“I don’t think he realised how offensive it was,” says Desire Onwochei, recounting an exchange with a fellow anaesthetist at a conference. He had decided to share his opinion that black people don’t enjoy cycling.
Also present during the exchange between the white anaesthetist and Onwochei, who is a black consultant at Guy’s and St Thomas’ NHS Foundation Trust, was one of her white female colleagues. “Later on that evening my colleague told me how uncomfortable she had felt in that conversation,” says Onwochei. “She said she felt bad that she hadn’t said anything but that she didn’t know what to say.”
Data and lived experiences1 unequivocally show that staff from ethnic minority backgrounds have a poorer experience of working in the NHS, from being more likely to be referred to the regulator than their white counterparts2 to being less likely to be appointed to a post after shortlisting.3 The NHS has long had strategies aiming for equality, diversity, and inclusion (EDI), but since the tragic murder of George Floyd in 2020 and the subsequent boost in the Black Lives Matter movement, more organisations are talking about being “antiracist.”
For Onwochei, her white colleague’s reaction was an example of being antiracist. Even though her colleague didn’t know what to say, she still “wanted to let me know that she didn’t think that what happened was right.” She adds, “It made me feel like she actually understands, and, for me, that was being antiracist—her identifying with me and showing her support to me.”
But what does antiracism mean, and what makes it more than just an elevated term for EDI?
Putting plans into action
Anton Emmanuel led NHS England’s Workforce Race Equality Standard (WRES) programme until 2023. He says that antiracism is about moving beyond just celebrating events such as black history month or Southeast Asian heritage month, which he says can be “tokenistic and non-challenging.”
Instead, he says, antiracism is about being truly disruptive when it comes to recruitment, advertising, fitness-to-practise processes, or deciding on promotion to boards. “You can’t take a quality improvement approach to our [current] processes, because the data tell us that in England and in Wales our processes are so fundamentally wrong,” he says, reflecting that data show a level of discrimination that can’t be tackled just through tweaks.
The WRES is a key priority in the Antiracist Wales Action Plan, which has been a programme for government commitment for Welsh ministers since 2022,45 aiming to ensure that Wales is an antiracist nation by 2030. In Wales, the WRES aims to collect detailed workforce data to pinpoint the actions needed by each organisation as a precursor to ensuring accountability in the health and social care sectors.
In the first stage, work has focused on gathering data from each of NHS Wales’s health boards, trusts, and special health authorities on how they’re performing on indicators related to race and then comparing this nationally. Emmanuel says, “The aspiration is that we use data as a central point to give local organisations the targets for what they should be focusing on,” adding that each NHS Wales organisation has now identified specific actions to take in response to the data. While he acknowledges that Wales’s relatively small size helps in making antiracism a national commitment, high level governmental support has been key to enabling people like him—with “lived experience”—to challenge systemic racism.
The WRES in Wales reflects on learning drawn from Emmanuel’s work in NHS England—an approach supported by the Welsh government’s key commitment to the Antiracist Wales Action Plan to try to do things better. “If it doesn’t work and we see that actually people have found a workaround, that’s where the accountability framework comes in,” says Emmanuel. “That’s why I’m really trying to reinforce that point to organisational leadership that you’re on the hook here: if by 2030 we’ve made no progress, you’re going to look daft.”
Asked what accountability will look like in practice, he says, “We’ve refreshed the Antiracist Wales Action Plan 2024-26 to provide a clear mandate for all NHS Wales board members to demonstrate antiracist leadership within their inclusion objectives, and for all NHS bodies in Wales to demonstrate and report progress in driving antiracism at all levels. This is the big ambition we’re working towards—the idea of providing strategic accountability that delivers real cultural change.”
Organisational change
While NHS England doesn’t have a central antiracism strategy, several organisations have made their own commitments. This includes NHS Providers—a membership organisation for NHS acute, ambulance, community, and mental health services, which stated its aim to become an antiracist organisation with the launch of its race equality programme in 2021.6
“It was about becoming an actively antiracist organisation and making sure we had an organisational culture where our staff feel safe, valued, and able to achieve their full potential,” says Isabel Lawicka, NHS Providers’ director of policy and strategy. “We also wanted to lead by example. We’ve always been really mindful that we’ve got a responsibility and a role for the staff in our organisation of about 100 people. But we’ve also, as a membership organisation, got an important role in helping our members make progress on race equality in the broader NHS.”
Through events and peer learning, the organisation is supporting trust boards in tackling race inequalities that affect their staff, patients, and service users. Lawicka says that engagement has been high, with over 90% of trusts joining at least one of NHS Providers’ specific race equality events since 2022. While NHS Providers already had a focus on inclusive leadership and diversity at different levels in the NHS before its antiracism statement, she says, this programme has for the first time made being antiracist a clear priority for the organisation.
However, while NHS Providers can be actively accountable for its own progress—for example, through planned personal objectives for its senior management team—it can’t formally hold its members to account. Softer mechanisms, such as asking trusts about their race equality efforts in NHS Providers’ annual sector survey, can be useful. “It’s self-reported by trusts, but it’s an important measure and a prompt for them,” says Lawicka.7
The NHS Confederation—the membership organisation for the whole healthcare system in England, Wales, and Northern Ireland (which included NHS Providers until 2011)—has its own antiracism strategy. Joan Saddler, the confederation’s director of partnerships and equality, says that its members work to tackle discrimination in all forms, including racism, as part of their responsibilities under the public sector equality duty.
