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Healthcare for Ethnic Minorities
8.11 p.m.
Baroness Uddin rose to ask Her Majesty's Government what assessment they have made of the effect of the policies outlined in the NHS Plan (Cm 4818) on healthcare for ethnic minority communities.
The noble Baroness said: My Lords, the Government are committed to reducing the inequalities within healthcare provision for all its citizens, and the NHS Plan points to the "inverse care law", whereby those most vulnerable are least likely to receive the healthcare they need. For the first time there is institutional recognition that inequalities and poor health are linked to socio-economic factors such as poverty, poor housing, low income and unemployment.
I am deeply hesitant to rise in this debate in case I am accused of a reversal of racism by raising the issue of the needs of minority citizens, given that we are currently in hot pursuit of challenging the status quo of assumptions on who is a citizen worthy of equality. Equally, I hesitate to follow in the Prime Minister's footsteps in saying that I am a great fan and admirer of the health service. Therefore your Lordships will appreciate that discussing equality issues within the health and social sectors is a complex scenario.
None the less, it has to be mentioned that, to date, many reports have highlighted an institutional weakness in relation to service delivery, employment and relationships with the voluntary sector. There is almost unanimous agreement that issues of equality in services and access to services have yet to become embedded into the management delivery mechanism and have not yet integrated into the performance measurement indicators. Recent CRE research backs up claims by individuals and groups that in many NHS trusts there is a disturbing gap between equal opportunities policy and practices and the experience of consumers.
I have been involved for more than 20 years in my local area, actively trying to change the way in which our local health authority provides care. In doing so, we pushed to the limit for the very little changes achieved in the early 1980s. It meant setting up advocacy projects, ensuring "paper" equal opportunity policies and campaigning on recruitment. The campaign for choice in maternity care came directly out of our own campaign for better provision for minority citizens. The impact was that choice
became possible for all women who used maternity care. Those gains were possible only because of individuals committed to bringing in those temporary changes. What was then fact, and is now evident, is that the needs of minority women remain beyond the reach of the mainstream planning agenda of our maternity services.Some of our experiences were subsequently endorsed, some 10 years later, by a report of which my noble friend will be aware, Action Not Words, which is applicable to today's strategic health planners and commissioners. The current service users and minority staff within the healthcare sector say that there is significant evidence to support the allegation that racial discrimination, direct and indirect, is embedded in the healthcare sector, predetermining and impacting on the health and social care services provided to minority citizens. It has to be said that this discrimination is evident in access to services, within the strategic framework of planning for services and, of course, in employment practices.
It is also worth drawing to your Lordships' attention—although I cannot go into details—a survey commissioned by the World Health Organisation, which found that certain groups in the UK, including minority citizens, do not enjoy fair access to the healthcare system. It also stated that there is a significant body of evidence suggesting that health services do not reach people from minority groups, and that lack of information and inappropriateness of care often deprive minority communities of access to a wide range of health and social care.
So the question is how the Department of Health can assist positively the impact of the modernisation agenda on minority citizens. While many of us welcome the new structure of localised healthcare provision, the reality for minority patients seems to be business as before. From what has been said by groups such as Social Action for Health in the East End and the King's Fund, the lack of strategic planning of health authorities and primary care groups continues to fail local minority populations.
Although recently data collecting has improved, the analysis does not appear to filter into integrating local minority populations into the planning of service delivery. In this way, one can conclude that the modernisation agenda has continued further to disadvantage the local community.
There is certainly a deep sense of unease and confusion among service users and staff about the new decision-making process. They feel that it is more unaccountable and unable to influence service delivery. What is the response of the Department of Health to the suggestion that very little has changed for minority citizens and that those services are hampered by institutional racism and by insufficient account being taken of demographic considerations in the planning of healthcare services? What strategy is being progressed for recruiting locally? How is the local minority voluntary sector being assisted and empowered to rival some of the external private sector competitors for contracting services? Not least of all,
what specific systems are in place for consulting local communities and ensuring and encouraging their full participation in shaping their local healthcare service?Last week I attended a conference organised by Young Mind and the Trust for the Study of Adolescence. The objectives were to highlight the specific mental health issues of south Asian young people and their families. It concluded that there are massive gaps in services. The health workers present reported that the existing training ill equipped them to deal with specific needs.
Perhaps I may share with the House a telling tale. Twenty years ago, as an unqualified social worker in a hospital crisis intervention team, I heard the same call for consistent responses to the needs of minority communities within the mental healthcare system. It is totally unacceptable that this situation should continue. One dare not think about the number of individuals and families who have suffered while we have been contemplating how to define "appropriate care".
The danger is that information about the needs of minority communities will remain poor and that we will become besotted with researching only culturally oppressed Asian women and aggressive African-Caribbean men. Many professionals are stuck with their 18th century views of minority citizens. The most illustrious of institutions cannot seem to equate the rise in mental health problems of African-Caribbean and Muslim men and women with the link between poverty, lack of opportunity, racism, Islamophobia and improper diagnosis.
One has to recognise that NHS prejudice, misunderstanding, racism and Islamophobia can be at their most oppressive in this area and that the NHS remains excessively unaccountable for its practices. There is too much research to ignore the conclusion that there is disproportionate discrimination in the operation of Britain's mental health system, especially as it is applied to African-Caribbean men and Asian women. I beg for urgent action on this issue. The National Health Service framework suggests everything that requires to be done. It needs only for us to ensure that it is implemented with urgency.
However we approach the reality of the health agenda and its impact on the ethnic minority community, we have to agree that, even post-Lawrence, the experience of minority consumers has changed very little in the past two decades. Given that the Lawrence report was commissioned by the Government, I believe that we cannot afford to lose face by failing to translate words into action.
I was recently involved in a discussion with the Macmillan cancer group organised by my noble friend Lady Howells, and I was again forced to conclude that services are accessible only to those who are articulate in seeking them out. There is a great need not only for training and awareness, but for a campaign aimed at the large number of patients for whom diagnosis and treatment come too late because they are unable to access services. I have no doubt that there is a similar pattern in relation to every disease. The only
conclusion that one can draw is that although we are up to date in our theory and our paper policies, our performance is nothing short of dismal.The most important point is that, although the NHS is Britain's biggest employer, and despite more than 20 years of race and equality legislation, the NHS has been slow to ensure racial equality in its workforce. Time does not permit me to deal with the CRE's investigation into that matter. However, the Race Relations (Amendment) Act 2000 may be our newest tool to argue for change in health and social care provision. The CRE's draft guidelines demonstrate what public bodies will need to do to make immediate progress on the four guiding principles.
