Category Archives: Discrimination

Evidence and policy priorities

There are stark ethnic inequalities in health: Black Caribbean, Pakistani, and Bangladeshi people have between six and nine fewer years of disability-free life expectancy than do White British people

Ethnic Minority health

How do we understand this diversity?

Making sense of ethnic inequalities in health – The epidemiological method

‘Epidemiology is the study of the distribution and determinants of disease. The main method of study, particularly for investigating the causes of disease, is to compare populations with different risks of disease. Ethnicity is a variable that is used increasingly to define populations for epidemiological studies.’

Senior and Bhopal (1994)

  • But this encourages an unreflexive and uncritical use of the concept of ethnicity. Ethnic groups are treated as pre-constituted entities with pre-specified properties, with an emphasis on the different/exotic.
  • Explanations are then ‘read’ from the ethnic and disease categories available in data. The presumed properties of ethnic groups, be they cultural or genetic, become the source of explanation for the disease outcome.
  • Rather, we need an approach that pays attention to the processes that lead to the construction and racialisation of ethnic identities, and how these processes shape life chances – what might be called fundamental causes.

Ethnicity, social relationships and social structure

Racial and ethnic groups … are discursive formations, calling into being a language through which differences are accorded social significance, and by which they may be named and explained. What is of importance for social researchers studying race and ethnicity is that such ideas also carry with them material consequences for those who are embraced by them and those who are excluded from them.

Solomos (1998)

The ways in which identities are perceived, valued, mobilised and interacted with are shaped by economic, cultural, legal, political and symbolic resources. Important here is how emotions are attached to symbolic resources, emotions around risk, danger, fear and disgust, which then shape the practices of individuals and institutions. ‘Racial life [is] suffused with shared passions, imageries and fantasies’.

Emirbayer and Desmond 2015

Racism as the fundamental cause

  • Racism has its origins in ongoing historically determined systems of domination that serve to marginalise groups on the base of phenotypic, cultural or symbolic characteristics, thereby generating a racialised social order.
  • Explanation, then, needs to examine the role of three inter-related dimensions of racism – structural, interpersonal and institutional.
  • Structural racism is reflected in disadvantage in access to economic, physical and social resources. This does not have just material implications, but also cultural and ideological dimensions, material inequality justified through symbolic denigration.
  • Interpersonal racism (ranging from everyday slights, through discrimination, to verbal and physical aggression) is a form of violence/trauma and emphasises the devalued status of both those who are directly targeted and those who have similarly racialised identities, thereby engendering meaningful psychosocial stress.
  • Institutional racism (first coined by Carmichael and Hamilton 1967) is reflected in routine processes and procedures that translate into actions that shape the experiences of racialised groups within these institutions.
  • These disadvantages, accumulating across a life course, are the drivers of ethnic inequalities in health outcomes.
Ethnic differences in household income

Ethnic differences in equivalised household income

Low birth weight by occupational class

Low birth weight by occupational class

Standardising for socioeconomic position:

Standardising for socioeconomic position

This reflects both the particular economic location of ethnic minority groups and the multi-dimensional nature of the economic and social inequalities they face, meaning that no realistic statistical adjustment can plausibly simulate randomisation.

Racialised socioeconomic inequalities mean:

  • Lower incomes;
  • Lower status occupations;
  • Poorer employment conditions;
  • Higher rates of unemployment and longer periods of unemployment;
  • Poorer educational outcomes;
  • Concentrated in economically and environmentally depressed areas (but positive effects of ethnic density);
  • Housing tenure;
  • Poorer quality and more overcrowded accommodation.
  • And inequalities that accumulate across the life course and across generations.
Persisting ethnic inequalities in unemployment

Persisting ethnic inequalities in unemployment 1991-2001-2011

Experiences of racism and discrimination:

  • One in eight ethnic minority people experience racial harassment in a year.
  • Repeated racial harassment is a common experience.
  • 25% of ethnic minority people say they are fearful of racial harassment.
  • 20% of ethnic minority people report being refused a job for racial reasons, and almost three-quarters of them say it has happened more than once.
  • 20% of ethnic minority people believe that most employers would refuse somebody a job for racial reasons, only 12% thought no employers would do this.
  • White people freely report their own prejudice:
    • One in four say they are prejudiced against Asian people;
    • One in five say they are prejudiced against Caribbean people.

Research across outcomes and contexts consistently shows the adverse impact of racism on health (for example, Wallace et al. 2016

Racism, discrimination and health:

Changes in levels of racism

Changes in levels of racism 1993-2009

Persisting prevalence of racial prejudice

Persisting prevalence of racial prejudice 1983-2013

Institutional racism in health services?

Access to and outcomes of care:

  • No inequalities in access to GP services.
  • No inequalities in outcomes of care for conditions that are largely managed in primary care settings:
    • Hypertension, raised cholesterol and, probably, diabetes.
  • The effect of healthcare systems – a health service with universal access and standardised treatment protocols?
  • Marked inequalities in access to dental services.
  • And marked inequalities in the US insurance based system.
  • And institutional racism evident in some areas:
  • Some inequalities in access to hospital services.
  • Ethnic inequalities in reported levels of satisfaction with care received.
  • And, mental illness and psychiatric services …

Conclusion

  • Racisms are fundamental drivers of observed ethnic inequalities in health.
  • In investigating this, it is important to examine the ways in which structural, interpersonal and institutional racisms operate and constitute one another.
  • Structural conditions of socioeconomic disadvantage and interpersonal experiences of racism both create an increased risk of poor health for ethnic minority people.
  • They also shape encounters with institutions that have policies and practices that lead to unequal outcomes – education, employment, housing, criminal justice, politics, etc., as well as health and social care.
  • Institutional settings represent sites where we see the concentration and mediation of structural forms of disadvantage and interpersonal racism. This is produced via both the unwitting practices and overt agency of individuals operating within particular structural conditions.
  • Institutional racism will take different forms, will operate differently, across institutions with a different focus – for example, the functions of institutions dealing with cancer screening compared with those implementing coercive treatments for severe mental illness.

Reflecting on Policy

  • There has been little development of policy to specifically address ethnic inequalities in health, only occasional, limited and local intervention, with no real evaluation of the impact of specific or general policy on ethnic inequalities in health.
  • For example, a shocking neglect of ethnic inequality in the Marmot Review – assumption that socioeconomic inequalities are unimportant for ethnic inequalities in health, or that general policies to address questions of equity will also address ethnic inequalities.
  • But not a policy vacuum, there are clear policies around identity, culture, community, segregation and migration, all of which are likely to negatively impact on ethnic inequalities in health.
  • And ethnic minority people have been disproportionately impacted on by public sector retrenchment (austerity measures).
  • In fact, the evidence base strongly suggests that policy development should focus on the social and economic inequalities faced by ethnic minority people.
  • Need short term policies to address economic inequality (tax, employment, welfare, housing, etc.).
  • However, the economic inequalities faced by ethnic minority people cannot be addressed by policies targeted at on average reductions in economic inequalities, because such policies don’t address processes impacting on ethnic minority people – reflected in institutional practices.
  • Example: early years investments, which don’t address the emergence and persistence of racial disadvantage in the education system and labour market.
  • Example: failure of favoured ‘up-stream’ interventions, such as SureStart, to engage with and meet the needs of ethnic minority groups.
  • Example: public sector workers bearing the cost of the recession.
  • Example: rise in part-time work and zero hours contracts.
  • Rather need long-term policies that promote equitable life chances and that address racism and the marginalisation of ethnic minority people – a focus on institutions, including politics and Government, is crucial.

Institutional reform: an example

  • As an employer, the public sector has the opportunity to provide significant leadership.
  • For example, in 2017 the NHS directly employed 1.2 million people, indirectly many more, so employment practices within the NHS are able to impact on the labour market nationally and regionally.
  • Ethnic minority people are over-represented in the NHS (and public sector) workforce – 22 per cent of NHS staff are not White, compared with 13 per cent of all workers.
  • Discussion around public sector employment has focussed on enhancing efficiency by reducing labour costs, consequently opening up opportunities for private investment.
  • Instead could use this as an opportunity to implement positive and equitable employment practices, setting a standard: employment rights, holidays, sick leave, study leave, maternity leave, job security, job flexibility, guaranteed hours, limits to unpaid overtime, promoting autonomy and control, and, importantly, pension rights.
  • Such changes are likely to mostly benefit those in lower employment grades and more precarious employment conditions – ethnic minority workers.
  • Could also address the marked ethnic inequalities within the public sector workforce – ‘snowy white peaks’ – rethinking institutional structures and practices, and addressihng pay differentials.
  • Reforming institutional cultures – the whiteness of institutions – and addressing discrimination and racism in the workplace.

