• Improving the inclusivity and equality in our application process
• Changing the award nomination process for NIHR Research Professorships to increase the number of nominations as long as one nominee is from an ethnic minority group
• Making funding calls and their promotion more accessible and improving how we reach underrepresented groups
• Introducing new policies and interventions to improve inclusion
• Establishing new coaching and mentoring schemes
• Setting diversity targets for selection committees.

1. Create an induction offer for named Health Inequality leads, including role guides and examples of actions to be taken.
2. Use national and local action learning sets, which are already in place in some areas, for named Health Inequality leads.
3. Create a repository of high-quality evidence, knowledge resources, methods and regularly updated case studies that reflect the progress that’s being made.
4. Commit to a long-term policy focus and a cross-government strategy that places addressing inequalities at the heart of system development.
5. Introduce an enabling accountability framework that puts inequalities on an equal footing with the most important performance metrics and encourages innovation and experimentation to reflect the complex nature of inequalities.

The RCP convenes the Inequalities in Health Alliance (IHA), which first called for a cross-government strategy to reduce health inequalities when it launched in October 2020.

Since then, the government has made several promising commitments that signal a move towards a more joined-up approach to reducing health inequality. The Office for Health Improvement and Disparities (OHID), the cross-government ministerial board on prevention and the Levelling Up white paper all hold great potential to be a catalyst to tackle health inequalities.

The RCP believes the government must now take the next step to strengthen and underpin this work with an explicit cross-government strategy to reduce health inequalities, involving all government departments, led by and accountable to the prime minister.

While it may seem that health inequality is a matter for the Department of Health and Social Care or the NHS, health and social care services can only try and cure the ailments created by the environments people live in. To prevent ill health in the first place, action must be taken on issues such as poor housing, food quality, communities and place, employment, racism and discrimination, transport and air pollution.

The RCP is calling for:

A cross-government strategy to reduce health inequalities, led by the prime minister, including targets and evaluation metrics that go beyond the government’s aim of increasing healthy life expectancy by just 5 years over the next 14 years.

92 senior leaders from the IHA written to the prime minister asking him to commit to a cross-government strategy to reduce health inequalities.

• Refugee Council’s policy note on health barriers - outlines the main issues refugees and people seeking asylum experience when they access health services.
• Therapeutic IAHC Communication Card - a double-sided card with useful vocabulary and phrases with translations. It can be used to speed up and clarify communication about health problems with healthcare professionals, people who work in supporting organisations and members of the public. It has been translated into five languages: Albanian, Arabic, Dari, Farsi, Tigrinya.
• Maternity guide for women on asylum support
• Maternity guide for professionals

These films are based on the Refugee Council's experience delivering the Health Access for Refugees Project (HARP):

• It is different over here: access to healthcare in the UK
• Experiencing the asylum process in the UK and impact on health
• Access to health for people seeking protection in the UK
• The right to be understood: the importance of interpreting
• Experts by Experience

This review examined 21 sets of data on skin lesions, including more than 100,000 images.

The findings of the review highlighted that many of the datasets were missing important information, such as how images were chosen to be included and evidence of ethical approval or patient consent. 14 of 21 datasets gave information on which country they came from and, of those, nine contained images from European countries. The review notes that only a small percentage of images were accompanied by information about the patients’ skin colour or ethnicity.

Among pictures where skin colour was stated (2,436 pictures), only ten were of brown skin and only one was of dark brown or black skin. Among pictures where ethnicity was stated (1,585 pictures), none were from people with African, Afro-Caribbean or South Asian background.

