Ethnic Inequalities in Healthcare: A Rapid Evidence Review

Conduct primary research on the direct and indirect impacts of racial discrimination by NHS staff and institutional processes on access to, experiences of, and outcomes of mental health services.

No response published in the seeded NHS RHO data

Establish repeated cross-sectional national community survey datasets of psychiatric morbidity and service use to provide high quality national data on the ethnic minority people's attitudes to, and experiences of, using mental health services.

No response published in the seeded NHS RHO data

Conduct a process and outcome review of interventions to address ethnic inequalities in both the NHS and VCSE organisations to establish 'what works', why and for whom. This should extend beyond simply reviewing studies that test the effectiveness of 'culturally appropriate/adapted therapy interventions' (where there is already a review) to consider systemic changes across levels of psychiatric care.

No response published in the seeded NHS RHO data

Enforce statutory guidelines on inclusion of national ethnic monitoring data in all NHS mental health clinical data that allows robust statistical Trust-level, regional and national analysis (including data linkage between clinical datasets) to establish where the inequalities are, and for which ethnic groups. This recommendation will require a dedicated drive by NHS England and NHS Digital to emphasise the importance of collecting and reporting these data, as well as providing the infrastructure to collect, analyse and interpret them. An online learning module on recording ethnicity data on the Health Education England, or equivalent, website should be made accessible to all NHS staff, to ensure staff are trained in routine collection of ethnicity data.

No response published in the seeded NHS RHO data

Establish relationships between ethnic minority VCSE organisations and NHS provider services in order to provide the high quality services for ethnic minority patients. NHS England and NHS Trusts need to work with partners across public service, the voluntary sector and community organisations in order to demonstrate commitment to tackling racial inequality in mental health services.

No response published in the seeded NHS RHO data

Sophisticated quantitative analyses are needed in order to describe and understand patterns of maternity care and outcomes across a wider range of ethnic groups, as well as intersectional inequalities and spatial and temporal trends. Research is particularly needed to identify inequalities in care that contribute to differential perinatal and infant outcomes by ethnicity.

No response published in the seeded NHS RHO data

Complementary research that engages closely with women and families to foreground their perspectives and experiences, especially for those in very vulnerable circumstances, is also needed. Stakeholders called for co-produced research to develop interventions and make services appropriate to the needs and priorities of under-served groups.

No response published in the seeded NHS RHO data

Mixed method and theory-informed research is needed to completely understand the ways in which healthcare providers and patients develop their understandings of one another and how positive relationships between healthcare providers and ethnic minority women can be achieved consistently. There is a need to interrogate the complexity of racialisation processes and how these are inflected by other markers of social status and difference alongside ethnicity. This work should include attention to understanding the institutional and system-level factors - structures, procedures and cultures - that undermine good quality care and how these can be recognised, resisted and transformed.

No response published in the seeded NHS RHO data

Data linkage is required across routine NHS maternity and neonatal datasets to allow analyses of patient journeys and outcomes, across mothers and their babies, and across service areas. Work is needed to ensure recording of ethnicity is complete and accurate. There is also a need to develop systems for the routine collection of data relating to key mechanisms and exposures, particularly experiences of racism and discrimination.

No response published in the seeded NHS RHO data

Renewed and serious efforts are needed to ensure ready access to high quality interpreting services and translated and audio format health promotion materials.

No response published in the seeded NHS RHO data

There needs to be a serious commitment from NHS England and NHS Improvement to tackle racist attitudes and behaviours among healthcare staff, and address structural dimensions of NHS systems that discriminate against ethnic minority women and their babies.

No response published in the seeded NHS RHO data

A systematic review of ethnic inequalities in access to, experiences of, and outcomes of digital healthcare (using a broad definition to include remote and digital appointments, the use of healthcare apps) is required to ascertain the extent of evidence in the field. The recommended review could be extended to cover the rollout of other digital services (in the public and private sector) to obtain evidence that the NHS could incorporate.

No response published in the seeded NHS RHO data

Research in this area should ensure that the ethnic categories employed are disaggregated as far as possible so that the experiences of different ethnic groups can be identified, as suggested by our stakeholder input. Further, where possible, there should be a specific breakdown of results by age, as our review indicated that ethnic minority older people particularly, may find digital healthcare inaccessible.

No response published in the seeded NHS RHO data

There needs to be digital literacy support (perhaps in the form of community digital hubs) for those who struggle with basic digital access. This should be in various mediums and languages taking into account different styles of learning and understanding. For example, health services could use audio and video messages in local public places and spaces, for a targeted approach, as well as using WhatsApp video and audio messaging to communicate directly with patients. Options to receive digital devices should be offered to patients where needed.

No response published in the seeded NHS RHO data

Undertake thorough evaluations of projects funded under the Adoption Fund by NHS X which are making use of digital technologies for patient care. For example, Cambridgeshire and Peterborough Integrated Care Service (ICS) are undertaking Empowering Digital Access in Maternity Services (EDAMS) to identify what the main barriers and blockers are to accessing digital services within the maternity pathway, and North West London CCG are undertaking a comprehensive review on patients receiving or needing community or mental health treatment to understand the scale of digital exclusion across North West London.