This was presented at our conference Public Health Priorities for Labour

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Impact on refugees, people seeking asylum, and other vulnerable groups

The Government recently proposed to amend a set of rules, known as the ‘NHS Charging Regulations’, which govern how people access healthcare in England, and when they have to pay for it. New regulations were laid before Parliament on 19 July 2017. This briefing explains what changes the new regulations seek to make – with a particular focus on their impact on refugees and people seeking asylum.

Which NHS services are currently free for everyone?

  • All GP services
  • Family planning services, compulsory mental health care, and treatment for a range of communicable diseases that might pose a public health risk and treatment provided in a sexually transmitted diseases clinic
  • Treatment of a physical or mental condition caused by torture, female genital mutilation, domestic violence or sexual violence when the patient has not travelled to the UK for the purpose of seeking such treatment
  • Accident and Emergency services

Health services affected by extending charging

  • Health Visiting
  • School Nursing
  • Community Midwifery
  • Community Mental Health Services
  • Termination of Pregnancy services
  • District Nursing
  • Support Groups
  • Advocacy services
  • Specialist services for homeless people and asylum seekers

Some people in the UK are not entitled to free NHS hospital care. This includes people who are here for short-term visits, undocumented migrants, and some asylum seekers whose claims have been refused. The situation is different in Scotland, Wales and Northern Ireland, where devolution agreements allow for different healthcare arrangements. There are already processes in place for hospitals to identify and bill patients for their care. The Government has now made new regulations extending NHS charges to community healthcare services, and placing a legal requirement for all hospital departments and all community health services to check every patient’s paperwork and charge up front for healthcare; refusing non-urgent care where a patient cannot pay. These two changes are looked at in more detail below:

Extending charges into community services

From August 2017, healthcare charges will be introduced for services provided by all community health organisations in England, except GP surgeries. Any organisation receiving NHS funding will be legally required to check every patient before they receive a service to see whether they should pay for their care and, in some circumstances, patients will be charged for accessing these services. See  full list of exemptions.

A wide range of health services may be affected (see above for details), including NHS organisations and, as of October, community interest companies and charities. These services are often specifically commissioned to reach marginalised communities and individuals unlikely to seek out NHS care. The introduction of charges undermines the vital role they play in protecting public health and safeguarding children and vulnerable adults. The Government has made multiple commitments to carry out an assessment of the unintended consequences of extending NHS charges on vulnerable people, pregnant women and children4, but this has not happened.
As we read the regulations, public health services commissioned through Local Authorities, which include public mental health and drug and alcohol services, will also be affected.
While the regulations do not alter the fact that GP services and Accident and Emergency5 services are currently free to all, the Department of Health have indicated this may be subject to review at a later date.

Introduction of upfront charging

From October, every hospital department in England will be legally required to check every patient’s paperwork before treating them, to see whether they are an overseas visitor or undocumented migrant and should be charged for their care. Every patient, British citizen or person under immigration control, will be asked about their residency status and will need to prove they are entitled to free NHS care. Pilots requesting all patients to provide two forms of identity prior to appointments are being carried out in 20 hospital trusts across England. The obligation to check patient paperwork applies to services exempt from charging on public health grounds, such as infectious disease departments and HIV clinics.
If a patient cannot prove that they are entitled to free care, they will receive an estimated bill for their treatment and will have to pay it in full before they receive any treatment other than that which is ‘urgent’ or ‘immediately necessary’, as defined by doctors on a case-by-case basis.
The regulations also introduce an obligation on trusts to record that a patient is not entitled to free NHS secondary care against that patient’s NHS number. Both this measure, and up-front charging, were not included in Department of Health’s 2016 consultation on NHS cost recovery and as such have not received public scrutiny.
These changes have been laid before parliament and will become law without debate unless there is an objection from either House.

What does this mean for refugees and people seeking asylum?

Refugees and people seeking asylum are exempt from paying for treatment. However, refused asylum seekers have different entitlements. Those in receipt of some form of statutory support (Home Office Section 4/ Section 95 support or Local Authority support) are entitled to free care. However, in England, refused asylum seekers who are not in receipt of support are currently chargeable for secondary (hospital) care, unless they started their course of treatment prior to being refused or qualify for a treatment based exemption (for example, they are HIV positive). The situation is different in Scotland, Wales and Northern Ireland, where the devolved governments have seen fit to ensure refused asylum seekers can still receive healthcare for free.
Under the new regulations, refused asylum seekers would become chargeable for a range of community health services in England, and would also be subject to up-front charging for non-urgent care.
Even under the current system, it is difficult for health services to accurately identify who is chargeable under the regulations and who is exempt, particularly when the immigration status of individuals regularly changes over time. Those who are most adversely affected are often the most vulnerable, who have little understanding of their rights or ability to advocate for themselves and navigate the NHS, particularly without a translator.

The result has been that all too often, even those who are exempt from charging – such as refugees and asylum seekers – are wrongly denied or charged for treatment, or deterred from accessing treatment altogether for fear of being charged. We are concerned that new plans to extend the charging mechanisms within the NHS will further deter people seeking refugee protection from accessing the healthcare they need.
Our key concerns about regulations to extend charging into community care settings, and introduce up-front charging are:

  • Up-front charging and the need to present paperwork proving eligibility for free care will increase barriers to healthcare for refugees, asylum-seekers and other vulnerable groups: There is a risk that healthcare, including lifesaving care, may be withheld from refugees and asylum seekers who are entitled to free care because they do not have easy access to paperwork and passports to prove entitlement. Other vulnerable groups, such as victims of trafficking, homeless people, elderly people, and those living with mental health conditions are also likely to be affected.
  • Preventing hard-to-reach communities from accessing essential services will lead to increased health inequalities: Any NHS funded organisation – including charities – that provides community based services such as termination of pregnancy services and community mental health services, will be legally required to check the eligibility of patients and, in some circumstances, charge patients. These services are often specifically commissioned to reach marginalised communities and individuals unlikely to seek out NHS care. The introduction of charges undermines the vital role they play in safeguarding children and vulnerable adults, and will result in increased health inequalities.
  • The extension of charging will have dire consequences for refused asylum seekers: Denying healthcare doesn’t make health problems go away. Due to their experiences in their country of origin, their journey to the UK, and sometimes their experience in the UK asylum system, people seeking asylum often have particular physical and mental health needs. Additionally, the poverty, homelessness and social isolation faced by many refused asylum seekers can exacerbate existing health conditions. With no permission to work in the UK, they are unlikely to have any means of paying for health services, and will be deterred from accessing even those services that are free for public health reasons due to fear of being charged at a later date, or being identified by the Home Office. Both the Welsh and Scottish governments, and Northern Irish Assembly have seen fit to exempt this group from charging.
  • These measures will further undermine public health: Taken together, the extension of charging into community care services, coupled with the likelihood that public health services commissioned through Local Authorities – such as drug and alcohol services – will also be affected by the regulations, mean that access to immunisation programmes, early diagnosis of communicable diseases, and other preventative care programmes which protect us all will be undermined.
  • All this will cost the NHS more money: The Government has not carried out a full and robust assessment of the impact and cost of the new charging regime. The anticipated financial saving for the NHS is small (£200,000 a year), based on little evidence and likely to be overestimated. For example, it is estimated community services face a cost of up to £13.64 per provider per year to cover the retraining of staff and associated administrative costs of implementing the cost recovery programmes, but this fails to properly to take into consideration additional administrative time to check paperwork. In addition, the confusion around eligibility will result in late diagnosis and treatment amongst groups most at risk, with significant long-term costs to the NHS, particularly when considering emergency interventions undertaken after an individual’s health has deteriorated and they require urgent or immediately necessary treatment. A case study from Northern Ireland during the period when migrants were charged for primary and secondary healthcare illustrates this point: An asylum seeker could not get access to an inhaler for her asthma after her asylum application was rejected. She consequently became so ill that she was admitted to the Intensive Care unit at Belfast hospital in November 2012 and had to stay in hospital for five days before being discharged. In her case, the cost of a prescription would have been £12.87, while the cost of a visit to A&E by ambulance and five days in hospital was £1,508.
  • New systems to check patient eligibility will have unintended consequences: As ID checks are carried out on all patients in advance of appointments, and medical professionals are tasked with judging whether treatment is urgent or immediately necessary, patient waiting times are likely to increase, putting the NHS under even greater strain. There is also the risk of racial profiling being used as a means to identify chargeable patients, leading to an increase in health inequalities (a breach of the Secretary of State for Health’s duty to reduce health inequalities under the Health and Social Care Act 2012). The only way to check eligibility for free NHS services which does not contravene equality law is to check everyone. Reviewing every patients’ immigration status will be time consuming, costly to administer and frustrating for both patients and NHS staff. It is difficult to see how repeat eligibility checks can be avoided as service providers will have to ensure that a patient’s residency status in the UK has not changed over time. In Northern Ireland, reviews were carried out every six months, but this was later judged to be unworkable and consequently carried out every 24 months. One of the problems encountered was that the Home Office often failed to confirm people’s immigration status. Furthermore, these checks will place an additional administrative burden on the Home Office, to the detriment of their ability to manage the wider asylum system.

