April 22 2020

The disproportionate deaths of NHS staff during COVID-19

Roger Kline, Research Fellow at Middlesex University Business School, discusses the disproportionate deaths for BME NHS staff.

Health and social staff are dying from Coronavirus and a disproportionate number are of Black and Minority Ethnic (BME) heritage. Ministers have finally agreed a Review of why so many BME staff are dying, though the terms of reference and timescale for reporting are currently unknown.

A Review is welcome as we do not know why so many dedicated health and social care staff (of all backgrounds) are becoming infected and dying. Not least the relative importance of workplace and other factors.

The NHS Providers briefing summarises the immense effort and flexibility shown by NHS employers and staff responding to the pandemic. However, it seems likely that decision making failures, particularly at Ministerial level have made that job much harder. Governments were warned on January 30 2020 by the World Health organisation (WHO) that COVID-19 was a ‘public health emergency of international concern’, the highest level of alert that WHO can issue, however it’s clear that the UK Government was ponderous in its response.

Risk assessments

One casualty was that two crucial risk assessments for NHS and social care staff which could (and should) have started in February 2020 did not – a Management of Health and Safety at Work Regulations (1999) risk assessment and an Equality Impact Assessment (EIA).

Between them they would have helped local NHS and social care employers determine which groups of staff:

  • might be especially at risk (e.g. pregnant women, older workers, with pre-existing health conditions)
  • might be at greater risk such as the poor (greater likelihood of chronic health conditions) or those from particular communities
  • in particular locations might be most at risk (most notably social care and residential and nursing homes)

The Care Quality Commission signed off their EIA for patients on 24 March 2020 but it is unclear which national body published an EIA for the NHS and social care workforce or required local employers to do so.

Existing advice

Government advice to the public is that “some people are at a higher risk and need to take extra steps to avoid becoming unwell” and states that “you may be at increased risk from coronavirus if you are 70 or older, are pregnant or have a condition that may increase your risk from coronavirus

The advice for people who may be at increased risk from Coronavirus is the same as for most other people. You should only leave the house for very limited purposes. It also lists a second category of people who are “extremely vulnerable” and are at very high risk of severe illness from COVID-19 because of specific underlying health conditions. These people are strongly advised to stay at home at all times and avoid any face-to-face contact for at least 12 weeks from the day they are contacted by their GP or healthcare team.

NHS Employers, the umbrella HR body for the NHS, issued guidance on 27 March 2020 which also distinguishes between staff who are in either “extremely vulnerable” or “at risk” categories. Whilst members of the public in the “at risk” group are advised to “only leave the house for very limited purposes”, NHS Providers states:

Staff who are deemed to be in what is described as less vulnerable “at risk” groups are advised to take particular care to minimise their social contact through social distancing. For these staff “employers should support individuals and consider adjustments or redeployment for any staff in the at risk group. Adjustments may include working remotely, for example in 111 services, ambulance dispatch or virtual patient consultations, or moving to a lower-risk area”.

The Royal College of Physicians, in guidance endorsed by 16 professional bodies, added a caveat:

In addition, those doctors with care responsibilities for vulnerable family members should also be given the option of stepping back from front-line care of patients with COVID-19, as part of their duty of care to that family.

Why might some NHS and social care staff groups be at particular risk?

Firstly, we know that people who are poorer (many lower graded NHS and social care staff from all backgrounds including BME staff) are more likely to have “underlying health conditions” and live in more crowded housing where social distancing may be impossible.

We have known for a long time that:

Evidence for a differential impact from pandemic influenza includes both higher rates of underlying health conditions in minority populations, increasing their risk of influenza-related complications, and larger socioeconomic (e.g. access to health care), cultural, educational, and linguistic barriers to adoption of pandemic interventions.

Protection of Racial/Ethnic Minority Populations During an Influenza Pandemic

For example:

  • African Caribbean people have a higher prevalence of high blood pressure
  • South Asians have higher rates of coronary heart disease and are up to six times more likely to have diabetes
  • Hypertension and diabetes are more than three times more likely in BME  groups in the UK.