There is good practice and projects in the health service, often led without adequate resources by individual champions and a vanguard. How will the Government build confidence among minority health service users? To the world, Britain rightly retains the reputation of a free and fair health service provider. With hand on heart, I can say that it is true that the NHS is second to none when care is provided regardless of race, religion or class. However, from all that I have heard, that assertion no longer applies to a significant minority of our citizens.
8.22 p.m.
Lord Parekh: My Lords, I thank my noble friend Lady Uddin for initiating this extremely important debate. When I first read the NHS national Plan I was both most impressed and a little disappointed. I was impressed because it is a determined and imaginative attempt to revitalise our health service and raise it to the highest European standards. I was disappointed because of its virtual silence on the great contribution that more than 20,000 ethnic minority doctors have made to our National Health Service and to the ethnic dimension of the health service itself.
The NHS national Plan says nothing, or very little, about the problems of ethnic minority doctors, the low morale of those confined to the cul-de-sac of non-consultant career-grade doctor posts, the differential incidence of certain diseases among the ethnic minorities and the different needs of those communities. Those are important issues because they affect the NHS's ability to sustain high morale among its staff and guarantee equal access to our people. I should like to highlight four or five important issues.
The incidence of diabetes, hypertension, coronary heart disease, stroke and vascular disease is much higher among ethnic minorities than among the population as a whole. The rate of diabetes is 2.2 per cent in the population as a whole, 5.9 per cent among Afro-Caribbeans, and 7.6 per cent among South Asians. The reasons have to do with genetic factors, dietary factors and lifestyle. However, if diabetes is identified in advance, as it can be, the state can be saved a lot of money and people can be saved a lot of suffering. We therefore need more screening and educational campaigns as well as warning and advising those at risk. I wonder whether such screening is carried out on a sufficiently large scale in areas with a high concentration of minorities.
The next issue is the sickle cell diseases, which are most prevalent among the ethnic minorities and can be found increasingly among mixed-race children. Umbilical cord blood tests are vital because they can identify those diseases well in advance. Take-up rates, however, seem to be no higher than 30 to 45 per cent. It is about time that the Government did something about that.
The incidence of high blood pressure among Afro-Caribbeans is very high: one in four women and one in six men are affected by it. Those communities need to be educated and advised to have regular check-ups, but I am not entirely sure that that is being done.
Afro-Caribbeans are diagnosed as psychotic out of all proportion to their presence in the population. Although the incidence of psychosis in that group is twice that in the white population, the rate of compulsory detention is about five times as high. The percentage of people receiving electro-convulsive therapy and drug treatment is also much higher in those communities than in the white population. By contrast, the amount of counselling provided to them is much lower. I should like to know what action is being taken to address those and the other special health needs of ethnic minorities and to redress the apparent inequality in the services provided to them.
Waiting lists are the next issue. We monitor waiting lists, thanks to the Government's initiative, but that is not done in relation to ethnicity and religion. That should be done so that we can have a clear idea of who is having to suffer more. Such monitoring should also be extended to accident and emergency wards, both before assessment and between assessment and the provision of treatment. We could then have a clear picture of whether all our people are receiving equal access to service delivery.
The cultural dimension of ethnic health is the next issue. Significant cultural issues relating to the treatment and care of the ill, the elderly and the dying have gone unnoticed. Attitudes to death vary, as do mourning practices and rituals relating to burial and cremation. Those employed in the health and social welfare services should be trained in cultural awareness and sensitivity.
Ethnically unrepresentative senior administrative staff is the next issue. Every organisation's culture and ethos are established by its senior staff; they set goals, allocate money, discipline staff, interview and process patients and deal with staff complaints. It is therefore of the utmost importance that the staff should be broadly representative of the community whom they serve. I am afraid that that is not the case in the NHS. Although the proportion of ethnic minorities in the national health trusts and health authorities has certainly increased since Labour came to power—I congratulate the Government on that—the number still falls far short of adequate representation. Barely 2 per cent of chief executives and senior directors in NHS trusts come from the ethnic minorities.
The NHS Appointments Commission, which is in charge of appointing 3,000 non-executive directors of NHS trusts and health authorities, is to be welcomed.
I assume that there are ethnic minority commissioners on that commission. I also assume that the commission will ensure that there is a significant ethnic minority presence in the 3,000-odd appointments that it will make.The lay and professional representation of ethnic minorities on the General Medical Council falls far below the desired level. That issue needs to be examined, as does the issue of ethnic minority representation in the Royal Colleges and specialist training agencies.
A particular concern to many of us is the category of non-consultant career-grade doctors. That category was created a few years ago to accommodate senior doctors who could not move up because of the limited number of consultant posts. Over time, it has become a dead-end and cul-de-sac. Most NCCGDs—between 75 and 85 per cent—are from the ethnic minorities. Some of them are as qualified as the consultants and in fact do their job in their absence. However, they are barred from becoming consultants, partly because the CCST—certificate of completion of specialist training—is not available to them and partly because their experience in current jobs is not taken into account.
Happily, we have amended the specialist medical qualification order to take account of training and qualifications obtained abroad. It is about time that we amended it to take full account of the experience of these doctors in their current jobs for promotional purposes. Many of these doctors—mostly, as I say, from the ethnic minorities—feel terribly demoralised, discriminated against and exploited. Unless something is done soon, their and the NHS's capacity to realise the goals set out by the Government will remain largely weakened.
Thanks to the decentralisation of decision-making, NHS trusts up and down the country are devising all kinds of short-term arrangements to meet their difficulties. Many have created trust doctors, but these doctors are provided with no mentoring and no training. Their working conditions are arbitrary and vary from one part of the country to another. They are in danger, I am afraid, of being turned into cheap casual labourers without stable career prospects. They naturally feel that their skills are inadequately utilised by the NHS.