Recommendations

The regulations should be withdrawn. The government should carry out and make public the results of:

  • an assessment of the impact of extending charges into community services on vulnerable groups, pregnant women and children;
  • an assessment of the impact of upfront charging and checking patient paperwork on access to services, health outcomes and patient waiting times, including an evaluation of the ongoing pilots taking place in hospital trusts;
  • an impact assessment evidencing the proposed regulations do not breach the Secretary of State for Health’s duty to reduce health inequalities under the Health and Social Care Act 2012;
  • a human rights impact assessment on upfront charging;
  • a public consultation on the parts of the regulations not included in the 2016 consultation on NHS cost recovery: upfront charging and recording information against NHS number (consistent identifier);
  • a more robust and thorough assessment of the true costs of introducing these measures.

On the completion of the above, any regulations to extend charging into new areas of care and / or introduce upfront charges should:

  • exempt all services that protect public health, including drug and alcohol services, community midwifery services, health visiting and school nursing;
  • exempt all services provided by charities or community interest companies;
  • exempt all community mental health services;
  • exempt all abortion providers;
  • exempt asylum seekers whose claims have been refused, as is the situation in Northern Ireland and Scotland;
  • require all decisions to withhold healthcare pending payment to be 1) subject to a second clinical opinion and (2) open to challenge by a patient
  • be accompanied by Department of Health guidance for hospitals and doctors 1) outlining how to implement the regulations in a way that is not discriminatory and does not violate human rights or increase health inequalities and 2) confirming that routine identity documents checks should not be carried out in services where NHS charges do not apply, such as infectious disease services and A&E, or in maternity services.
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An announcement by Justine Greening, Minister for Women and Equalities, on 29 June indicated that Northern Irish women will no longer have to pay to access terminations in England. Motivated by the proposed amendment of backbench Labour MP, Stella Creasy, the government avoided a vote in the Commons on the issue and declared instead that they will pay for Northern Irish women who travel to mainland UK for abortions.

Such an announcement is to be welcomed. Northern Ireland was never covered by the 1967 Abortion Act which allows for terminations in England, Scotland and Wales. Although there has been a Marie Stopes clinic in Belfast since late 2012, it operates within an incredibly restricted legal framework which only allows for abortion in cases where there is a long-term risk to the woman’s health. As such, around 1000 women travel to England every year to access terminations. Depending on their personal circumstances, such a procedure can cost between a few hundred to a few thousand pounds. This ruling will therefore substantially diminish the financial impact that Northern Irish women seeking terminations face.

Abortion is politicised in Northern Ireland in a manner that does not compare to the rest of the United Kingdom. Protests continue to occur regularly outside the Marie Stopes clinic in central Belfast and Northern Irish politicians openly espouse anti-abortion sentiment that would rarely be heard in Westminster. Whilst there has been a steady drip of legislative action encouraging change (in late 2015 a high court judge in Belfast ruled that the legal situation in the province regarding abortions contravenes human rights law), on 29 June 2017 the Court of Appeal in Belfast ruled against the 2015 judgement. It argued again that this area was for the devolved Assembly to rule on, and could not be changed by the courts.

Earlier in June 2017, in relation to the case of a 15-year-old girl who had travelled to England for treatment, the Supreme Court in London ruled that women in Northern Ireland were not entitled to free abortion treatment on the NHS. Creasy’s amendment emerged in response to this. In the light of these judgements, her actions in the Commons and the declaration by the government take on even more importance. The legal system appears to have been exhausted as an avenue for change, so political action on this is to be welcomed.

Such action has been seen before, but has, until now, been unsuccessful. In 2008, Diane Abbott MP fronted a similar amendment to the one that Creasy argued for, proposing that the 1967 Abortion Act be extended to Northern Ireland. Then, however, the Labour-led government of the day aligned with the argument made by Northern Irish MPs (and courts, in both judgements referenced above), that this matter was entirely devolved and should be left to the attention of the Assembly.

Whilst it is true that abortion law has been devolved to Northern Ireland since 2010, national Parliament at Westminster could have made the decision that it made this June at any point since 1967. In light of the negative attention that the Conservative-DUP deal has received due to the very conservative beliefs of the DUP regarding abortion and LGBT issues, it is hard not to see the recent decision as damage limitation. Accused of making deals with a party which appears to espouse ideas antithetical to the majority of British voters, the Conservative government can now hold up this funding announcement as a way to both distance themselves from the DUP’s social conservatism and illustrate their own liberal values.

This move also illustrates once again the weakness of the current government. Creasy’s amendment looked set to pass easily, with substantial support from Conservative members. Will there be more backbench opposition challenges like this? It would appear likely, especially in light of a fractured Conservative party, reeling from the poor General Election result.

The government’s recent announcement does nothing to change the legal situation regarding abortion in Northern Ireland. Abortion will remain illegal (including in cases of rape, incest and fatal foetal abnormalities) except in extreme physical or mental circumstances. And although it now appears that Northern Irish women will not have to pay for the terminations they seek in England, they will still face substantial costs in terms of travel and accommodation.

In addition, this decision does not remove the more fundamental injustice of this situation. Women will still have to travel, leaving family and support networks behind. Women with complicated citizenship statuses, caring responsibilities or those in abusive relationships may find it impossible to travel at all. The decision by the government is to be welcomed, but it does not place Northern Irish women on an equal footing with their English, Scottish and Welsh counterparts. They still deserve better.

This first appeared on the British Politics and Policy blog

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In December 2015 I was approached by Jeremy Corbyn and Kate Green, then the shadow minister for women and equalities, to chair a review with an advisory group made up of academics, policy experts, elected representatives and grass roots organisations to make recommendation on a future race equality strategy. On the eve of the anniversary of the 1965 race Relation Act, Jeremy Corbyn stated: “Fifty years ago today (December 8) the Labour government of Harold Wilson introduced the first Race Relations Act – outlawing discrimination based on ethnicity. Labour has a strong track record. As recently as 2010 we passed the Equality Act.”

Two events in December 2015 and February 2016 started the 18 month process of collecting evidence and having dialogue with a range of stakeholders inside and outside the party.  The race equality advisory group was established in February 2016 to lead a consultation and make recommendations to Jeremy and the shadow team on key issues for Labour to consideration around policy development. In addition, as part of the review of the party’s governance structures, Shabana Mahmood and Kate Osamor were also conducting a review around BAME representation for the national executive committee.

However, the shadow cabinet resignations and the leadership race had a major impact on the review. Also the party focus was around the issue of anti-Semitism, which led to the Shami Chakrabarti report. The timescale for the review has been scaled down further especially if there is an early election as a result of the fallout of Brexit.

There is now a greater degree of urgency to respond to this consultation. The feedback will help shape Diverse Communities Manifesto which is being led by Dawn Butler, shadow minster for diverse communities. We are looking for written submissions by January with plans to prepare a report early in the new year.

The timing of this review is important as race is now slowly back on the political agenda as a result of the reports in August 2016 by UN Committee on race (CERD) which, every five years, reviews Britain’s record on race equality. There has also been a rise in hate crime since Brexit, rather depressingly.  In response to these reports Theresa May is now conducting a government wide public audit on race equality. Elsewhere David Lammy is continuing his review of the criminal justice system and impact of BAME communities.

It is clear that structural racism and social mobility are major issues in Britain which the coalition and the Conservative government not only failed to address but, in many ways, exacerbated with an austerity programme and failure to implement the Equality Act 2010. Too often the government and the media have spent excessive time debating migration of Eastern Europeans from the EU and the experiences of refugees caught in war and conflict. By doing this, we miss the real debate about the increasing wealth, income and power of exclusivity and privilege  taking us back to Victorian Britain. Today working class, women, disabled, LGBTI and BAME communities are further disfranchised and marginalised economically and socially.

