How losing a sense of belonging damages healthcare

“Where are you from” is a question I’m often asked. There was a time when I was bothered by being asked this. As an immigrant seeking a sense of belonging, probing my origin story tended to put me on the defensive—understandably so, because it generally wasn’t asked out of curiosity, more out of suspicion, distrust, and dislike. Some patients didn’t want a doctor who wasn’t white. A few made it obvious, others were more subtle. A rare patient would unexpectedly break into Urdu or Punjabi, always a lovely moment. Only once was a patient overtly racist.

Today, it’s a question I mostly welcome, since it is usually posed out of curiosity or empathy. As the three clinicians in our careers clinic rightly conclude, it’s all about context (doi:10.1136/bmj.q435).1 In fact, WAYF is a question I often ask. I ask it because I love to know where people or their families are from, whether that’s somewhere in the UK or somewhere around the world. I want to make people feel at ease, to connect. I want to understand what motivates them. People, usually, enjoy talking about themselves, as long as they sense you are sincere in your interest. Admittedly, there is a fine line to tread between belonging and “othering.”

Knowing where someone is from can, for example, open up a meaningful conversation about the future of healthcare in Northern Ireland (doi:10.1136/bmj.q462) or how Scotland is making a long term investment in child health despite the immediate health crisis (doi:10.1136/bmj.q476 doi:10.1136/bmj.q448).234 We might learn more about the Welsh roots of the founder of the NHS, and about a new play depicting Aneurin Bevan’s tenacity and vision (doi:10.1136/bmj.q478).5

On a corporate level, however, we might be better off with the scepticism that distance brings. The perception of Palantir as a company is that it is not to be trusted with patients’ data. Large parts of its contract for the NHS federated data platform are redacted, along with a related NHS contract with another company. A legal challenge by the Good Law Project is demanding transparency (doi:10.1136/bmj.q455).6

More evidence on corporations, this time an umbrella review, underlines the association between ultraprocessed foods and a range of adverse health outcomes (doi:10.1136/bmj-2023-077310).7 Our editorialists propose a framework convention on ultraprocessed foods like that on tobacco (doi:10.1136/bmj.q439).8 And, new research concludes that oncology drugs recoup their costs irrespective of their added benefit (doi:10.1136/bmj-2023-077391).9 Little wonder, since the vision for life sciences is all about new drugs (doi:10.1136/bmj.q467).10

Julie Silver and colleagues expertly dissect the issue of belonging, how it is subtly distinct from diversity and inclusion, how it depends on feeling valued and needed, how it is a uniquely personal experience, and how it can play a central role in preventing the health workforce attrition that is a global phenomenon (doi:10.1136/bmj.q392).11 A sense of belonging, they say, is one of the “most basic human needs,” and it is being ignored.

For me, as a young doctor in the 1990s, a sense of belonging came from the hospital “firm” structure, which meant—however busy you were and however unloved you felt—you were always part of a team. You were also associated with one hospital or region for long enough to develop a sense of belonging to a “place” as well as to your team.

It’s clear that the UK’s reforms to medical training over two decades have stripped away that sense of belonging. Staff are no longer people to invest in or value: they are resources to be shuffled around on a giant spreadsheet. And that shuffling is too frequent or too dispersed for staff to feel that they belong or for them to put down roots for a stable personal life (doi:10.1136/bmj.q410).12

If anything, staff and patients are being further alienated. It’s a process that preceded the covid pandemic and was accelerated by it (doi:10.1136/bmj.q487).13 This week brings us another example of “medical professional” role confusion instigated by a medical regulator whose objective should be clarity (doi:10.1136/bmj.q494), as well as a moving story of how a deaf child’s communication needs were overlooked after cochlear implant surgery (doi:10.1136/bmj.q480 doi:10.1136/bmj.p2615).141516 Creating a culture of belonging is a responsibility for individuals, organisations, and governments. It will undoubtedly make for a better health and care service for staff and patients, regardless of where they are from.