NHS bureaucracy, although mercifully rationalised in recent years, still remains a nightmare for many ethnic minority doctors. Its decision-making procedures are arcane and depend on networking and informal arrangements. Ethnic minority doctors are generally not terribly good at this, partly because they are not in senior managerial positions. They, therefore, feel marginalised and remain unable to sensitise decision makers to the ethnic minority dimensions of their decisions. That is particularly acute in relation to recently recruited overseas doctors whose navigational skills through the labyrinthine bureaucracy of the NHS are not yet fully developed.
To conclude, I know that the Government are determined to achieve the goals of the NHS Plan. They can do so only if the morale of the ethnic minority staff remains high and they are fully involved in determining the quality of service delivery to all our people, including the ethnic minorities. We can raise their morale and ensure their full participation in decision-making only if we rationalise career structures, ensure non-discriminatory systems of promotion, merit awards and discretionary salary rises and make senior administrative staff ethnically more representative than they are today.
8.32 p.m.
Lord Chan: My Lords, I thank the noble Baroness, Lady Uddin, for introducing this important and timely debate. I declare an interest as Ethnic Health Adviser to the North West Regional Office of the NHS and to the Commission for Health Improvement.
The NHS Plan published in July 2000 makes only five direct references to ethnic minority communities. Paragraph 2.11 states:
- "We now live in a diverse, multi-cultural society".
- "people in minority ethnic communities are less likely to receive the services they need".
- "by 2004, all people in contact with specialist mental health services will be able to access crisis resolution services at any time. The teams will treat around 100,000 people a year who would otherwise have to be admitted to hospital, including black and South Asian service users for whom this type of service has been shown to be particularly beneficial".
The health of minority ethnic groups was investigated in 1999 in a health survey for England published last year. The following findings are significant. First, South Asian and black Caribbean men used GP services between 1.5 and three times more than men in the general population. Age-adjusted contact rates with GPs were significantly higher in South Asian and Irish women.
Secondly, Pakistani and Bangladeshi men had rates of cardiovascular disease about 60 to 70 per cent higher than men in the general population, while Chinese men had lower rates. The picture was similar for women. Prevalence of cardiovascular disease in black Caribbean women was 33 per cent higher than in white women.
Thirdly, rates of stroke among black Caribbean men were two-thirds higher than in the general population. Indian men had stroke rates 40 per cent higher than the general population.
Fourthly, black Caribbean and Pakistani women were over 20 per cent more likely to have high blood pressure. Bangladeshi and Chinese men were 25 per cent less likely than men in the general population to have high blood pressure. Ethnic minority people with high blood pressure were more likely than those in the general population to receive treatment.
Fifthly, I shall not elaborate on diabetes as that was covered by the noble Lord, Lord Parekh.
Sixthly, obesity is a major risk factor for cardiovascular disease, diabetes and premature death. All men in ethnic minority groups had lower rates of obesity than in the general population. But among women, Pakistanis and black Caribbeans had significantly higher rates of obesity than in the general population. Women from all ethnic minority groups, including the Chinese and Irish, had higher levels of central obesity than in the general population, making them at higher risk of type 2 diabetes.
Seventhly, in regard to lifestyle activities, Bangladeshi, Irish and black Caribbean men had higher rates of cigarette smoking than the general population. High fat and low fibre consumption was greatest among Irish and Bangladeshi people.
This national survey shows that the health needs of ethnic minority groups are not identical but vary with specific groups. These at-risk groups and individuals have to be identified in order to address the ethnicity factor in health inequalities. The Government have to their credit published policies promoting social inclusion, racial equality, tackling harassment and setting high standards of healthcare. They include Vital Connections, a National Service Framework for Equalities published in April 2000 and the Race Relations (Amendment) Act of November 2000. Although these policies are most welcome, their benefits can be seen only when policy implementation occurs in NHS trusts. But because of the plethora of health policies demanding the attention of management and staff in the NHS, black and minority ethnic patients and carers have so far experienced little evidence of improvement in healthcare. What needs to be done to improve healthcare for ethnic minority communities? The NHS Plan 2000 indicated the changes necessary for this improvement.
The basis of these changes depends on a cultural change in the attitude of NHS staff working with patients. All must accept that we live and work in a multi-cultural, multi-ethnic Britain. The reality of this is obvious in our metropolitan areas. But ethnic minorities live in all districts of Britain. In more than 80 per cent of districts served by the NHS, ethnic minorities form less than 5.5 per cent of the local population according to the 1991 national census.
A written strategy for improving ethnic minority health is necessary in all parts and organisations in the NHS and in local authorities. This strategy is as important for the welfare of the smaller number of black and minority ethnic people spread thinly in 80 per cent of Britain as it is for the greater proportion who live in metropolitan areas. Components of such a strategy would comprise training staff in cultural
awareness and competence, the provision of trained interpreters for people whose first language is not English, and a policy of equality of treatment for ethnic minority staff.All NHS staff everywhere, particularly front-line workers in contact with patients, need training in cultural awareness and competence. Ideally, that should take place in our medical and nursing schools. Training should focus on issues including clinical diseases and mental health, health beliefs and the support required by local ethnic minority users and their communities. Listening to the experience of patients from local ethnic minority communities would be essential. Cultural awareness training will help NHS staff to avoid stereotypical discrimination such as assuming that ethnic minority patients have a low pain threshold and complain unnecessarily. It will help to overcome prejudice against people who wear traditional clothes or who are not fluent in the English language.
It will also help to overcome intolerance of ethnic minority older people who have not acquired fluency in English and need trained interpreters to use services. In that context, relatives of the patient are not appropriate interpreters because that would breach confidentiality and lead to embarrassment and stress if, for example, a child is the interpreter. People of all backgrounds tend to revert to their mother tongue as they grow older and during periods of ill health. Therefore, the need for interpreters and bilingual staff in the NHS will rise as ethnic minority first-generation migrants grow old in this decade.
Finally, the NHS Plan wants to retain and increase the number of doctors, nurses and other staff who are needed for a first-class service. Ethnic minority people working in the NHS still feel that they are being discriminated against on grounds of their ethnic origin rather than their clinical competence. I hope that the Minister will be as concerned as I am about the excess of ethnic minority doctors—about 40 per cent—who are being asked to stay at home without an official note of suspension while allegations about their clinical competence are being investigated. One could understand that if complaints came from patients, but a significant number are being investigated only because white colleagues have complained about them. I speak from my experience in the North West region.