As a result of the EU referendum there has been a fivefold increase in hate crime and uncertainty for millions of people from migrant and BAME backgrounds about their future status in this country. Global campaigns and the domestic launch of Black Lives Matter highlight racism faced by Black British people who are racially profiled and on occasion have died in police custody or a secure environment. The Prevent strategy, which aimed to tackle fundamentalism with the Muslim community, actually increased Islamophobia. We have now reached a crossroads in Britain where there is growing racial, social and class divide. We must call in to question how tolerant are we society in 2016.

Despite individual BAME achievement and success in politics, medicine, science, public services, media, sports, the arts and business, these communities still face discrimination. It has led to a growing gap between survival and aspiration which risks holding back third and fourth generation young BAME people despite their qualifications and abilities.

In many ways it feels we are going backwards as a society to the time just after the second world war with the arrival of the SS Windrush ship in June 1948 where the colour bar and infamous slogan used many landlords, and indirectly by employers, was “No blacks, No Irish and No dogs”. It was a fact of life regardless of the fact many of the migrants from former colonies now part of the Commonwealth served in the war and their parents made a similar contribution between 1914 and 1918.

Sixty years on and, despite race equality legislation which successive Labour government introduced, structural and interpersonal racism is getting worse, much like inequality. The Olympics in London was one of the most successful games built around the vision of diversity and inclusion but it feels like a dream and illusion after the toxic campaign during the EU referendum.

That is why Angela Rayner, shadow education secretary and shadow minister for women and equalities, and I launched a race equality consultation in August 2016 around the time of the EHRC and United Nations CERD.

Jeremy Corbyn also has recently reaffirmed his commitment in placing race equality as part of his future vision for Britain at a recent Black History Month reception.

We are still seeking the following responses to the key questions below as part of the consultation:

  • What would you identify as the key issues and themes around race equality that need to be addressed over the next five to ten years?
  • What are the top three policy measures/actions you would like to see to promote race equality?
  • What is the best way to ensure race equality is given full consideration in the policy and manifesto development process of the Labour Party?
  • What action should be taken to help eliminate race discrimination in Britain?
  • What action should be taken to protect race equality legislation now that the UK has decided to leave the European Union?

See the consultation document here and submit your response to  raceequality2020@gmail.com by 13 January 2017.

Finally, although we have the best race equality legalisation and practice in Europe, there is still a lot of work to done to tackle structural issues affecting BAME communities in relation to health and social care, housing, education, stop and search, business, employment, the arts, and civic and public life.

It important to acknowledge the achievements and aspirations of our multicultural and faith society in working towards a fair and just Britain for all – that is why Brexit negotiations and parliament must accept this.

First published by LabourList

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Saturday 24 September 2016

Conference. Thank you for inviting me here to address you and I apologise about the disruption caused by the other engagement this morning. Thank you to you all for the inspirational contribution that you and the women that have come before you make to this incredible movement of ours.

I know everyone in this room today will want to join me in offering Sarah Champion our full and warmest support. Sarah you are a truly inspiring campaigner, who we all have complete trust in and I know you will continue with the excellent work you are doing.

The advances for women in Britain and around the world have been fought and won _ by determined campaigners like you working together for real change often in the face of intransigence, resistance and even abuse. That’s the legacy of women in our movement.

But there’s one person who isn’t here today. And she would be if it weren’t for an act of hatred and violence that has robbed two children of their mother and the Labour Party of a valued and cherished friend. So many of you here today knew Jo we will never ever forget her never forget what she stood for never forget what she campaigned for and together – united – let us fight for the things that would make her proud. Nobody who has seen the films and photographs shared by Brendan Cox can have failed to be touched by the images of a woman so clearly delighting in spending time with her young children. They remain in all our thoughts – and it is to them today that I would like to send my continued best wishes on behalf of all the Labour family.

As colleagues from across Parliament noted in their moving tributes to Jo she was adamant that there was much more that united than divides us. And there is no better way we can honour Jo’s memory than ensuring we unite and are resolute in our pursuit of making the world a better place.

We must ensure that the Labour Party remains at the forefront of championing policies which promote equality. That is why, earlier this week I urged the NEC to vote through a policy-making women’s conference, so that the voice of women across our movement can be heard loud and clear in our policy-making process.

The economic stagnation caused by austerity has seen a desperate drop in living standards for many people but it is women, above all, who have borne the brunt of this failed and destructive economic experiment. The Women’s Budget Group has found that 86 percent of the Government’s so-called tax and welfare ‘savings’ have come at the expense of women.

The U-turns and concessions we have wrung from this Government in the last year have in the main been victories which have stopped further cuts that would have disproportionately impacted upon women such as the cuts to Tax Credits. I am pleased that having set out a clear anti-austerity, pro-investment economic policy Labour has changed the terms of economic debate in this country.

But there is much more to be done. Our society continues to be marked by grotesque levels of inequality, magnified by the actions of this Government and the previous Coalition. We have to address the indefensible penalties which women pay in their everyday lives simply for being women. We need to keep campaigning loud and clear to tackle inequality wherever it is found.

I would like to pay tribute here to Paula Sheriff for her campaigning work on the tampon tax It is campaigns like that that will make the difference on so many issues for women across Britain. It means tackling inequality in the workplace where women remain in the lowest paid jobs and too often are paid less than men even where they are doing the same job.  I am proud that through our Workplace 2020 campaign, the Labour Party is setting out an ambitious vision for dealing with these issues I urge all of you to get involved in that campaign. And I want to pay tribute to Siobhan McDonagh for standing up for low paid women at M&S who are being deprived of the benefits of the increase in the minimum wage.

We know that creating a society in which everyone can achieve their full potential will also drive the creation of a stronger economy and that economic equality benefits us all. The Women1s Business Council estimated that equalising men and women1s participation in the economy would add 10 percent to GDP by 2030.

During the recent leadership campaign, we put forward a range of policies aimed at achieving equality for women policies built on the work done over the past year.

Through investing £500 billion backed up by a publicly-owned National Investment Bank and regional banks in infrastructure, manufacturing and new industries to move us to a high skilled, high tech, low carbon economy. We can transform our country’s economic fortunes and the opportunities and life chances of women across the country. We have set out concrete measures to achieve equal pay. Improving access to justice through abolishing Tribunal fees. Providing the Equality and Human Rights Commission with enhanced powers. Strengthening employment and trade union rights and taking on the occupational segregation in our labour market which contributes so much to women’s concentration in low paid, insecure work.

I have committed to the Labour Party publishing a regular ‘gender audit’ of our policies to better communicate the positive impact all our policies will have on moving us towards a more equal society. And I have committed to consult on establishing a high level, strategic Women’s Advisory Board supporting the work of the Shadow Secretary of State for Women and Equalities and linked to the Leader’s Office to ensure gender equality is at the heart of all our policies.

I would like to take a moment here to thank Angela Rayner an MP who throughout the summer fought tooth and nail to hold the Tories to account on education, grammar schools, equality and women1s rights. Not for one second has she paused in that fight and I want to thank her for all that she has done.

To enable women1s equality we need to remove the barriers to their participation whether that is because of insecure work expensive childcare or entrenched out­ dated attitudes. The TUC report 1Still just a bit of banter?1found that more than half of all women polled have experienced some form of sexual harassment in the workplace. This is unacceptable. Campaigns such as the Everyday Sexism project have powerfully used social media to expose the day-to-day examples of sexism in every aspect of women1s lives.  Under my leadership1 the Labour Party has committed to consulting and working with women’s and other relevant organisations on how to strengthen the law and its implementation to tackle sexual harassment and threats online and increase organisations1 responsibility towards promoting safe and respectful ‘community standards’ online.

‘Reclaim the Internet’ which many colleagues here today1 including Jess Philips have been supporting brings together women1s campaigns think tanks trade unions and media platforms to challenge the abuse that women face online.

Women who are in the public eye including women in politics face greater challenges, and outrageous abuse both on and offline. Wherever abuse occurs1 it is incumbent upon us all to ensure that it is taken seriously and challenged. And we must acknowledge the terrible truth that the abuse, threats of violence and bigotry that women in all walks of life are subjected to online are a manifestation of attitudes, culture and society offline. Some 85,000 women are raped in England and Wales every year and domestic violence remains an appalling blight on our society. It will affect a quarter of all women in their lifetime. Two women a week continue to be killed by their current or ex-partners.

