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Strategies for embedding equality, diversity and inclusion Strive to achieve best practice in recruitment, retention and career progression practices as employers throughout the employment cycle. Support the development of good diversity practice by collecting and sharing examples of practical activities that contribute to progress. Achieving good and exemplar practice over time. Having allies who can confront discriminatory practices. Goal setting with training. Discussions on the subtler aspects of discrimination. Top management support. Framing equality, diversity and inclusion training so it doesn’t legitimise bias. Consistent reinforcement. Leading by example, act as role models for inclusive behaviour and challenge inequality.

Bell Ribeiro-Addy, Member of Parliament (MP) for Streatham, who secured this debate, reiterated the key statistics around black maternal health and mortality in the UK: Black women are still four times more likely to die in pregnancy or childbirth. Black women are up to 83% more likely to suffer a near miss during pregnancy. Black babies have a 121% increased risk of stillbirth and a 50% increased risk of neonatal death. Miscarriage rates are 40% higher in black women, and black ethnicity is regarded as a risk factor for miscarriage. Black mothers are twice as likely to give birth before 37 weeks of pregnancy. MPs contributing to the debate made several calls for Government action on these issues, asking them to: Set a target to end racial maternal health inequalities. Implement the Joint Committee of Human Rights recommendations on black maternal health, as well as those included in the Health and Social Care Committee’s report Safety of maternity services in England. Launch an inquiry into institutional racism and racial bias in the NHS and medical education field. Engage with black women in improving their experiences of maternal health services. Identify those barriers to accessing maternal mental healthcare services and increasing the accessibility of mental health services after miscarriage and traumatic maternal experiences.

Key stats featured in the briefing paper are: 17% of over 65 years old said they lacked a suitable device to download a COVID-19 contact tracing app (Health Foundation 2020). 66% of all adults had never used the internet or apps to manage their health before the COVID-19 pandemic (Lloyds 2020). 19% of people booked GP appointments online in 2020 (GP Patient Survey 2020). The publication sums up its “top 10 takeaways” from the workshop. These include advice to: Address the knowledge gap – increase the quantity and quality of data, especially with poorly served groups. ‘Improve what you know’ by evaluating with early adopters, sharing what works and what doesn’t. Support those already innovating and implementing change, through peer learning and practice sharing. Reach out to other practice managers and a wider workforce audience, with guidance on practical steps to increase digital inclusion for health and care. Grow the number of local, welcoming spaces which support digital inclusion by using ‘existing assets’ such as GPs, community centres, libraries and disused retail outlets. Call on strategic commissioners in health and local government to ‘drive action’ on digital inclusion projects. Support community organisations to build people’s digital skills, confidence and trust – including on disinformation and data sharing. Build ‘better bridges’ between local health, care, voluntary and community sectors, promote ‘shared values’ – such as rights of access to health care – and enable collaboration. Drive continuous improvement of digital tools through patient voice and user experience feedback, and promote more inclusive design of digital services. Build on learning and innovation from COVID-19, and develop a ‘call to action’ across government departments to address digital and health inequalities.

Toolkits include: 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

The report draws out the barriers patients may face, which broadly fit into the following five themes: Socio-economic barriers Complex health systems, health literacy and education Cultural barriers Race, ethnicity and discrimination Geographical barriers. Nine recommendations are made within the report, which are categorised under the following five themes: Personalising care Supporting patients emotionally and financially Better demographic data capture Improving outcomes through research Investment in the stem cell register. Read the report in full by following the link below to the Anthony Nolan website, or you can access it by downloading the attached PDF. no_patient_left_behind_final.pdf

The COVID-19 pandemic has brought to the forefront health inequalities relating to the colour of a patient’s skin. However, this is not a new issue and patients have always faced barriers in healthcare due to the colour of their skin. Impacting factors can include explicit racial bias, which includes discrimination and prejudice; implicit racial bias; missing data; lack of trust; and reduced access.[1] These can lead to misdiagnoses and delays in treatment, which can ultimately cause harm and preventable death. 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: Epstein H. Why the Color of Your Skin Can Affect the Quality of Your Diagnosis. The Society to Improve Diagnosis in Medicine (SIDM) 2018. 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). Singh N. Decolonising dermatology: why black and brown skin need better treatment. The Guardian 2020. McFarling U. Dermatology faces a reckoning: Lack of darker skin in textbooks and journals harms care for patients of color, Stat News 2020. Simmons T. I’m a Black Woman and My Skin Cancer Was Misdiagnosed for Nearly 10 Years. Prevention 2021. Bickler P, Feiner J, Severinghaus J. Effects of Skin Pigmentation on Pulse Oximeter Accuracy at Low Saturation. Anesthesiology 2005; 102, 715–719. Elahi A. Covid: Pulse oxygen monitors work less well on darker skin, experts say. BBC News 2021. Mukwende M, Tamonv P, Turner M. Mind the Gap: A handbook of clinical signs in Black and Brown skin, 2020.

Introduction - The case for a cross-government approach Chapter 1 - Promoting good mental health and prevention Chapter 2 - Tackling inequalities in mental health Chapter 3 - The NHS and support at the point of need Chapter 4 - Helping people with mental health problems to live well in the community Chapter 5 - The mental health workforce

Covid-19 health outcomes The pandemic's implications for wider health and wellbeing Changes in the wider determinants of health The experiences of some groups disproportionately affected by the pandemic Public perceptions of Covid-19 and health inequalities Recovery, risks and opportunities Conclusions