In conclusion, I ask the Minister to focus on the implementation of policies and to promote an ethnic health strategy for all NHS trusts. The Commission for Health Improvement should be given the task of monitoring the performance of NHS trusts along those lines to improve ethnic health and healthcare.
8.41 p.m.
Baroness Pitkeathley: My Lords, I, too, wish to thank my noble friend Lady Uddin for giving us the opportunity to debate this important issue.
I shall concentrate my remarks on patient involvement—that is, on aim three of the NHS Plan, which is about shaping services around the needs and
preferences of patients and giving patients and citizens a greater say in the NHS—and on the implications of that for making the voices of patients from ethnic minorities heard in the new-look health service to which we are all so committed.It cannot be denied that the NHS Plan is aspirational rather than definitive in some of the plans that it lays out, but one thing about which it is very firm is the central place of the patient's voice within the health service. No one could pretend that when the NHS was established patients were seen as its most important focus, strange as that may seem to us nowadays. Lip service has been paid to the importance of the patient over many years but it is only now that it is beginning—I emphasise that word—to become a reality.
I take every possible opportunity to tell noble Lords that my own recent prolonged stay in hospital was made as comfortable as was possible in the circumstances by the concern of all staff—from cleaner to consultant—to put me, as the patient, at the centre of their concerns. They never did anything to me without explaining the procedure and its possible effects and discussing my feelings about that. I am aware that that was perhaps easier to do in my case, as an articulate, well-informed patient who would, frankly, have shouted pretty loudly if they had not done so. But it certainly was not dependent on that. I saw the same care exercised with all patients, and there was particular sensitivity to cultural differences. Problems did arise, though, in the matter of language for patients whose first language was not English, where translators were not available—say, at a weekend or in the middle of the night—especially when family members were unable to accompany the patient. Clearly, more focus and more resources are necessary there, as the noble Lord, Lord Chan, reminded us.
Other issues that must be tackled as a matter of priority have been set before us by my noble friend and other noble Lords. However, the area in relation to which I am most concerned about the needs of ethnic minority patients involves ensuring that their input into policy development will be as influential as possible. The proposed changes to the structure of the NHS, especially those placing responsibility and budgets as near as possible to local communities—that is, at the primary care level—should facilitate that, but only if people from ethnic minorities have the opportunity to be part of the new structures. Membership of primary care trusts must be representative, as must patients forums and patients advocacy and liaison services. Strenuous efforts must be made to ensure that. It may not be enough simply to advertise in the ethnic minority press or broadcast media. Searches must be done in local communities, people from ethnic backgrounds must be appointed as chairs or senior officials so as to provide an example and, above all, training must be provided so that appropriate skills can be developed.
I do not myself subscribe to the view that was expressed forcefully in your Lordships' House at Second Reading during the passage of the Health Act; that is, that there are not enough people about who are willing to undertake the onerous tasks of participating in the management of the NHS. However, there may not be enough people available in the traditional places in which we have sought them. That is why the responsibility that will be placed on the commission for patient and public involvement in health, which will be established, to seek adequate representation in lay membership from all sections of the community, will be crucial. It is particularly important that that new body has a responsibility placed on it for training patient representatives. We must never forget how forbidding and mysterious newly established bodies can be to those who are not familiar with committee structures and procedures. If we do not take the time to inform and train people and, more importantly, to change our practices to accommodate the skills and experiences they bring, rather than expect them to fit a prescribed view of how lay members should operate, we will lose the benefits that lay members, no matter what background they come from, can bring. There is more to making processes open than simply advertising in the local paper. I hope that we shall never forget that.
Further, we must ensure that the council for the regulation of healthcare professionals, which is to have a majority of lay members—I am aware that that is another controversial issue—must similarly seek to ensure that the lay membership includes adequate membership from minority ethnic communities.
Finally, I would like to give an example or two of innovative approaches to healthcare for ethnic minorities, which are being put in place. We should not forget the positive action being taken. I refer to the approaches being put in place by the New Opportunities Fund, the lottery distributor of which I am chair, under our £300 million "Healthy Living Centre" programme. For example, almost £1 million goes to a South London health initiative that is led by a partnership of 11 key African organisations. The project will provide health promotion, cultural activities and volunteering opportunities for African communities in South London. Schemes will include health promotion for African men, after-school clubs, a children-and-families project and a health project for African women. There will be training opportunities and information on seeking work. In East London, thanks to a £1 million grant from the New Opportunities Fund, a healthy living centre without walls will benefit the most vulnerable people in Tower Hamlets and surrounding boroughs, including asylum seekers and those from minority ethnic backgrounds. Activities will include a pharmacy programme, mental health work and regeneration and resettlement projects. Information in people's mother tongues will address the language and cultural barriers.
In Sheffield, I recently opened a most inspiring project in one of the deprived areas of the city, where money from the New Opportunities Fund is being used to refurbish a huge Victorian building that houses
a library and swimming baths, to create a healthy living centre that will provide, for the mostly Bangladeshi community, not only space for exercise, opportunities for woman-only health sessions and before and after-school activities for children, but also a credit union, careers advice and even a co-operative for growing healthy food. Those projects remind us, as does the NHS Plan, that our NHS should be as much about establishing and maintaining good health as it is about sickness. We must ensure that that aim is fulfilled and that it is inclusive of all members of our society.8.49 p.m.
Lord Desai: My Lords, I, too, thank my noble friend Lady Uddin for initiating the debate. Last week my noble friend Lord Hunt met a group of us in order to discuss this problem. I was very grateful to him.
I have little to add to what other noble Lords have said. I have no experience of serving on an NHS body, and my experience as a patient is rather limited to the past two years or so. But I want to reiterate what my noble friend Lord Parekh and the noble Lord, Lord Chan, said; that is, that, so far as I know, the cluster of coronary heart disease, high blood pressure, diabetes and renal failure disproportionately affects the Asian population, especially younger men in their 30s and 40s who are not normally aware of such problems.
I had the salutary experience of attending a presentation held by the National Kidney Foundation. The event was sponsored by my noble friend Lord Chandos, who is a patron of the charity. I was very impressed because it was explained that a problem concerning blood pressure and diabetes—especially type 2 diabetes—is that patients do not feel discomfort in the course of their daily lives. Therefore, they say, "What is going on? I am all right and can get about". However, when one sees what happens at the other extreme, with renal failure or stroke being a possibility, it brings home that these are serious problems.