Colleagues in the women’s PLP have done an inspiring job of highlighting issues of domestic violence. One of the women in my own team said that she had been moved to tears by the powerful testimony of Angela Smith recently in Parliament as she recounted the tragic story of one of her constituents whose children were murdered by her abusive partner. That is why we are determined to resist at every opportunity the imposition of further cuts on services for women and girls facing violence cuts which have been devastating.

Supporting the provision of services re-balancing the economy ensuring that the law protects the rights of women. These are all changes in the world out there which I am confident we all want to see and they are changes which will only come about, I believe, if we are prepared to make changes in the world in here within our own Party.

Our party should be as inclusive as possible. I am committed to taking forward the recommendations of the Chakrabarti Inquiry to consult on and introduce a wider Equal Opportunities Policy, training and guidance for both Party members and staff. If we are to increase women’s representation, voice and power in society as a whole we must increase them too within the Labour Party. I have been clear in my support for All Women Shortlists to achieve 50:50 representations in Parliament. We should aim for 50:50 representations across all public offices with gender balanced shortlists.

Making this conference a representative and democratic annual policy making conference is a step towards strengthening women’s voice within the Labour Party.

Whatever result you were hoping for in the leadership election, I imagine that we are in agreement that it is deeply regrettable that the announcement of the election result should have been scheduled for the same day as this conference.

I hope very much that you will all enjoy Women’s Conference and that this will have been a rewarding and enriching day for you all. And I hope that for those of you who remain here in Liverpool you will find the rest of the week equally enjoyable and stimulating. I look forward to working with you all over the coming weeks, months and years and building a united Labour Party that together can win the next election and win for women across Britain.

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In its early days, the NHS was an institution that valued and worked in accordance with a strict hierarchy. Consultants and other doctors occupied the top positions, with nurses taking their much lowlier place close to the bottom of the pile. The gender of those who staffed our hospitals and surgeries also reflected a wider societal gender divide, with almost exclusively female nurses existing primarily to enact the wishes of almost exclusively male doctors. Decision-making rights were concentrated amongst the males, at the top of the NHS power structure.

Nursing today is a very different proposition and, rather than being ‘trained on the job’ in a piecemeal way, the vast majority of nurses today either hold a degree or are studying towards one. Additionally, many of the qualifications nurses are achieving are in specialist medical areas. Nurses are no longer auxiliaries to the main medical prowess of doctors- they are experts in their own right, holding valuable knowledge and insight in areas like diabetes, obesity, obstetrics, pharmacology, pain control… the list is endless. With their new expertise, these nurses have achieved higher pay scales, with many reaching the earning power of their doctor colleagues.

So, why are these changes taking place?

There are a number of reasons, both societal and scientific. In society more broadly the lines between traditionally ‘male’ and ‘female’ roles have become very blurred. Although nursing as a profession remains dominated by women, that too is gradually changing. There are far more male nurses today than there were even a few decades ago, and there are also a much greater number of female doctors. In fact, today more women go to medical school than men. In the UK, in 2013, some 55% of first year medical students were female. As the old-fashioned division between male / female, doctor /nurse breaks down, so to does the way we, as patients and colleagues, perceive the roles. However, changes to the nursing profession don’t only reflect a shift in gender roles; the way the role is changing is also down to major technological and scientific advances.

New nursing methods, innovative machines and better research have freed nurses from many of the labour-intensive chores that once defined their working lives. Like housewives of old, a nurse’s daily life was once full of cleaning; a constant fight against infection and filth. Today, with machinery bearing the brunt of this work, nurses are more likely to be found processing illuminating data or contributing to important research than they are scrubbing floors.

A hierarchy of nursing still exists, as anyone observing a nursing teams’ colour-coded uniforms (which correspond to different band roles) will attest. However, nurses today have opportunities to climb a pay scale ladder and / or to branch off into interesting and rewarding specialisms; something simply not possible 100 or even 50 years ago. Inarguably, these are positive developments, for nurses of either gender, but also for the patients who rely on them.

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New research by University of Manchester academics has revealed for the first time how harmful repeated racial discrimination can be on mental and physical health.

Several studies have already linked racial discrimination to poor mental and physical health but no study has ever studied the impact numerous attacks over time have on a person’s mental health.

The study, published by Dr Laia Becares and colleagues in the American Journal of Public Health, was looking at the accumulation of experiences of racial attacks over time including being shouted at, being physically attacked, avoiding a place, or feeling unsafe because of one’s ethnicity.

Dr Becares, Research Fellow in the University’s School of Social Sciences and in the Centre on Dynamics of Ethnicity, said: “Studies that assess the association between racial discrimination and health, or examine exposure at a certain point in time, underestimate the harm of racial discrimination on the mental health of ethnic minority people and its contribution to ethnic inequalities in health.”

In this research increased mental health problems were shown to be significantly higher among racial minorities who’d experienced repeated incidents of racial discrimination, when compared to ethnic minorities who did not report any experience of racism.

The study also found it was the fear of avoiding spaces and feeling unsafe due to racial discrimination that had the biggest cumulative effect on the mental health of ethnic minorities.

Dr Becares said: “This finding would suggest that previous exposure to racial discrimination over the life course, or awareness of racial discrimination experienced by others, can continue to affect the mental health of ethnic minority people, even after the initial exposure to racial discrimination.”

The research used the ethnicity sample of Understanding Society which is a dataset used to examine research questions with participants over time – this allowed the researchers to add up all experiences of racial discrimination that people have experienced across five years to find out whether these were associated with changes in mental health.

Dr Becares added: “Our research highlights just how harmful racial discrimination is for the health of ethnic minorities. We see how it the more racism ethnic minority people experience, the more psychological distress they suffer from. This is important in light of the documented increase of racist attacks after Brexit.”

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This is reproduced with permission from OurNHS openDemocracy 

The sharp recent increase in reported hate crime – the worst rise on record – is linked to the EU Referendum, according to Mark Hamilton, head of the National Police Chiefs’ Council. He said last week “Some people took that as a licence to behave in a racist or other discriminatory way.”

The imagery and language on immigration used by Nigel Farage, Boris Johnson, Michael Gove and others has made the unspeakable acceptable.

This is raises several big challenges for the NHS.

The NHS would collapse overnight without the contribution of EU and Black and minority ethnic workers. Anyone who thinks otherwise is living in cloud cuckoo land – including any minister who thinks the immigration status of these staff should be a bargaining chip in EU negotiations.

There are 110,000 EU workers in our health and care system. Ten per cent of our doctors, and more than 20,000 NHS nurses, are from another EU country. Well over 200,000 staff in the NHS (a third of doctors and a fifth of nurses and midwives) are from Black and Minority Ethnic backgrounds. The NHS is the largest employer of Black and Minority Ethnic staff in the UK.

EU staff by nationality by NHS trust

EU staff by nationality by NHS trust and CCG

Source: Health and Social Care Information Centre, NHS Hospital & Community Health Service (HCHS) Workforce Statistics, as at 31 March 2016; and House of Lords Library

But racism in Britain has deep roots. A generation of Irish nurses were poorly treated. The MacPherson Report demonstrated how deeply race discrimination had become embedded in the culture of public services.

Staff are discriminated against in appointments, in disciplinary action, in bullying, are less well treated when they raise concerns, wait longer to be promoted, and do less well on discretionary pay. The evidence is clear from NHS workforce data and staff survey data consistently show that BME – but until recently, concerns were greeted with wilful blindness.

The NHS has a poor track record in tackling other forms of discrimination, too. Disabled staff and LGBT staff suffer high levels of bullying, for example. Women are still seriously under-represented in more senior posts.

Yet the evidence is now clear that discrimination, and especially discrimination against BME staff, impacts adversely on patient experience and care.

Most race discrimination in the NHS is subtle. It is well hidden, or the unintended consequence of stereotypes, bias and a culture where injustice is difficult to challenge. Understanding individual experiences is crucial. Often black and minority ethnic staff bottle up their response because to sharing it is seen as unsafe and threatening – both for them and for those who hold power at team, division, profession and organisational level.

More overt racism

But the toxicity of the Referendum campaign has now helped legitimise more overt forms of racism.

Racist graffiti has appeared on NHS premises.

We’ve heard anecdotally of an increase in patients wanting to only see a white, ‘British’ member of staff.

Patients demanding healthcare from a healthcare worker of a particular ethnicity has been unusual in the NHS.

