05 Jun 2023
The murder of George Floyd at the hands of US police in May 2020 reinvigorated the call for anti-racism across the Global North. Mental health bodies also joined this political moment, but the problem of institutional racism was identified as a problem in the NHS long before the surge of public interest following Covid-19 and Black Lives Matter. In this blog, Phuong Hua, a postdoctoral researcher funded by NIHR ARC North Thames, introduces her research on institutional racism in inpatient mental health wards.
What is institutional racism?
One of the earliest definitions was by Carmichael and Hamilton who defined racism as a system of structural inequality that was perpetuated through institutional sanctions in various contexts including law enforcement, healthcare and education. Institutional racism was first given legal recognition in the Macpherson report in 1999, which was published in response to the death of Stephen Lawrence in England. This report, which is widely used in public service settings in the UK, defined institutional racism as “the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin.”
Despite the clarity of this definition, institutional racism in health care remains difficult to detect as it does not always involve overt attitudes or behaviours but instead, is embedded in existing practices, procedures, patterns and policies that privilege members of particular racial groups, like white/Caucasian. The term, ‘institutional racism’ is also used interchangeably with ‘ethnic disparities’ in healthcare suggesting that are gaps in our understanding of what constitutes institutional racism. Although there is substantial evidence of ethnic disparities in aspects of patient care such as involuntary admission, few studies have investigated whether institutional racism is the causal factor underlying these disparities.
The current situation
Many NHS trusts are guided by the Equality Act 2010 which offers protection against discrimination based on nine “protected characteristics.” These are: age, disability, race, sex, sexual orientation, gender reassignment, pregnancy and maternity, religion or belief, and marriage and civil partnerships. The NHS Constitution also includes a duty “not to discriminate against patients or staff and to adhere to equal opportunities and equality and human rights legislation.”
Multiple cultural competency programmes have been initiated by the NHS, but few studies have evaluated the effectiveness of these programs for reducing institutional racism. Some examples include:
- The NHS Health and Race Observatory was established and hosted by the NHS Confederation - addresses the specific health challenges facing people from BME background. (NHS Race and Health Observatory | NHS Confederation)
- NHS Employers diversity and inclusion partners programme – supports health and care organisations to create inclusive workplace cultures. (Diversity in Health and Care Partners Programme | NHS Employers)
- South West London and St George’s Mental Health has a virtual Anti-racism hub – houses a range of resources to guide staff on cultural sensitivity, modelling antiracist culture as a leader, race fluency etc. (Anti-racism hub: “Anti-racism is everyone’s business” (swlstg.nhs.uk))
Where research can make a difference
I have been involved in public health research for several years, focused on marginalised populations and healthcare inequalities, particularly in the inpatient setting. During my PhD, I noticed a major shortage of research - particularly qualitative or mixed methods research - that focused on social determinants of mental healthcare and systemic issues such as racial discrimination. There have also been few opportunities to conduct cross-cultural research or investigate racial/ethnic disparities in inpatient care experiences. My postdoctoral research project seeks to fill this gap, to examine institutional factors perpetuating racial biases towards ethnic minority inpatients.
The inpatient setting is a key touchpoint for vulnerable populations in a crisis – although, as I have observed through the research conducted, it is a setting that can reproduce societal racism and the inequalities reported in other contexts (such as law enforcement and education). My project represents a rare opportunity to explore how institutional racism operates from the perspective of individuals who have a lived experience of inpatient care and who also identify as ethnic minorities. The study will have major methodological implications and improve co-design work and patient/public involvement in research, particularly when working with ethnic minority populations.
I also hope to produce a theoretical model or framework of institutional racism that can be embedded in existing anti-racism and cultural competency training programs across NHS Trusts. It remains unclear whether their existing programmes focus on institutional racism and how this is addressed at senior management levels. In producing a theoretical framework, this tangible output can be used as a prompt for organisational discussions and hopefully reduce the ‘culture of silence’ around race-related issues in healthcare. Wider institutional problems related to NHS healthcare such as understaffing and power imbalances may well be perpetuating racism and could be further addressed in the current study.
How to get involved?
My study is currently looking for participants. If you have ever used an NHS mental health service for adults and identify as part of an ethnic minority, we invite you take part in a focus group in London (held in July - September 2023). We recognise that as mental health service users, you are experts by experience. All participants will be reimbursed for their time in the focus group discussion.
The purpose of this study is to work with ethnic minorities who have a lived experience of NHS mental healthcare. We will produce a theoretical framework to illustrate patients’ experiences of institutional racism to present to NHS trusts. The focus group will be an opportunity to discuss your experiences of institutional racism in a safe space among individuals who may have similar stories.
Please contact me via p.hua@qmul.ac.uk if you would like further information.
