Racial health inequality: everyone has a part to play
Published: November 2020
A call to action
Health systems should be fair. Can a health system be fair when the most deprived areas of England live around 19 fewer healthy years than the least deprived? Can a health system be fair when, taking account for geography, socio-economic characteristics and pre-existing conditions, males of Black African background retained a 2.5 times higher rate than those of White background? Creating a fair healthcare system which will address this unjust divergence of outcomes requires everyone to engage in the design and delivery of healthcare services.
Prioritising the issue
Within the broad sphere of ‘health inequalities’, racial health inequality has been brought into sharp focus by recent global events. We have seen rich countries reserving access to the majority of global vaccine supply and #BlackLivesMatter has ignited an international awareness of racial inequality. There are many important areas of inequality, but we cannot afford to risk doing nothing by trying to do everything at once. 2020 has exposed the stark disparities in care that ethnic minorities receive, and it is clear that there will be no overcoming this until we tackle issues of race and ethnicity head on.
But historically there has been a reluctance to engage with the ethnicity aspect of health inequality due to this topic’s contentious, demanding and complex nature.
To address this, we must first be willing to put a name on the issue. The stigma around acknowledging racial health inequalities within a healthcare system, particularly at a local level, needs to be overcome. The problem cannot be solved by apportioning blame, but rather by accepting that what has gone before has not been good enough and moving forward in the right way.
Secondly, organisations need to be willing to invest in making change. The representation of BAME staff and having policies that build in equality as part of quality measures are a crucial answer to the institutional aspect of this racial health inequality, but they are not always easy to do. They require time and resources to implement effectively.
Thirdly, a complex problem requires a joined-up solution. This means putting the people affected at the heat of the issue and listening. Racial health inequalities are the product of a complex mix of environmental and social causes and inter-related dimensions that are structural, institutional and interpersonal. But improving the health outcomes of BAME communities will no longer remain an intractable problem as soon as we adopt a solution which involves those communities. A joined-up solution requires organisational leaders, system leaders and the government to recognise the role they have to play.
Creating a new social contract
Top-down approaches centrally design healthcare services around the needs of the average patient and roll them out across the country. The less you have in common with this average demographic, the worse outcomes you will have when using the services. When the average demographic is determined by disproportionately white patient advocacy groups and voluntary clinical studies, a top-down approach will always result in worse health for minority groups.
In order to address racial health inequalities, a new social contract must be created that goes beyond individuals paying their taxes, the government apportioning funds to the NHS and healthcare services being provided back to individuals as patients. As well as exchanging taxes for comprehensive services, healthcare systems must provide a platform for patient voices in exchange for active participation and articulation of what is important to local communities. Place-based approaches to healthcare rely on each side engaging as equal partners to design systems that meet the needs of local communities and to address inequalities.
The role of system and organisational leaders in this new social contract is to work with BAME communities rather than for them. This requires taking a community centred approach which emphasises the value of meaningful engagement with local communities at the level of place and the contribution that BAME communities can make to improving health outcomes. They must support community participatory research which engages patients to understand the structural, institutional, social, and environmental determinants of health to gain a full understanding of health and care needs. This includes recognising the diversity within BAME communities and creating safe spaces by building trust. Building this trust is difficult and takes time, but it is a fundamental aspect of the place-based approach. Building on this trust and shared understanding, solutions to address health inequalities and culturally sensitive clinical services can be co-produced. The delivery of these solutions can then be planned and implemented with diverse communities, leveraging local assets and supporting those who need to deliver them. Finally, these solutions need to be monitored moving forward to ensure that they are achieving their intended purpose.
On the other side of the social contract, individuals and communities must be willing to speak up. The process of developing place-based solutions only works if people are willing to actively share their values as part of this process and accept the invitation to engage when it is offered. When it is not offered, and organisations or systems are not taking a place-based approach, there is an opportunity to apply community-driven political pressure to ensure that it is offered. Leaders rely on the people they represent to provide the political ammunition required to make a change. This means signing petitions, writing letters, organising peaceful demonstrations. Make it clear you want to be heard.
Supporting the solution
Addressing racial health inequality may be contentious, demanding and complex, but the problem is not intractable. Taking a place-based approach can support better access and outcomes for BAME communities than top-down, professional-led clinical models. The recent proposals for legislative reform of ICSs suggest that ‘places’ should be the building block for the future health and care system so there is reason to be hopeful. This approach must still be facilitated by systemic and institutional measures: ensuring NHS organisations are acting as responsible anchor institutions to address the wider social determinates of health; improving BAME staff representation; and mandating comprehensive ethnicity data collection. But we can all play our role in creating a more just healthcare system which brings together communities and health systems to tackle racial health inequality.
 Office for National Statistics, ‘Health state life expectancies by national deprivation deciles, England and Wales: 2015 to 2017’
 Office for National Statistics, ‘Updating ethnic contrasts in deaths involving the coronavirus (COVID-19), England and Wales: deaths occurring 2 March to 28 July 2020’
 Integrating Care – The next steps to building strong and effective integrated care systems across England