But it happens. Some 17 years ago one London primary care trust felt it necessary to agree a policy that, should families demand to see a white health visitor or district nurse on a home visit as some had, then that request would be refused, and advice and care would then only be available from a Health Centre where that request would be refused again. Two years ago, Dr Nadeem Moghal described how the parents of a child in a hospital where he used to work refused to have any doctors caring for their child who were other than white. He said: “the clinical director concluded that because of the nature of the disease and the clinical need of the patient, the parents request would be enabled”. In other words, the hospital would uphold the parents’ request. And until a board level inquiry reversed the decision, which the parents eventually agree to abide by, care was organised so that only a white British doctor attended to the child.His article rightly referred to Macpherson’s definition of institutional racism

“The collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture, or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantage minority ethnic people.”

Days after the Referendum result, a Leicester Musculoskeletal Radiologist Dr Ali Abbasi ‏tweeted “@drmaliabbasi Last night a Sikh radiographer colleague of mine was told by a patient “shouldn’t you be on a plane back to Pakistan? we voted you out”. 

Sometimes these issues are not easy to tackle. When my dad’s care home called us some years ago to say he had racially insulted a member of staff we were astonished. He was a life-long opponent of discrimination in all its forms. His dementia had first caused him to start swearing, something he had never done in his entire life, and then this. We spoke at length with dad, and repeatedly, explained it was not acceptable and must stop. It did. To this day I still cannot understand what happened.

Sometimes the racism is overt and violent. Last year a patient who subjected two healthcare assistants to racial and homophobic abuse was fined, after a prosecution brought by NHS Protect’s Legal Protection Unit (LPU), after the police stated that they were unwilling to take further action. (The LPU advises health bodies on a wide range of sanctions that can be taken against those who assault, harass and abuse NHS workers).  

In 2013, recorded racist verbal and physical attacks against those working in the NHS were on the rise, according to a Freedom of Information request by BBC radio 5 Live. Their investigation found that; the number of such attacks in the NHS had risen 65% since 2008 with a total of 567 racist incidents, though I suspect there may be significant under reporting.

The large-scale 2015 NHS staff survey (and previous years’ surveys are similar) shows that White and BME staff were equally likely to experience harassment, bullying or abuse from patients, relatives or the public in last 12 months, but BME staff were more likely (25%) to report experiencing harassment, bullying or abuse from staff in the previous 12 months compared to white staff (22%).

BME staff were more likely (14%) to experience physical violence from patients, relatives or the public in last 12 months than White staff (12%) and more likely (3%) to report experiencing physical violence from staff in last 12 months than white staff (1%).  

The survey figures show that in fact BME staff are more likely to experience harassment, abuse, bullying and violence from fellow staff than they are from the public. And any bullying of staff impacts on patient care, making effective teamwork hard and making staff more reluctant to raise concerns or admit mistakes.

The risk of the post EU Referendum toxicity is that discrimination may rise despite the fact that NHS employers, on the whole, were quick to react to Brexit, understanding the risk of alienating their workforces.  

Some suggestions

The ringing of bells by the Leave campaign and the wringing of hands by the Remain supporters does nothing to prevent the potential undermining of EU and BME staff within the NHS.

Since 2015 the mandatory Workforce Race Equality Standard has produced data that validates the belief of injustice and the pain already experienced by many BME staff. And the Standard has obliged (or helped) organisations to hold a mirror to themselves and requires organisation to improve the treatment of their BME staff.

So here are a few suggestions for anyone in managerial, governance or leadership roles in the NHS. Good trusts have already actioned some of these points.

  1. All staff should be informed about the evidence of the positive contribution that EU and BME staff make to the NHS. All managers should be informed and confident to tackle the issue, and trade unions must be involved. A good start would be this excellent blog on EU staff.
  2. Create a safe space for discussion but not for tolerating racism. Allow staff to raise difficult issues and ask questions troubling them, in a way that effectively challenges prejudice.  Leaders should meet EU staff and BME staff directly affected, as the best ones already have, to listen to their concerns and their ideas for responding to this challenge – and offer practical support.
  3. Underline the principle of zero tolerance for racist behaviour of any kind, whether from patients or staff. This may not always be easy – for example where unwell patients are abusive – but think through how to respond in line with the principle of zero tolerance, including whether patients can choose to be treated by white staff.
  4. Strongly encourage staff to formally report all instances of bullying, abuse, harassment or violence (from whatever source) as a health and safety incident (for example, using Datix) as well as through the HR department. Make clear that anyone seeking to prevent such reporting, or retaliating when staff do, will face disciplinary charges. Managers must model the behaviour they expect of others.
  5. Be proactive. Use staff survey data to identify hot spots of bullying, violence, and discrimination working with unions and staff networks to intervene proactively. Undertake full (not just sample) surveys to better understand such patterns.
  6. Bear in mind that there is extensive evidence of the less positive experiences of BME patients (and indeed other minority groups such as LGBT patients) and the NHS needs to ensure that is not worsened by the current climate too.
  7. Learn how the best organisations how they are tackling these issues – staff survey data will give a clue but beware tick box approaches focused solely on policies, procedures and training. Ensure there is a dedicated member of staff, working with unions and staff networks, who concerned staff can contact. Take advice from NHS Protect when necessary.
  8. Check out current advice to employers on what else they can do to support staff from the EU.
  9. Recognise that the current environment makes it even more important to engage fully with the NHS Workforce Race Equality Standard whose principles of fair treatment for all can be easily applied to EU staff. Tackling discrimination against BME (and EU) staff requires a determined effort to change workplace culture – something that will benefit all staff and all patients.
  10. Support calls for adequate funding for the NHS. An underfunded NHS, with growing queues for care and treatment, encourages some to blame “foreign” NHS users even if the contribution of “foreigners” to the NHS both as staff and as taxpayers outweighs their so-called “burden”.  

The legacy of hostility to immigrants, and lies about NHS funding, which helped deliver the vote to Leave the EU can be turned around. Don Berwick rightly said

At its core, the NHS remains a world-leading example of commitment to health and health care as a human right – the endeavour of a whole society to ensure that all people in their time of need are supported, cared for, and healed.”

The collective effort of a hundred and more different nationalities within the NHS to care for our population is a living riposte to xenophobia. The NHS demonstrates, more clearly than anything else can, the positive contribution that staff – from all nationalities and all backgrounds – make to the national good.

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NHS England’s – and as a consequence, the Government’s – refusal to commission Pre-Exposure Prophylaxis (PrEP) is as short-sighted as it is stupid. Around seventeen people in the UK are newly diagnosed with HIV every single day, and we have available to us a drug, Truvada, which has been shown to reduce the risk of contracting HIV by between 90 and 99 per cent. In a large international study, those gay men that took at least four doses a week saw 96 per cent fewer infections. A UK study saw a figure of around 86 per cent. Whichever figure you accept, it’s a significant impact in ending the transmission of HIV, and the closest thing we currently have to a cure.

Now I accept Truvada is not cheap – I hate talking about healthcare in purely economic costs (it’s people’s lives we are really talking about here) but even in crude economics, the lifetime costs of treating somebody with HIV could reach around £380,000. By limiting PrEP prescription to those most at risk of contracting HIV, we could drastically reduce the number of infections and the associated lifetime costs.

Now the Government claims that the cost may have to be absorbed by existing local authority public health budgets – which have been slashed repeatedly by the very same Government. And that causes an additional issue: assuming councils did this, ALL of the costs of prescribing PrEP would fall to local authorities, whereas the NHS would be the beneficiary of ALL of the financial savings in hospital treatment, care and lifetime treatment no-longer being necessary. The Local Government Association has rightly called the decision an “attempt to create a new and unfunded burden on local authorities.” And some local authorities would clearly have to devote far more resources than others – authorities such as Manchester and Brighton & Hove, and other similar areas with large LGBT, MSM or African BAME communities, would almost certainly have to spend more than other councils.

The Labour Party has consistently called on the Government to reconsider this counterintuitive position. In my Urgent Question to the Public Health Minister, I made the point that the Health Secretary could delegate the power to commission PrEP to NHS England via Section 7a of the NHS Act 2006, but that this would need to be accompanied by appropriate funding. This, in our view, proves that the Government has made nothing more than a political decision, and is hiding behind legal advice.

The UK was once a world leader in the fight against the HIV epidemic, and yet now it’s lagging behind other countries in Europe. Offering PrEP to people at risk of infection would help us to significantly turn the tide in this fight. It is time for the Government to use its section 7a powers and put this situation right.