No response published in the seeded NHS RHO data

NHS England should make mandatory equality assessments which are recommended under the Public Sector Equality Duty (PSED) for any services moving from in person to digital appointments in order to assess the extent to which ethnic minority groups would be affected by such a move.

No response published in the seeded NHS RHO data

Research is required to understand at what points in the care and referral pathway in genetic testing and counselling services, ethnic inequalities are apparent, and what the nature of these inequalities are. Particularly, quantitative and qualitative research is required to understand ethnic minority patients' experiences of genetic counselling. Many identified studies were concerned with antenatal screening and testing with very little research evidence on ethnic inequalities in access to other genetic services and technologies.

No response published in the seeded NHS RHO data

Ensure research studies of ethnic minority groups are designed to address gaps in knowledge and to inform service provision and ensure a range of ethnic minority groups are represented. This should particularly be actioned by large funders of health research such as NHS organisations, UK Research Innovation (UKRI), National Institute of Health Research (NIHR) and The Wellcome Trust. Our review found that there was a substantial proportion of studies that focussed on Pakistani populations but none that focussed on for example, Gypsy, Roma or Irish Traveller groups despite previous evidence that these groups are particularly disadvantaged in access to health care.

No response published in the seeded NHS RHO data

Increase the ethnic diversity of genomic studies. This is imperative if these studies are to be used in the future for personalised or precision medicine. Current initiatives by Genomics England, such as the Diverse Data Initiative are likely to benefit from using recruitment methods designed and run in partnership with the voluntary, community and social enterprise (VCSE) sector and via community settings, many of which have already established trust in ethnic minority populations.

No response published in the seeded NHS RHO data

Genomics England should develop a scientific framework within which to conduct genomic studies that includes clear reporting on samples used, and consensus descriptions of ethnic and ancestral groups.

No response published in the seeded NHS RHO data

For ethnic minority people who do not speak English, interpreters must be provided at the main points at which routine genetic screening and possible referral to genetic counselling and testing are likely to be discussed, in particular for phone appointments, GP consultations and maternity contacts.

No response published in the seeded NHS RHO data

Conduct a systematic review of racist experiences in the workforce to see for which specific professions and settings there is evidence of racial abuse.

No response published in the seeded NHS RHO data

Conduct a systematic review (of global literature) of what interventions work to improve racial inequality in large institutions. The review should be theory-driven, using a conceptual model which centres institutional racism. Reviews have been completed on a smaller scale already and there are examples of smaller scale initiatives, but there would be considerable added value of bringing these together with findings from international settings.

No response published in the seeded NHS RHO data

Research needs to investigate how experiences of institutional, structural and interpersonal racism impact on both the mental health and career outcomes of NHS ethnic minority staff. Most of the evidence in our review treated mental health outcomes (broadly defined) and career progression as separate but the two are likely to be interlinked.

No response published in the seeded NHS RHO data

National datasets such as WRES need to ensure that all NHS staff in all sectors, including casually employed staff and those working in subcontracted services, are represented in order to present a comprehensive and accurate picture of workplace inequalities facing ethnic minority staff within the NHS.

No response published in the seeded NHS RHO data

NHS England and NHS Improvement should review recruitment and staff development procedures to understand where the greatest barriers to ethnic minority staff's progression (promotion, career development, pay) lie.

No response published in the seeded NHS RHO data

Enforce Guidelines on Ethnic Monitoring Data: Ensure that patients' ethnicity is (1) recorded and (2) recorded accurately (i.e., self-reported ethnicity) in all interactions with NHS staff. Our review found that research studies using clinical data often had substantial amounts of missing ethnicity data.

No response published in the seeded NHS RHO data

Produce better NHS Statistics: NHS Digital should provide national NHS statistics on service use by ethnic group, age and gender (at a minimum) and allow for clinical data to be linked across datasets in order to improve the monitoring of clinical outcomes for ethnic minority populations and to enhance the quality of research that can be undertaken with ethnic minority populations.

No response published in the seeded NHS RHO data

Invest in Interpreter Services: Greater resource needs to be allocated to the provision of interpreters in NHS Trusts; we found that high quality interpreters were not being provided in mental healthcare, in GP surgeries and at various points along the maternal health care pathway. Interpreter services need to be readily available for in person, telephone and digital appointments.

No response published in the seeded NHS RHO data

Work to build trust with ethnic minority groups and key VCSE organisations: Produce and implement a plan of work to build trust with ethnic minority groups and voluntary, community and social enterprise (VCSE) organisations that work with ethnic minority populations. Our review found that some ethnic minority people delayed or avoided help seeking for health problems due to past experiences of racist treatment by healthcare professionals or due to similar experiences of their friends and family. Improving ethnic minority people's trust in NHS services will, subsequently, improve health outcomes through increased access to these services.

No response published in the seeded NHS RHO data

Invest in research to understand the impact of racism on healthcare: Finally, greater investment in research understanding the mechanisms that underpin and drive ethnic inequalities in healthcare is imperative if the mechanisms and systems that give rise to ethnic inequalities are to be disrupted.

No response published in the seeded NHS RHO data