I want to urge, as did the noble Lord, Lord Parekh, a blanket screening of the section of the population likely to be affected by such illnesses. That may enable us to find out where the problems lie. I also urge the need for a good educational programme—perhaps through advertising on various ethnic television channels, such as Zee TV and so on. That would bring home dramatically to people who believe that they are healthy or that there are no problems how serious such illnesses can be.
I end with a somewhat sceptical note. I believe that we should do everything that we can to improve the NHS so that it provides an equitable health service. But it is not easy. We know that, after 50 years, health inequalities persist among the general population. The influence of class is very strong, and the problem becomes much worse when class and ethnicity coincide. We should be aware that the type of problems which we have discussed come from the confluence of class, ethnicity and gender. Therefore, there is much to learn.
8.53 p.m.
Baroness Rendell of Babergh: My Lords, I, too, thank my noble friend Lady Uddin for asking this Question and for bringing the subject to the notice of your Lordships.
In December 2001 my right honourable friend the Home Secretary said:
- "And just as we need to defeat racism, so we must protect the rights and duties of all citizens and confront practices and beliefs which hold them back, particularly women".
- "people adopt healthier lifestyles",
- "tackle the underlying causes of ill health".
- "more prevention—better help and information on healthy living".
- "more action to help prevent ill health".
The Government's new rules for immigrants, revealed last week, suggest that newcomers to the United Kingdom should pass a test on British customs before receiving a passport. They would also be required to promise to respect and uphold British rights, freedoms, values and laws. Surely those must include the Prohibition of Female Circumcision Act 1985. Noble Lords know well by now—if only because I persist in raising the matter in your Lordships' House so often—that in the 17 years that have elapsed since then, no prosecutions have been brought. However, that is not because there have been no offences. The law has certainly not been respected by the many who have compelled their daughters to submit to female genital mutilation.
Ethnic minorities in the United Kingdom whose origins are in Somalia, Ethiopia and the Sudan are those principally affected. If there is any difficulty in this country in having them "cut", as the expression is, the practice is to take female children back to their home country, ostensibly for a "holiday". As the NHS Plan stresses that there should be more action to prevent ill-health and more help and information on healthy living, I want to ask my noble friend the Minister whether these measures will extend specifically to female genital mutilation. Will more efforts be made to reach ethnic minority women, particularly older women, who see genital mutilation not only as the norm but as desirable, proper and hygienic? Will they be specifically targeted? And will communities be told of the health risks affecting women in their daily lives, in sexual relations and in childbirth?
Another step forward in this area would be the provision of more clinics, of which at present there are very few, undertaking reversal and repair procedures
to mutilated women. Contrary to popular belief, such reversals are very successful. Too few women know of their existence or are aware that, in ideal cases, women may attend them without referral letters from their GP.The NHS Plan will, as stated on page 13, bring health improvements across the board for patients,
- "but for the first time there will also be a national inequalities target".
Can a health service which boasts, on page 4 of the NHS Plan, of shaping,
- "the needs and preferences of individual patients",
- "different needs of different populations",
8.58 p.m.
Lord Clement-Jones: My Lords, I add my congratulations to the noble Baroness, Lady Uddin, on initiating today's debate and, in particular, on her broad-ranging and trenchant speech. I was especially interested in the fact that in contributions from the Government Benches noble Lords have more than simply asked the Government for a progress report on the NHS Plan; there have been some extremely positive suggestions which go much further than the NHS Plan itself.
I believe that there has been a very strong symmetry. It has not only been a question of the access of ethnic minority patients to treatment and the quality of that treatment; it has also been a question of the treatment and recruitment of staff and of patient and community involvement in that treatment. I believe that that tripartite approach has very much informed the debate today. Clearly a great many health issues concern ethnic minority communities.
I shall not rehearse again the issues raised in the health survey for England, mentioned by the noble Lord, Lord Chan, and the Acheson report. However,
a great number of issues affect different forms of ethnic community, whether heart disease, stroke, diabetes, obesity, TB—it has not been mentioned today—hypertension and so on. I feel strongly about mental health. If anything, that causes greater hardship where there are inequalities, particularly inequalities in diagnosis. I do not think that that has yet been grappled with properly.Clearly, the issue is wide-ranging. It goes further than simply health. The Acheson report, which was a great milestone, made that clear. It is to the credit of this Government that they commissioned the Acheson report, which in a sense laid down a marker that there was such a thing as society, that this was a new era, and that one was looking for joined-up government. The Government should take the credit for that. The Acheson report highlighted some of the socio-economic factors which significantly disadvantage ethnic minority communities—unemployment and the proportion living in poverty in different communities.
The report recommended a wide range of policies well beyond the health area: to reduce income inequalities and improve the living standards of households in receipt of social security benefits; and to improve the opportunities for work and ameliorate the health consequences of unemployment. In particular, it recommended improving the availability of social housing for the less well off and improving the quality of housing. The Minister will reply in the context of health. However, it is important that steps to improve health are measured in relation to those areas.
The Acheson report also outlined real problems of access for members of ethnic minority groups—for instance, in finding access to a GP. Longer waiting times are experienced in the surgery. The time spent with the GP was felt to be inadequate. They were less likely to be referred to secondary or tertiary care from the GP.
In another survey, 87 per cent of ethnic minority mental health patients believe that services are "institutionally racist" and have higher admission rates to psychiatric hospitals. The National Surveys of NHS Patients Coronary Heart Disease 1999 published in March 2001 demonstrates higher levels of criticism of treatment in the area of coronary heart disease. In a recent survey, even NHS Direct is underused by ethnic minorities, as the recent NAO report shows. What are the underlying causes for that? That is the large backdrop. This huge issue requires energy and cross-departmental working to overcome the problems.