She acknowledges, however, that more could be done. Not all state funded health and social care providers are required to meet the public sector equality duty, but Saddler believes that a worthwhile step would be consulting with racially minoritised communities on whether a national antiracism action plan for health and social care would improve outcomes to tackle racism.
She says, “The deadly impact of racism will continue unless we learn lessons of the past and present and stop enabling racism and inequality by using the same solutions that haven’t stamped out racism.”
Teaching doctors to be antiracist
For some organisations, an antiracist NHS starts when doctors and medical professionals are in training. Deepak Kumar is the undergraduate GP lead at Anglia Ruskin University’s School of Medicine and heads up work on the medical school’s antiracism agenda. Its antiracism work is organised around four key areas set out by the BMA’s racial harassment charter for medical schools8: supporting individuals in speaking out, robust processes for reporting and handling complaints, mainstreaming EDI in the learning environment, and tackling racial harassment in work placements.
Anglia Ruskin’s antiracism commitment involves signposting students to where they can get help and advising on what they should do if they’re racially harassed. It aims to ensure that complaints are raised to the appropriate level, and it reviews the curriculum to ensure that EDI is embedded in every single session and not just an “add-on.” Kumar points to the school’s dermatology teaching as an example: “Previously we had one lecture that was focused on dermatological conditions in different skin tones, but now, for example, we’re showing what eczema looks like on different skin tones within the eczema session.”
One of the most thought provoking sessions, says Kumar, is the bystander intervention training, which aims to empower students to become “active bystanders.” One scenario involves someone who witnesses a colleague being racially harassed by a member of staff, to encourage students to think about what they could do in such a situation.
In another scenario the students witness a doctor being harassed by a patient, to help them understand how to set boundaries and challenge a patient who may be racially harassing them while maintaining the doctor-patient rapport. Kumar says that Anglia Ruskin’s internal survey data show that after the session around 95% of students said that they would feel empowered to speak out if they witnessed a colleague being racially harassed, up from 60% before the session.
Despite Anglia Ruskin’s relatively small medical student population—the medical school was set up five years ago and enrols only 100 students a year—Kumar hopes that its antiracism work will have a positive impact. “There’s something around cultural humility, cultural awareness, and producing a group of doctors who are aware and empowered. If you’ve got a doctor who is aware and empowered, it’s positive for the workforce and positive for patients,” he says.
Partha Kar, coauthor of a five point NHS action antiracism plan published in 2023 as part of NHS England’s Medical Workforce Race Equality Standard (MWRES),9 believes that since late 2022 the political climate in UK government has shifted further right and that, as a result, national level efforts on antiracism in England have faltered. In his view there’s been a return to the lens of EDI, which he thinks is less effective than antiracism. Kar says, “If you put it all in one box as with EDI, you deal with nothing,” he says. “It actually opens you up to the critics on the far right who say, ‘Well, it’s a waste of time and money.’”
Setting boundaries
So far, race equality indicators show a mixed picture. Data on referrals to the General Medical Council, for example, show that the difference in referral rates has fallen by 54% in recent years, from 0.58% among ethnic minority doctors and 0.3% among white doctors in 2016-20, to 0.31% among ethnic minority doctors and 0.18% among white doctors in 2020-23. In the same period the difference in referral rates between UK trained and international medical graduate doctors fell by 62%, from a difference of 0.42 percentage points to 0.16.2
In England, the WRES shows that the percentage of ethnic minority board members has increased year on year at the national level, although the percentage of board members recording their ethnicity as BME (black and minority ethnic) hasn’t kept up with the increasing percentage of BME staff in the NHS workforce overall.3 Other indicators, however, continue to reveal a lack of progress—or backsliding in some cases. At 76% of NHS trusts, white applicants were “significantly more likely” than ethnic minority applicants to be appointed from shortlisting in 2023, up from 71% in 2022.3
One problem, says Kar, is that few people are willing to raise their voices publicly on the subject. He says that those in positions of power would rather not change things, meaning that “antiracism hasn’t really progressed much beyond soundbites, apart from certain areas.”
Several surveys have shown that doctors avoid speaking out about racism for fear that calling out seniors and colleagues could negatively affect them.1 Onwochei acknowledges that the nature of medicine as a profession makes it hard for individuals to speak out. For example, doctors find it difficult to refuse to treat a patient who displays racist behaviour, as they believe that they have a duty of care to the patient.
Onwochei says that she’s learnt to set better boundaries for herself as she’s progressed though her career. “When I was a junior doctor, I’d just try to brush it off and rise above it,” she says. “But the older I’ve become and the more progression I’ve made in my career, the less I tolerate it, unless that patient is in a compromised state where if I walk away they’re going to suffer. But if that’s not the case, I will walk away from that situation.”
She would like health trusts to back up doctors who walk away from such situations by making it clear that patients who racially abuse staff won’t be treated, rather than placing that patient in the hands of a white doctor. “But I think it will take a very bold trust to state that they are antiracist to the point where, if a patient is racist to a staff member, we as a trust are not going to treat that patient,” she adds.
For Kar, establishing a national lead on antiracism would be a big step forward for the NHS in England, while establishing clear markers of accountability. Otherwise, he warns, “it always falls to other people to do.”
Footnotes
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance: Commissioned; not externally peer reviewed.