

Professor Mayur Lakhani CBE FRCGP FRCP SFFMLM

GP Principal, Highgate Medical Centre, LE12 7UD

CCAS Senior Clinician

West Leicestershire Clinical Commissioning Group Chair

Chairman of The Faculty of Medical Leadership and Management (FMLM)

Honorary President, Birmingham Medical Leadership Society (BMLS)

Immediate Past President of The Royal College of GPs


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