Why is progress on race equality so slow in the UK?
By Sara Hodgkinson & Sarah Salway
A new report from the Equality and Human Rights Commission highlights widespread racial inequality and warns that failure to tackle this deep-rooted disadvantage will exacerbate societal divisions. EHRC Chair, David Isaac, noted that the report exposes a ‘very worrying combination’ of a post-Brexit rise in hate crime and long-term systemic unfairness and race inequality.
Along with ethnic inequalities in employment, education, criminal justice and living standards, the EHRC report also highlights health and healthcare inequalities. The report confirms that, despite an apparently strong legal and policy framework, barriers to high quality healthcare persist for people of minority ethnic identity. This apparent inconsistency between national policy and local reality was the motivation for our recent research project that looked into the role of healthcare commissioning organisations in delivering equal access to health services for minority ethnic groups in England. We wanted to find out why progress towards race equality is so slow in the UK.
Healthcare commissioning is the process of planning, procuring and monitoring health services to effectively meet the health needs of the population. Between 2010 and 2013, we carried out a large-scale study to examine healthcare commissioning in England which was, at that time, predominantly carried out by Primary Care Trusts. The study included case studies, stakeholder workshops, and interviews with professionals. We spent a large amount of time talking to people as they went about their jobs, observing the work of the organisations and reviewing the documents produced. We wanted to find out whether and how ethnic diversity and inequality is considered within health commissioning in the UK.
We found that minimal attention was being given to ethnic diversity and inequality within healthcare commissioning. Three key themes emerged from the research, suggesting why this might be. First, minority ethnic health inequality is not a high policy concern. Despite racial inequality in England remaining a hot topic both within the media and in academia, there appears to be a lack of discussion and action at policy level to effectively address the matter. Few national resources include any consideration of ethnic diversity or equal access to services for minority groups and there is no performance monitoring related to this agenda. Marginalisation of minority ethnic health was found to be consistent at national and regional level and, while some areas of good practice were identified at local level, the work tended to be piece-meal and without broader impact.
Second, we found widespread uncertainty among policy makers as to whether inequality is even really an issue. Some senior leaders were unconvinced of the existence of inequalities between ethnic groups, despite a growing body of evidence to the contrary, others did not view such inequalities as a priority. Without acknowledgement of the issue and its importance, ethnic inequalities in healthcare will continue to be overlooked at all levels.
Finally, interviews and case studies pointed to a lack of clarity at policy level as to how ethnic diversity and inequality should be addressed within the national health system. Limited data on patterns of ethnic health inequalities, together with a lack of understanding of the subject among senior leaders and the tendency of some managers to blame minority groups themselves for poor access to services, were also important barriers. Minimal understanding – both of the issue and of how to address it – undermines people’s confidence to act, resulting in the problem being downplayed and overlooked.
Our study primarily highlights obstacles to ethnic equality in healthcare in England, though we did find some factors promoting positive work. Importantly, we found that action on ethnic diversity and inequality was rarely prompted by national directives but was rather driven by committed individuals who championed the issue locally. Such individuals did, however, struggle to maintain momentum without clear leadership on the issue from local managers or central government. Good work remained siloed and was often short-lived.
How, then, can equality in healthcare access be improved? Our study suggests the need to enhance the skills, confidence and competence of individual managers and commissioning teams and to improve organizational structures and processes that support attention to ethnic inequality. However, it is also clear that greater political will and clearer national direction is required to produce the widespread system change needed. Our conclusions therefore mirror those of the recent EHRC report which calls for a ‘comprehensive race equality strategy’ that goes beyond the current ‘patchwork of initiatives’, is underpinned by good data, and monitors progress against clear targets.