Although to some degree unambitious, it is difficult to fault the aims of the NHS Plan. It recognised the specific health needs of different groups including people with disabilities and minority ethnic groups. The key initiatives in the plan are specific. When the health Minister replies, we need to know precisely whether those carefully timed commitments have been met. Those targets are that by 2002 a new health poverty index will combine data about health status. Local targets for reducing health inequalities will be reinforced with new national targets. By 2003—we need to know that work is in progress—after the
review of the weighted capitation formula, reducing inequalities will be a key criterion for allocating NHS resources to different parts of the country. Personal medical services schemes will be created by 2004. By 2001 local NHS action on tackling health inequalities and ensuring equitable access to healthcare will for the first time be measured and managed through the NHS performance assessment framework. We have the change of management through CHI. The noble Baroness, Lady Pitkeathley, referred to the new Bill. We look forward to seeing whether that measure will be incorporated in CHI'S terms of references.Where have the Government reached on all those issues? There has been a number of welcome initiatives. I could add to those mentioned by the noble Baroness, Lady Pitkeathley. It was fair to mention them. The Sure Start project—an early set of projects—continues. I hope that my tobacco Bill will add to the smoking cessation strategy. We have the national school fruit scheme. We have the national service framework for coronary heart disease. There are and have been good and valuable initiatives. However, until the Department of Health can track health inequalities and the outcome of initiatives taken, and undertakes regular surveys of patient satisfaction among the ethnic minority communities, there will still be an inadequate evidence base for effective action.
Furthermore, in areas such as mental health the position is not adequate. In December last year, Jacqui Smith stated that high security hospitals have undertaken a range of initiatives to improve the situation of black and ethnic minority patients and that there will be a national strategy in the future. But the pledge is that the mental health taskforce will produce consultation papers in the spring of 2002. If there were no historical context to that, that might sound very reasonable. But it is long overdue. It was promised in October 2000 by the Minister's colleague, John Hutton. Why has there been such an inordinate delay on a matter of such importance?
There are a huge number of issues. We could debate the matter for a much longer period. Monitoring under the Race Relations (Amendment) Act 2000—it has not been mentioned today—is surely important. The department has published a race equality agenda for health authorities, PCGs and PCTs. What consistency is there? How binding is the guidance given? What involvement of local communities will there be, as the noble Baroness, Lady Pitkeathley, pointed out? In a survey published recently in the health service journal, Mohammed Memon showed that the reports from health authorities and primary care groups were very patchy in demonstrating an appreciation of ethnic minority health issues and the actions that need to be taken in response to them. Will there be the resources to ensure that that race equality agenda can be put into effect?
In conclusion, there are many administrative and language barriers which make access to healthcare more difficult. Many noble Lords have mentioned the cultural issues as well. The setting up of new translation and interpretation services is of great
importance. Increasingly, it is becoming clear, as the King's Fund has pointed out, that health advocacy is an important route to improved access for minority ethnic groups. The Acheson report suggested that health workers should be trained in "cultural competency". Many noble Lords referred to that.Almost exactly three years ago the Minister, in reply to a Starred Question of mine, accepted the importance of all the above. He pledged implementation of the White Paper, The New NHS: Modern and Dependable, so that there would be staff training on cultural issues, interpreter services, advocacy services, translation services and so on. It is important that those early pledges given by the Government are implemented. If they are not implemented, further pledges will have little credibility. I hope that implementation has not been dismal, as the noble Baroness, Lady Uddin, said, but we await with interest the Minister's reply.
9.8 p.m.
Lord McColl of Dulwich: My Lords, I thank the noble Baroness, Lady Uddin, for initiating this debate. The NHS Plan is certainly a very long list of wishes. I hope that the Government will concentrate on those areas where there is clearly a great deal of work to do.
I agree with the noble Lord, Lord Desai, that Asians in this country are facing a great danger of developing diabetes. Fifteen to 20 per cent of adults are already diabetic and another 20 per cent already have a technical impairment in the way in which their bodies deal with sugar, which means that they are in danger of developing full-blown diabetes with all its attendant heart complications.
With a problem of that magnitude, we need to screen all those at risk. That was done before in the famous Bedford survey, with which the late Lord Butterfield was associated in the 1970s. Government funding is urgently required to find out the best and the most economic method of screening all those at risk. There is no shortage of enthusiastic medical experts who could start such work almost immediately. At St Mary's Hospital, for example, a detailed survey has been planned which would investigate 2,000 Afro-Caribbeans, 2,000 Asians and 6,000 white Caucasians. All they need to start that work are the funds. Will the Government help?
As the noble Lord, Lord Clement-Jones, hinted, there has been quite a lot of controversy in relation to schizophrenia in Afro-Caribbeans and quite a lot of discussion about whether it was being diagnosed too frequently, especially in young Afro-Caribbeans. However, recent research has shown that, by and large, the diagnosis has been correct in most cases. Some useful research was carried out by Dr Mackenzie at the Whittington Hospital, in conjunction with Robin Murray at the Maudsley Hospital, who rechecked the diagnoses. He brought over from the West Indies a West Indian psychiatrist who confirmed almost all the diagnoses.
There was no problem with diagnoses. However, they discovered that abnormalities in the genetic make-up and in the brain scans were present in a large
number of white schizophrenics, but the genetic element did not appear to be present in the black schizophrenics. Therefore, we assume that the development of schizophrenia in Afro-Caribbeans has much more to do with their environment, which includes large extended families, poverty, stress, and racism, which may be the kind of stress that would make such matters worse.The Nile Centre in Hackney has provided an alternative to hospital treatment for Afro-Caribbeans and the centre gives them help without compulsion, which has great advantages. Of course, the problem of these people is aggravated by not having a home, a job or confidence in people. There is no doubt that underfunding is a great problem in London. There is a shortage of key staff, especially community psychiatric nurses who work under very stressful circumstances and find it difficult to afford housing. The London health authorities appear to rely far too much on agency nursing staff which means that schizophrenic patients will see a different person at every appointment, which does not exactly inspire confidence.
However, there is some good news. A number of new NHS medium-secure units in London have been opened. For that we are grateful. Compliance among schizophrenics is actually better than it is in the general population as a whole. It is 60 per cent among the Afro-Caribbeans. The compliance in schizophrenia is better than it is in diabetes. But the problem in schizophrenia is that the result of not taking the pills is of course much more severe. Compliance depends on what sort of medication is being given. The more old-fashioned, the more unpleasant and the more side-effects, the less the compliance.