 

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I landed at Heathrow on 26th January 1991 with three pounds in my pocket and a turban on my head. In my head were Oxford spires, Bertie Wooster, Pink Floyd, Sir Humphrey Appleby from Yes, Minister and the Marylebone Cricket Club—as well as a firm conviction that I would feel at home. I was heading for Hounslow in west London to get some cash from a family friend before going to the General Medical Council (GMC) offices near Great Portland Street to register, and finally to Lincoln to start work as a junior doctor. At Heathrow, I asked an elderly lady how to get to Hounslow, admitting that I only had £3. “Don’t worry love, you will get there and still have change left for a drink.” Paradise: where women you have never met call you “love.”

The GMC office was tricky to find. Outside the tube station, I asked directions from a group of youngsters who snarled: “Fuck off.” Disheartened, I turned to a man rushing somewhere. He looked at my creased paper with the GMC address and phone number, rang the number on his brick-sized mobile phone to find out where it was and walked me to the front door.

Lincoln was trickier still. Flat, everyone white, and not a turban or dark skin in sight. Walking back the first evening from a corner shop, I was stopped by three young men. Tattooed and aggressive, they wanted to know if I was aware that their country and my country were at war. They thought I was Iraqi. They were in no mood for lessons in geography, religion or culture; my pleading that I was a Sikh from India was of no interest. As they started to push and shove me, a group of women across the road came over. They were nursing students and one of them had seen me earlier that day trying to find my way round the hospital accommodation. One of them shooed the guys off with language that would do a seasoned sailor proud. I was close to tears. She took me to her flat, made me the most welcoming cup of tea I have ever had, and said: “Don’t mind those dickheads, love.” Love, again

I was bewildered. This was not the England I thought I knew. My ancestors came from a small clan of Kashmiri Brahmins who converted to Sikhism in the 18th century. Indian Kashmir has now almost been cleansed of its non-Muslim population; my clan, a successful minority in Kashmir, has been without a home for three decades. I was lucky; I grew up in Delhi. I was training to be surgeon and living a recklessly indulgent life till Indira Gandhi’s assassination in 1984. In the aftermath, I joined groups seeking justice for the Sikhs. By 1990, it was clear that there would be no justice.

I decided to leave India and found a job as a charity worker in Ethiopia. Three weeks before I was to leave, a work opportunity arose from England, as a psychiatry trainee in the East Midlands. Confronted with a dilemma, I invited friends over and opened a bottle of Indian Scotch. After several drinks a friend suggested: “Why don’t you stop over in England to see how it is? After all, England is on the way to Ethiopia.”

After arriving in Lincoln, I became exquisitely sensitive to racism. My antennae twitched at every perceived slight and humiliation, even when, in retrospect, some incidents had benign and often slightly comic explanations. I remember being asked to attend to an elderly lady who wanted to leave an inpatient ward against medical advice. As I approached the ward, she was standing by the door arguing with a nurse. She looked at me and said: “Look, my taxi is here.” Having examined her, I told her I was going to detain her under the Mental Health Act. She was incredulous: “How can it be right that you can come to my country and stop me from leaving?” I explained that I was simply doing my clinical duty as required by law. She asked which law it was and which party had been in government when it was passed. I said it was the 1983 Mental Health Act and although I was not certain, I thought the Tories had been in power. “Bloody Tories” she exclaimed, still struggling to accept that someone like me could override her will. In her world, people like me were taxi drivers or corner shop owners. Was she driven by racist or malicious intent? I don’t think so. Racism would be an easy charge, but doesn’t explain everything.

In those early years, I could easily find examples of pervasive and pernicious racism within society and in the NHS. A consultant I worked with told me that I must return to my country after completing my training, since there were “too many of your kind” in the UK already. I witnessed subtle prejudices and downright discrimination against ethnic minority candidates in exams and interview panels. In what was then the NHS merit award system, I noticed how white consultants locked themselves in closed committees and handed out financial rewards to each other, ignoring their often equally worthy non-white colleagues. A London medical school had a systematic way of excluding applications from non-white and female candidates, based on name recognition. At a party, a slightly drunk female colleague accused me of “building mosques in the UK” and having “four wives back home.” When I explained that I was a Sikh, not a Muslim, she said: “Of course you are going to deny being a Muslim.”

Yet my everyday life was not an accumulation of disagreeable experiences. The racist events stand out not because these were common, but because these sharply contrasted with everyday life among the friendly, decent, scrupulously fair and unfailingly polite population that makes up the bulk of Britain. I quickly made friends, learnt to love ales, started attending concerts by my teenage rock heroes. I also worked out the hidden intricacies of English as spoken by the English. In a meeting, if your view was considered “interesting,” it meant you might be right. “Very interesting” implied that you were obviously barmy. When the English called you “Sir,” they were distancing themselves. When they were amusingly rude, you were one of them. I was lucky I worked with people who were accustomed to working with ethnic minorities on an equal basis. I suspect my experiences would not have been the same in a different class and professional setting.

So how racist is Britain? The answer depends on one’s reference point. Compared with a utopian society of flawless human beings, Britain undoubtedly harbours some people with racist prejudice. Compared with human societies as they exist in the real world, Britain is one of the most tolerant and welcoming nations in the world. Had I moved from New Delhi to Chennai, Kolkata or Hyderabad, I would have faced discrimination based on language, culture and geography. Tribal affiliations are part of being human. And many countries, including those from which most migrants originate, have a shameful record of discrimination and human rights violations. India regularly experiences large-scale violence, often triggered by trivial religious or political disputes. A Muslim man was recently lynched because it was suspected that he had beef in his house. The UK should not be judged by India’s standards. It is also not right to expect the UK to live up to an unrealistic standard, where every individual is non-racist, and where everyone has the right to be offended by a subjective interpretation of someone else’s words; where history has to be washed clean of racist impurities; and where white culture is a homogenous monolith that subjects an equally homogenous minority group to its malevolent intent.
Swaran Singh wearing his hair down and a "fiendish leather jacket"

Swaran Singh wearing his hair down and a “fiendish leather jacket” 

Everything to do with race cannot be always attributed to racism. Some years back there were serious suggestions that ethnic minority patients should only be seen by ethnically matched clinicians—apartheid within the NHS. This followed evidence that ethnic minorities were more likely to be diagnosed with a serious mental disorder, and were more likely to be detained under the Mental Health Act. There is robust evidence that the reasons for higher rates of mental illness and detention lie with the socio-economic disadvantages experienced by some minority groups, including societal marginalisation and discrimination, but these factors are outside the control of the NHS. Under pressure from anti-racist groups, successive governments have accepted the charge that mental health services are “institutionally racist,” and have spent hundreds of millions of pounds on race equality—as if sending psychiatrists on cultural sensitivity training courses would improve the social disadvantage of minority communities. (Ironically, the one part of the NHS with disproportionately large numbers of ethnic minority staff is mental health care.) No one would say GPs were racist because they diagnose higher rates of coronary artery disease in people from the Asian subcontinent or hypertension in those of Afro-Caribbean origin. The remedy for such ethnic differences in health lies in implementing social change that reduces exposure to risk factors for heart disease and high blood pressure, not in blaming doctors. But such is the power of the racism charge that politicians are forced to act before they have had time to think.

In my first year in the UK, a white woman with post-mastectomy depression refused to see me because she felt that someone from my “culture” would not be able to understand her. I wrote to her asking to meet up before she decided whether I could help or not. She did, and we had a successful therapeutic relationship. White patients cannot demand that only a white doctor sees them. If as an ethnic minority patient, I demand that an ethnically matched clinician should see me, I am saying to my white friends: I am equal to you, but you are not equal to me. Our shared humanity and the commonality of human suffering, pain and loss should allow us to understand the influences of culture without demanding that patients from minority ethnic groups be treated in a fundamentally different way.

I led research, commissioned by the Department of Health, to understand the experiences of ethnic minorities seeking help (The Enrich Project.) In our research, we asked black and Asian communities whether they want to be seen by someone from their own background. No one asked for it; everyone said that they don’t care about the ethnic origin of the clinician as long as the clinician was competent and treated them with respect and dignity.

When we meet another human being, each one of us makes the same spontaneous, automatic, instantaneous and involuntary judgements about them: male or female, adult or child, my tribe or not my tribe. These are evolutionary responses designed to assess threat. Is the other person a potential friend, foe or mate? Tribal costumes and decorations are primarily designed to confirm “us versus them” status. Hence the importance in all societies of visible markers of difference. There is a famous saying in anthropology: “in some ways we are like everyone else, in some ways we are like some other people, in some ways we are like no one else.” Between our common humanity and individual uniqueness is the separation of our tribe.