Commenting on the review, one of its authors, Dr David Wen from the University of Oxford, said:

“We found that for the majority of datasets, lots of important information about the images and patients in these datasets wasn’t reported. There was limited information on who, how and why the images were taken. This has implications for the programs developed from these images, due to uncertainty around how they may perform in different groups of people, especially in those who aren’t well represented in datasets, such as those with darker skin. This can potentially lead to the exclusion or even harm of these groups from AI technologies. Although skin cancer is rarer in people with darker skins, there is evidence that those who do develop it may have worse disease or be more likely to die of the disease. One factor contributing to this could be the result of skin cancer being diagnosed too late.”[1]

Dr Neil Steven, member of the National Cancer Research Institute Skin Group, Honorary Consultant in Medical Oncology at University Hospitals Birmingham NHS Foundation Trust, also commented on these findings:

“Skin cancer affects more than 200,000 people each year in the UK alone. Some types of skin cancer are more aggressive than others so quick diagnosis and treatment can be vital. We already know that there are not enough pictures of people from black and Asian backgrounds in the textbooks we use to train doctors. The findings of this review – that pictures of people with darker skin are under-represented in datasets – raise concerns about the ability of AI to assist in skin cancer diagnosis, especially in a global context. I hope this work will continue and help ensure that the progress we make in using AI in medicine will benefit all patients, recognising that human skin colour is highly diverse.”[1]

References

1.    National Cancer Research Institute, Data available for training AI to spot skin cancer are insufficient and lacking in pictures of darker skin, 10 November 2021.

Related reading

• Raynor M, Essat Z, Ménage D, et al. Decolonising Midwifery Education Part 1: How Colour Aware Are You When Assessing Women With Darker Skin Tones in Midwifery Practice? The Practising Midwife, Volume 24 Issue 6 June 2021.
• Mukwende M, Tamonv P, Turner M. Mind the Gap: A handbook of clinical signs in Black and Brown skin. 14 September 2021.
• Neil Singh. Decolonising dermatology: why black and brown skin need better treatment. The Guardian, 13 August 2021.
• Rebecca Tatum. ‘Mistreatment’ due to the colour of your skin. the hub, 12 August 2021

• Nationwide study of more than 1 million pregnancies in England finds that socioeconomic inequalities account for a quarter of stillbirths, a fifth of preterm births, and a third of births with fetal growth restriction—a condition in which babies are smaller than expected for their gestational age.
• South Asian and Black women living in the most deprived areas experience the largest inequalities in pregnancy outcomes.
• Estimates suggest that half of stillbirths and three-quarters of births with fetal growth restriction in South Asian women living in the most deprived 20% of neighbourhoods are potentially avoidable if this population had the same risks as white women living in the most affluent 20% of neighbourhoods.
• Similarly, about two-thirds of stillbirths and about half of births with fetal growth restriction in Black women from the most deprived neighbourhoods are potentially avoidable if they had the same risks as white women from the most affluent neighbourhoods.
• The authors call for concerted action by maternity services as well as public health professionals and politicians to protect women and their babies through a combination of population approaches and targeting high-risk groups, addressing both wider determinants of health (eg, poverty and structural racism) and specific risk factors (eg, maternal smoking). 

• To develop a plan of action in collaboration with key partners that will deliver sustainable and measurable change.
• To focus on high priority areas that will make a difference to the lives of our people.
• To deliver better health outcomes for our people by focusing on health and wellbeing.
• To tackle health inequalities within our workforce and local communities.
• To commit and invest in an ongoing programme of work focused on improving the experience and wellbeing of our Black, Asian and Minority Ethnic people.
• To ensure our people have the opportunity to co-design a long term strategy “Nothing about me without me”.
• Everyone sees equality and inclusion as their responsibility and we adopt a proactive approach.

• Data collection, validation, stratification and application of patient information to address disparate outcomes
• Cultural competency and implicit bias training and education
• Diversity and inclusion in leadership and governance roles
• Sustainable community partnerships focused on improving equity

Dangerous gaps in training

Medical training has, to date, primarily centred on diagnosis in white-skinned individuals, leading to conditions being overlooked in darker skin. Lack of understanding on how changes from the norm may manifest in individuals with darker skin could mean that early developing illness is missed.[2] In a column for The Guardian, doctor Neil Singh highlights that during his medical training it was almost always assumed that his patients would be white.[3] He argues that this prejudice is harmful and can be deadly when it comes to dangerous skin conditions.