The treatment of schizophrenia presents problems. During the first episode, on the whole things are for the Afro-Caribbeans as they are for most schizophrenics, but it is with the subsequent attacks of schizophrenia that the problems arise. They then tend to be put on high doses of old drugs. There has been plenty of research into the extent of the problem, but not nearly enough on developing solutions.
I should also like to echo the remarks of the noble Lord, Lord Parekh, about the great debt that we owe to the hundreds of ethnic minority doctors, particularly those who work as GPs in inner city areas. We ought to remember that a very large number of them will be retiring soon. That will leave a huge gap. I wonder what plans the Government have for dealing with this enormous problem.
Perhaps we ought also to remember that it is not just ethnic minorities who have difficulties in the NHS. Often it is the elderly who unfortunately have been described as "crumble", "dross", and "wrinklies". But the good news is that there is a more pleasant name to apply to them. They are now called the "twearlies" because as they wait to board the bus just before nine a.m. when transport is free for them, they say to the driver, "Too early?" At least, "twearly" is better than "dross" and "crumble".
Finally, as the noble Baroness, Lady Pitkeathley, has already stressed, surely the emphasis must be on treating every person with respect irrespective of their age, colour or sex. Whoever they are they should be treated with respect, wherever they come from, whatever they believe and however they behave. It is that last part which presents the most difficult variable of all.
A conscientious GP aged 40 sleeps one night a week away from home on the floor of his surgery so he can be near to his patients when any emergency arises. At three a.m. he is rung up by a mother who says, "Can you come to the house and see my son who has ear ache?" The GP quite rightly says, "It would be better if you brought your son here where we have all the equipment so that we can see into the ear and put matters right". "No", she says, "neither my husband nor I can possibly bring the child because we are both completely drunk". The GP goes 10 miles out into the country in the middle of winter and provides the correct treatment. He actually takes the antibiotics. He goes home, goes to sleep and half-an-hour later he is woken up by the same woman who says, "My husband and I are not satisfied with your treatment. We are going to put in a formal complaint tomorrow". From time to time some of the one million people employed in the NHS do need the patience of Job.
9.17 p.m.
The Parliamentary Under-Secretary of State, Department of Health (Lord Hunt of Kings Heath): My Lords, I thank my noble friend Lady Uddin for the opportunity of debating such an important issue tonight. I should like to place on record my thanks to her and to the many other noble Lords who have spoken in this debate and who have made such a contribution to the health of many people from black minority and ethnic populations in this country. As the noble Lord, Lord Clement-Jones, said, many positive suggestions have been made tonight about the way in which the Government should take forward their programmes and policies in this area. That is something which I am very happy to consider in the light of our discussions.
It is certainly clear from the Acheson report and other studies that there are very significant health inequalities among people from black and minority ethnic communities. But it is also equally clear that if the NHS is to win the battle to tackle these inequalities, not only must it be determined and focused in its health policies and programmes, but it must ensure that as an employer it invests in improving diversity, tackling discrimination and harassment and takes a holistic view towards the implementation of the policies which have already been clearly set out and which many noble Lords have mentioned.
My noble friend Lady Uddin spoke about institutional weakness in both service and employment and about the need to ensure that action is firmly rooted in performance management. I have no doubt that she is right. One can have all the policies in the world, but unless they are implemented they do not amount to very much.
Let us first consider the issue of service. As my noble friends Lord Parekh and Lord Desai suggested in relation to the clutch of diseases affecting many people from black and minority ethnic populations, the statistics are absolutely striking. The death rates from coronary heart disease among first-generation south Asians aged 20 to 69 are about 50 per cent higher than the England and Wales average. The death rate from strokes among those aged 20 to 69 years and born in the Caribbean is more than 50 per cent higher than the England and Wales average. Perinatal mortality among Pakistani-born mothers is nearly twice the UK national average. It has already been mentioned that diagnosis of schizophrenia is three to six times higher among African-Caribbean groups than in the white population. Women born in India and East Africa have a 40 per cent higher suicide rate than those born in England and Wales.
I could quote many other examples. They provide the background and the reason why it is important that we tackle such issues effectively. I believe that we have the right policies. We have the NHS Plan which signals to the service the need to become more responsive to black and minority ethnic communities and to provide services which take account of their religious, cultural and linguistic requirements.
The noble Lord, Lord Chan, was disappointed by the number of references in the plan to black and minority ethnic populations. However, as the noble Lord, Lord Desai, suggested, making the reduction of health inequalities a priority in the NHS Plan, and the promise of national targets for the first time ever, sets the really important foundation on which we address these problems in future.
Alongside that, as again the noble Lord, Lord Chan, suggested, the Race Relations (Amendment) Act is a piece of landmark legislation with practical underpinning to test our commitment to ensuring that our services meet the needs of black and minority ethnic communities, and that the NHS is a good employer. For the first time, public authorities such as the department will be subject to a positive statutory duty to promote race equality. As I have said, it is one thing to have the plans and targets; it is another to ensure that they are implemented.
In relation to service improvement, I believe that the National Service Frameworks present us with the ideal method and opportunity to target some of these striking and worrying divergences in the illnesses among many black and minority ethnic people in this country.
National Service Frameworks, for the first time, allow us to set national standards for the provisions of services and to ensure that, in setting those standards, we target the people who are the most vulnerable. That applies as much to coronary heart disease as to diabetes. My noble friend Lord Desai raised a number of questions in relation to diabetes. He is right to say that type 2 diabetes is up to six times more common in people of south Asian descent and up to three times more common in those of African and African Caribbean descent. We have published the first part of
the National Service Framework. We shall be publishing the second part later. I believe that that will give clear guidance to the health service in relation to diabetes.As regards screening, we are seeking advice from the National Screening Committee on that very matter. Once we receive that, we shall carefully consider it in relation to the implementation of the National Service Framework. The noble Lord, Lord McColl, made a subtle bid for funds for a particular project. I shall certainly look into that matter and respond to him.
Strokes are another area of great concern. At present we fund stroke awareness through the Section 64 grant scheme for a project to raise awareness of strokes and the associated risk factors among African Caribbeans. There is an information pack which will have fact sheets on high blood pressure, the effects of diet, the risks from smoking and alcohol, and the importance of exercise. But we need to do more than that, just as we need to do more in the area of mental health.
