In the 21st century, you would be forgiven for thinking that health inequalities were a thing of the past. Sadly, incidences of inequality remain both widespread and shocking, the statistics depressingly stark. Black women are four times more likely to die in childbirth than white women. Two thirds of healthcare workers who died from Covid-19 came from ethnic minority backgrounds. And Black and ethnic minority doctors are consistently over-represented in all stages of the ‘fitness to practise’ process.
In September 2022, we published our report,
Safer care for all, which looked at some of the biggest challenges affecting the quality and safety of health and social care across the UK. One of the report’s central themes was the major and persistent inequalities affecting patients, service users and healthcare professionals.
Patients and service users sharing one or more protected characteristics may be more likely to experience a poorer outcome and may be more vulnerable to major failings of care – for example, four of the most recent major patient safety scandals have affected women. And while we are building an increasingly clearer picture of healthcare disparities, surprisingly little is known about those who make complaints about poor care or misconduct by health and care professionals, or the barriers preventing particular groups from complaining.
Professionals are also affected. Research has shown that certain groups of healthcare professionals are affected disproportionately by professional regulation processes, such as referrals into fitness to practise processes. For example, Black and minority ethnic professionals are twice as likely to be referred to their regulator, the General Medical Council (GMC), by employers compared to white doctors. There are also differing levels of academic and career attainment between certain groups, particularly women and those from ethnic minority backgrounds.
To try to tackle the insidious problem of healthcare inequality, we made several recommendations in Safer care for all, calling for action by other bodies (including regulators and governments), and committing ourselves to helping bring about solutions. We called for regulators and registers to work collaboratively to improve the diversity of fitness to practise panels and other decision-makers to ensure they reflect the diversity of their communities.
We also said the system as a whole needs to improve the way it collects data about the protected characteristics of people who make complaints about their care, so we can begin to identify differences in how care is delivered and how complaints are handled.
In December 2023, we sought to shine a spotlight on this important topic again by hosting an event to examine the role of healthcare professionals in tackling health inequalities.
Over 90 people came together to be part of the conversation. The discussion revealed five priorities – in particular, actions that could be taken by regulators – that could make a real difference towards addressing, and solving, the problem of healthcare inequality.
1. Listen to patients and service users
It’s clear that patients and service users are best placed to report on their experiences and suggest solutions. So why do they, so often, have to shout to be heard? We need to be better at listening to those who raise complaints.
Unfortunately, the system does not make it easy to complain. We have a complicated complaints landscape that is difficult to navigate. This issue is exacerbated by a lack of data on who is complaining and why. Regulators need more and better data to help them understand experiences of care across diverse groups.
2. Education, education, education
Education shapes culture for generations to come. With the right education, we can teach professionals – right from the start of their careers – the importance of addressing health inequalities. There must be consideration of health inequalities not just in the curricula, but in the language, codes and standards that underpin it.
Regulators must work with others to shape education and training for healthcare professionals. And as improved cultures start to take root, it is up to regulators across the system to reinforce expectations throughout a professional’s career.
3. Balance the carrot with the stick
Sometimes, change happens with the gentlest of encouragement; sometimes a firmer stance is required. Regulators need to find the right balance when dealing with professionals – between incentives (the carrot) and enforcement measures (the stick) – so that they can promote compliance without creating undue burden or stifling growth.
Improvements in practice can be encouraged with Continuing Professional Development and guidance to help professionals better serve the populations they care for. Regulators must also demonstrate courageous leadership and have mechanisms in place to hold healthcare professionals and organisations to account.
Despite a plethora of legislation (the Equality Act, Workforce Race Equality Standard, the Disability Standard and the Accessible Information Standards), health inequalities are still widening. This needs to change, and enforcing existing requirements is an important part of this.
4. Regulation should set a good example
Inequalities exist within regulation, such as disproportionate fitness to practise referrals, inconsistent fitness to practise decisions, and differential attainment in education, training and career progression. Add harassment, bullying and discrimination faced by many NHS staff into the mix and we have a culture where some professionals don’t feel valued and, in some cases, are forced out of the profession. This needs to change. It is inherently wrong that anyone faces discrimination and inequality. It is also important to have a healthcare workforce that represents the diversity of our communities.
Regulators should act in the areas where they have influence. They can support action to tackle systemic racism and discrimination, such as in curriculum design. Compassionate regulation can also make a real difference in supporting healthcare professionals to contribute to tackling inequalities involving patients. The process of building health equity must be equitable itself.
5. Speak with one voice
No one organisation can tackle health inequality alone. To give professionals the confidence and support to do the right thing at work, healthcare organisations must speak out and make it clear that the provision of equitable care is non-negotiable. Collaborating across organisations, professions, systems and UK countries can achieve this.
The PSA has commissioned research to look at whether a common code of conduct across professions might help to support a unified approach. We will also be reviewing our Standards of Good Regulation to make sure the expectations we have of regulators are sufficiently high where health inequality is concerned.
Ultimately, we need a collective response to reverse the tide on health inequalities. Regulators and those with influence in this area must establish where their contribution lies and make sure we are all pulling in the same direction so that safer care for all really does mean ‘all’.