A lack of diverse imagery

In dermatology, where images are critical for diagnoses, the lack of images of darker skin poses a barrier to proper treatment and medical education.[4] A study in the journal Social Science and Medicine found that only 4.5% of images in medical textbooks feature dark-coloured skin, which makes it difficult for doctors to learn how to diagnose people of all skin tones.[5] Skin conditions that involve redness or pinkness in light skin can be subtler or harder to see in dark skin, and doctors who haven’t been adequately trained with such images are prone to misdiagnose their patients.[4] Dermatologists say the lack of images is one reason why many conditions, including cancer, can go misdiagnosed or underdiagnosed in darker-skinned patients. As a result, the five-year melanoma survival rate for black patients is just 70% compared with 94% for white patients.[4]

Midwifery: monitoring wellbeing

An example of where skin issues are prevalent is in midwifery, where skin assessment is important in monitoring mothers’ wellbeing – looking for changes in skin appearance using visual and tactile cues that might indicate deviation from normality.[2] Although visual signals are more readily discernible in women with light skin tones, they may be more challenging to detect in women with darker skin.[2] It is therefore crucial that midwives are educated to assess and recognise skin changes in all skin tones so that they can care for women with confidence using clinical judgement.[3] Maureen Raynor reports that ‘we need midwives to be colour aware instead of colour blind’ to help improve treatment of their patients.[2]

Pulse oximeters and false readings

Another example where skin colour plays a role in potential poor treatment is in pulse oximeter testing. In a study, the three tested pulse oximeters overestimated arterial oxygen saturation during hypoxia in dark skin participants.[6] These false readings could lead to health deterioration and lack of necessary treatment. This has been evident during the COVID-19 pandemic, where pulse oximeters have been seen to overestimate oxygen levels in black patients. NHS England is issuing updated guidance, advising patients from Black, Asian and other minority ethnic groups to continue using pulse oximeters, but to seek advice from a healthcare professional.[7] Experts believe the potential inaccuracies in pulse oximeters may be a contributing factor to some of the deaths in dark-skinned COVID-19 patients.[7]

An increasing awareness of the need for change

To address biases concerning the colour of a patient’s skin, in some cases clinics have been set up where people can see dermatologists who have greater knowledge around darker skin tones. In the United States, major cities now have such ‘skin of colour clinics’, many operating under the name ‘ethnic dermatology’.[3]

A petition exists urging the UK General Medical Council to require that medical schools include a diverse representation of skin tones in their teaching.[3] Moreover, the handbook ‘Mind the Gap’ has been produced to educate and raise awareness of how clinical signs and symptoms can present differently on darker skin.[8] Concerned members of the general public have also contributed to this issue – Ellen Buchanan Weiss has established the website ‘Brown Skin Matters’, which provides interested parents and doctors with a collection of images showing how skin conditions can present differently in richly pigmented skin.

Final thoughts

In conclusion, patients with darker skin experience a greater chance of misdiagnosis than white patients, with higher odds of suffering increased harm from diagnostic errors.[5] This is due to lack of education and medical training, non-representative images and available resources, as well as systemic racism. Much has been done in the way of improving this situation, but a wider movement will be needed to ensure that darker-skinned patients receive equal treatment to white-skinned patients.

References:

1. Epstein H. Why the Color of Your Skin Can Affect the Quality of Your Diagnosis. The Society to Improve Diagnosis in Medicine (SIDM) 2018.
2. Raynor M, Essat Z, Menage D et al. Decolonising Midwifery Education Part 1: How Colour Aware Are You When Assessing Women With Darker Skin Tones in Midwifery Practice? The Practising Midwife 2021; 24(6).
3. Singh N. Decolonising dermatology: why black and brown skin need better treatment. The Guardian 2020. 
4. McFarling U. Dermatology faces a reckoning: Lack of darker skin in textbooks and journals harms care for patients of color, Stat News 2020.
5. Simmons T. I’m a Black Woman and My Skin Cancer Was Misdiagnosed for Nearly 10 Years. Prevention 2021.
6. Bickler P, Feiner J, Severinghaus J. Effects of Skin Pigmentation on Pulse Oximeter Accuracy at Low Saturation. Anesthesiology 2005; 102, 715–719.
7. Elahi A. Covid: Pulse oxygen monitors work less well on darker skin, experts say. BBC News 2021.
8. Mukwende M, Tamonv P, Turner M. Mind the Gap: A handbook of clinical signs in Black and Brown skin, 2020.

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