The high rates of diagnosis and over-use of the mental health system were mentioned by the noble Lord, Lord Clement-Jones, and my noble friend Lady Uddin. I was interested in the remarks of the noble Lord, Lord McColl. We recognise those high rates in the targets that have been laid down in the national service framework for mental health services. We have set targets to improve that situation. As the noble Lord, Lord McColl, suggested, part of that is the extra investment in the provision of secure beds—24-hour staffed beds and access to services 24 hours a day.
We have also made progress in creating assertive outreach teams to reduce the possibility of people with severe mental illness opting out of services and having services provided largely in their own homes. My noble friend Lady Uddin made particular mention of the needs of African Caribbean men and Asian women. I should expect the national service framework, as it is implemented, to take account of that.
We have also established a mental health task force which is preparing strategies that are specially designed to meet the needs of black and minority ethnic groups. Professor Sashi Sashidaran, a task force member, chairs that group which has been charged with drafting a strategy. It is in the process of finalising content and aims to ensure that the range of issues across the mental health national service framework and the NHS Plan are addressed in the hope that it will go out for consultation later this year.
A number of comments were made on ethnic monitoring. Information is vital in addressing health inequalities and improvements in health. As a matter of policy, the department introduced the 2001 census categories in its data collections, which provide an opportunity to address broader issues such as quality and use of race information. That is not simply a matter for action at national level. At local level the strategic health authorities and the primary care trusts have to pay close attention to the users of their services
and the illnesses from which their users are suffering to ensure that their health promotion and service delivery programmes are targeted on the riskiest areas.I listened once again to the moving remarks of my noble friend Lady Rendell concerning female genital mutilation. The Government condemn FGM totally and unequivocally. My noble friend is right to mention the Prohibition of Female Circumcision Act 1985 and she is right that no prosecutions have been brought. I understand that that is because of the shortage of complaints and the difficulty in obtaining evidence and finding witnesses. The Government's main approach in this area has been to gain access to the communities involved to help educate them into accepting that FGM is a totally unacceptable practice that must be abandoned.
In answer to my noble friend's specific points, our responsibility is to treat victims of this brutal practice, and we shall do that sympathetically. She raised a number of points concerning the degree of services available to women who have been so mutilated, and I shall explore that within the Department of Health.
I listened with great interest to the noble Lord, Lord Chan, in relation to improvements in interpreting and language support. A number of very important points were made by my noble friend Lady Uddin, the noble Lord, Lord Parekh, and other noble Lords about work force issues. Those issues are vital not only to ensure that we tackle service provision but are important in their own right. The NHS Plan introduced an improved working life standard, which made it clear that every member of staff in the NHS is entitled to work in an organisation that can prove it is investing in improving diversity and tackling discrimination and harassment.
My noble friend Lord Parekh asked particularly about the issue of doctors and race inequality in medicine. The Chief Medical Officer commissioned MORI to run focus groups and one-to-one interviews with black and ethnic minority doctors to seek their views regarding racism, inequality and unfairness affecting their career or career progression. Those results will be incorporated into a report on race inequality in medicine later this year.
I accept also the points the noble Lord raised in relation to the number of black and minority ethnic people in senior positions in the NHS. We have set a national numerical target of 7 per cent to improve representation in executive director posts at board level. We are keen to see that that happens. Through the "Tackling Harassment" programme, the extension of the "Zero Tolerance" campaign and the various other initiatives we have taken, we are determined to ensure that the NHS is a model employer and tackles racism and discrimination in every way it can.
The noble Lord, Lord Chan, raised the issue of suspended doctors. My understanding is that there are currently 29 hospital doctors who have been
suspended by their employers for more than six months. We wish and expect NHS employers to treat all staff equally and not to discriminate on grounds of race, ethnicity, gender, sexual orientation, disability, religion or age. It is right that we look at the procedures by which doctors are suspended to ensure that those principles are fully enacted. It is also worth making the point that we established the National Clinical Assessment Authority to improve the handling of doctors who, for one reason or another, run into difficulties within their employing authority. That should reduce the number of long-term suspensions of doctors, but also deal with the issue of whether discrimination exists against doctors from minority ethnic or black groups. We expect the new clinical assessment authority to give expert advice to employers and to help them avoid overreaction in some cases.An important issue was raised in relation to the involvement of local communities in the development of services and policy. That is vital. My noble friend Lady Uddin referred to local community groups and women's health issues. My noble friend Lady Pitkeathley, in paying a tribute to staff, said that the NHS had to do much more to involve local people in decisions about their future health. That is the context in which the new proposals contained in the NHS Bill, which we shall shortly be debating, to improve public and patient involvement, very much come to the fore.
My noble friend asked whether, within patient forums, advocacy or the national commission, we would ensure that there were sufficient members from black and minority ethnic communities. We will very much seek to do that. Indeed, it will surely be a test of the proposals that we are putting forward, which are much stronger than the present ones, that they cater for the needs of everyone in our community. I certainly agree with my noble friend Lady Pitkeathley that the role of the Commission for Patient and Public Involvement in providing training and support for those involved in patient and public involvement will need to reflect the needs of the whole of our society and will have an important role in supporting and monitoring the performance of many of those local public involvement bodies.
The noble Lord, Lord Clement-Jones, asked about health inequality targets. He will recall that we announced the first ever health inequality targets in February 2001 and gave a commitment that they would build on the local targets for reducing health inequalities. We continue to work hard in that area to make sure that they happen.
At the end of this important debate, no one should be in any doubt that we are determined to ensure that services for the National Health Service are as first rate for members of the black and minority ethnic communities as they are for anyone else in our society. No one can deny that the NHS Plan, National Health Service frameworks and various other policies that we have laid down make it clear that we expect services to be provided in that area.
It is worth recognising that many important developments and local projects have taken place, but that there is a long way to go. We must make sure that current pockets of good practice become systematic and mainstream throughout the NHS and in social care. The challenge to the department and to the National Health Service is to ensure that those policies and programmes are implemented in a firm and satisfactory way.
The Government are committed to working with all those who want to see full equality in health and social care and to making sure that that happens. My noble friend has done a great service to the House in bringing this important matter to our attention. I assure her that the Government want to proceed and to study carefully the points raised in the debate today.
- House adjourned at twenty-four minutes before ten o'clock.
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