Secondly, we know that BME staff disproportionately work on the front line in the NHS and social care, whether as doctors, as nurses, as healthcare assistants and in adult social care. More than half the BME nurses in London work on the lowest grade (Band 5) and less than 2% in the middle and senior managers (Bands 8a – 9).

Thirdly, as Robert Francis’ 2015 Speaking Up Review found, BME staff are significantly less likely to raise concerns at work because they fear they will be taken less notice of, and/or be disproportionately victimised if they do so. We also know from successive NHS staff surveys that BME staff and staff with disabilities are more likely to be bullied by colleagues and managers than other staff bullying.

Fourthly, staff (from all backgrounds) have expressed concerns that amongst the staff expected to work in circumstances where the available PPE does not meet the minimum PHE standards, or where social distancing is extremely challenging are staff in “at risk” groups.

We do not know the balance of responsibility for the disproportionate deaths and illness of BME health and social care staff between “external” underlying causes and workplace risks. But clearly, workplace risks will play an important part.

Addressing workforce risks

NHS Trusts have made immense efforts to keep a viable service going in the face of rapidly increasing demand and substantial numbers of staff off sick. The NHS Providers guidance was an effort to ensure more vulnerable staff were placed less at risk. But, under pressure, there is no question that some staff with “underlying conditions”, at greater risk, who might be less likely to speak up, were asked or required to work where there was inadequate PPE or poor social distancing.

Similarly some staff were told they could not be found other work even if a household member was particularly vulnerable and those staff would have included BME staff who were disproportionately on the front line.

Why were those risks not highlighted sufficiently? Is that in part because the overall diversity of the health and social care workforce is not reflected in the diversity of the UK’s health and social care leadership? We know inclusive diverse leadership is better leadership, yet, the Cabinet ministers directly influencing the NHS during the pandemic, and their senior experts, are overwhelmingly white men. It is perhaps not surprising that issues of inclusion and diversity were not upper most in their thinking. Those dying do not look like those deciding.

Key questions

Based on numerous discussions with staff where Trusts are doing what they should be doing, here are some questions the Review team might consider:

  1. Where NHS Trusts have cross-checked staff who become ill (not just deaths) with COVID-19, and their ethnicity, role, gender, age, nationality with whether they had “underlying conditions”, what did they find?
  2. Where NHS Trusts cross-checked how many staff who have become ill from COVID-19 were asked to work in situations where PPE was inadequate or social distancing difficult to observe, what did they find?  What proportion of these were staff returning to work, or students and newly qualified staff?
  3. Where Trusts have “listened with attention” in a safe environment to staff at special risk, what did they find? In particular, what did their BME staff tell them?
  4. Where NHS Trusts found staff are worried about raising concerns linked to COVID-19 and their work, how have Trusts prioritised ensuring those voices can be heard? Especially as it may well be that some of the most vulnerable staff are those least willing to raise concerns.
  5. How can NHS Trusts best demonstrate that whilst “command and control” will be part of the current pandemic response, respect and inclusion should be too? The recent NHS efforts to improve poor workforce culture in bullying, discrimination, inappropriate discipline and the silencing of staff who raise concerns must not in vain.

We do not know the answers or even all the questions about these NHS and social staff deaths. But surely we don’t need to wait for all Trusts to do what the best ones are already doing?

The final point

Too much of the available guidance places responsibility on individual staff to raise concerns. It would be much better if the organisation took the bulk of the responsibility, given that these are system issues, not individual ones.

The Royal College of Physicians guidance on Ethical dimensions of COVID-19 for front-line staff states:

Doctors have a duty to protect the public from harm, an extension of which is the right to protect themselves from harm so they can continue to care effectively. In this respect, it is ethical for those doctors who would be harmed by contracting the virus to refrain from treating patients with (or suspected) COVID-19.

No healthcare worker wants to find themselves in that situation. The Review must ensure that, going forward, none do, especially those (such as BME staff) who may be at greater risk.

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Comments:

Kim Holt (23/04/2020 18:21:28)

Brilliant summary. Important and long overdue answers required to these questions. Thank you

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