Race and ethnicity are just one way of dividing us, and in my experience, class is a deeper dividing line in British society than ethnicity. Many such divisions can be overcome by commonalities of language, values, traditions, food and social networks. We need shared symbols. Witness how debates about the niqab are so difficult and disconcerting. In a free society, the state has no business telling people how to dress, and yet dress that creates a complete visual barrier between people not only emphasises difference, it can also seem a rejection of shared social norms. While I would never dream of asking a patient to change the way they dress, I know that I would struggle to conduct a mental state examination or engage in psychotherapy with a person in full niqab since I would have no access to the non-verbal cues that are so important in the therapeutic encounter. Governments have a much trickier job balancing individual freedom with social cohesion. I wonder how British society would react if traditional Digambar Jains, some of whom live naked, were to demand the freedom to live true to their faith in this country.

There are disadvantages in considering racism as a sufficient explanation for all ethnic differences everywhere. We found in our Enrich project that for the same poor experience of care, white families would blame “poor services” while black families would blame “racist services.” If the problem is formulated erroneously, wrong remedies are applied, which risk exacerbating rather than alleviating the problem. On 19th September 1990, Rajiv Goswami, a 20-year-old from Delhi University, set himself on fire in a public place in New Delhi in protest against the government’s plan to increase the compulsory quota for lower castes, from school placements to senior government jobs. Within a few days, 150 young people attempted suicide in protest, often in public places. I interviewed 22 of them, six of whom subsequently died. None had a serious mental illness. But each had experienced reverse caste discrimination, either directly or against a family member. They were upper caste but poor. By assuming that caste was the only source of disadvantage, the government intervention was discriminating against people for whom being upper caste had conferred no advantage. Today, in the UK, white working-class boys have the greatest attainment gap in education. No one speaks up for them, since they are not an ethnic or racial minority. Would anyone consider the hugely successful East African Gujaratis in Leicester an oppressed group? Race is not the only, or even the biggest, barrier to success in the UK.

In 25 years of living here, I have seen Britain make huge and positive strides towards equality and against racism. The kind of racism I experienced in my early years is increasingly rare, although there is a worrying recent increase in hate crimes in some parts of our society. No mainstream politician in Britain would make the kind of statements routinely heard from Eastern European leaders. Although it is difficult to be sure, I suspect very few people, certainly among the younger generation, harbour the kind of naked prejudice that was apparently common in the 1970s. This is a cause for celebration, even as one has to guard against complacency.

I now tell new arrivals to the UK that it is easy to integrate into British society. Get a dog and strangers will start talking to you while walking in the park. Go to the pub, even if you don’t drink. Spend Sunday pottering in your local garden centre. Encourage your children to participate in host culture and traditions. You will make many friends in Britain. British people are more than happy to meet you halfway, but you have to make a start too—you have to walk towards them, not walk away and isolate yourself with your own kind. For culture is not an impermeable barrier between people that, if breached, inevitably leads to conflict. Our common humanity transcends our tribal loyalties.

Two years after I arrived, I had to apply to the GMC for full registration, which required a positive reference from each consultant I had ever worked with. I got the references, including from the consultant who had wanted me to leave the UK. He could have easily wrecked my chances of staying in the UK, but didn’t. I asked him why he had given me a positive reference. He said that he had been unable to lie. I can call him a racist, or I can acknowledge that even when he could have hidden behind the anonymity of the GMC process, his basic decency and sense of fairness won out. A quarter of a century in the UK has only confirmed for me that most people I meet are decent, kind, fair and free from racism.

We must not deny, ignore or excuse our tendency to stereotype and our unwitting prejudices against people not like us. I remember many years ago leaving a rock concert in an area that was supposedly home to far-right extremist groups. I decided to take a cab rather than walk home. It was about 2am, I had my long hair down and was wearing a fiendish black leather jacket. I saw a large shaven-headed white young man getting some cash out. I hesitated. We looked at each other. I had no choice but to approach the cash point. As I got behind him, he looked at me and said pleadingly: “You are not going to mug me, are you?” I burst out laughing, in relief and astonishment, that he was scared of me. There we were, each trapped in our own prejudices, and finding the other threatening.

We know the world only through a narrow perspective—our personal past and our current understanding of the world. We cannot see the world afresh every moment. To claim to be colour blind or prejudice free is to lie to oneself. We all have prejudices. In a decent society, the best we can do is to be aware of these and try our best not to let them influence our judgment. By and large, most Britons, from all ethnic and racial groups, try their best.

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Psychiatry has always lagged behind general medicine and governments be they Labour, Liberal or Conservative have consistently failed to address the disparity. But mental health affects one in four of our populations and can cost the country in many ways. The cost of psychiatric services is just a small part, mental health problems can damage physical health, can limit a person’s capacity to work, can affect the health of relatives and can place a burden on the police, the courts and prison service. So why then as a country are we neglecting a health problem that affects so many and costs so much?

Throughout our society mental health is the elephant in the room. The effect of stigma and discrimination should not be underestimated. It can leave sufferers frightened to ask for help, scared to tell friends and family, ashamed of their illness and ashamed of their history. To be quite honest most people should know from reading that tackling stigma and discrimination has to be a priority if health outcomes are to be improved.

But the fact that discussing mental health is such a taboo leaves mental health being brushed continually under the carpet. Perhaps then it’s not surprising that the increasingly vociferous body of NHS campaigners have barely touched upon the damage that has been inflicted upon psychiatric services by David Cameron’s government.

Our politicians are elected to serve the people and govern according to the wishes of the people. So until the people start speaking up and saying that mental health needs investing in, it simply won’t happen. If tackling stigma and discrimination did nothing more that open up conversations about mental health and make it sociably acceptable to talk about then that would be huge.

Starting that conversation is crucial to improving outcomes for those affected by mental health but also crucial in encouraging campaigners to call for better services. It should not be something that a person has to hide away for fear of being rejected by their community. It should not be something that a person has to hide from potential employers. But it is.

Yes we have laws against discrimination. But they are close to meaningless for the many people who have a history of mental illness and have to fight against discrimination in everything they do. People with mental illness are often lacking in self-confidence and they are not going to be fighting back when the services they rely on are withdrawn. And they won’t fight back against government policies such as welfare cuts that make life hard. They really do need other people to stand up for them.

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Frances O’Grady, General Secretary of the TUC hundreds of prominent people  and politicians from all major parties, call for the autumn statement to ensure that mental health is treated on a par with physical health (requiring much greater investment). Ten areas of concern are set out. The conclusion is that those experiencing mental ill health “suffer discrimination in our publicly funded NHS.”

The call is timely and the breadth of support is welcome evidence of a higher level of public understanding of the crisis in mental health. The benefits to society of early and effective intervention (reflected in people being able to continue in employment or education) are rightly argued. The benefits to the individuals and their families are equally critical.

Discrimination against people with mental health issues has been around since time immemorial, but awareness has grown recently reflected in the increasing numbers of high profile figures who have spoken out about their own experiences.

Unfortunately, this awareness has coincided with a worsening of the numbers affected. This results from a combination of developments . The cuts in NHS mental health provision stand out as the sharp end of the problem. Less accepted are the causes. Mental ill health has a multitude of causes, but unions have highlighted the negative impacts of stress at work resulting from cuts, redundancies, restructuring, increased workloads, pay restraint and in-work poverty, zero-hours contracts and casualisation. Some early intervention solutions were identified at a TUC seminar in February (read the report) but the case studies presented there painted a bleak picture of the problems. While better NHS care is vital, preventative action is better. But that depends in part on changes to wider government policies.

Those not in work fare little differently but people’s experience of the benefits system can also be a source of stress. The charity Mind has just published its finding that people receiving Employment Support Allowance (ESA) are “more likely to be punished than helped into work” by a factor of three, and that 83% of those on the Work Programme said the experience had made their mental health worse.

The letter recognises disparate impacts on some communities, with a disproportionate over-representation for African-Caribbean and African communities needing adult services. The analysis could be extended. The Equality and Human Rights Commission report “Is Britain Fairer” (published last week) added in the vulnerability especially of young lesbian, gay, bisexual and trans people to mental ill health and a heightened risk of suicide: despite the real advances in acceptance of LGB and T people this statistic is raw proof that the job is far from done.

Stigma continues to be associated with mental health. It means that most people are unwilling to admit to it – especially in the workplace where they know they risk losing their job and struggling to be re-employed in a discriminating employment market. Let us campaign for equality for mental health in the NHS but recognise that wider changes are needed if the numbers needing NHS treatment are to be brought down in the first place.

First published on the TUC blog

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