Unsurprisingly, health inequalities are a key driver of the disproportionate impact of Covid-19. Some ethnic groups are more likely to have underlying health conditions and find it more difficult to access medical care. Evidence also suggests that the social and economic inequalities faced by ethnic minorities can lead to poor health outcomes. The Marmot review describes this as the “social determinants of health”. [1]

Public health challenges such as high levels of obesity, cardiovascular disease and diabetes disproportionately fall on some of the UK’s Black, Asian and minority ethnic communities, and it is important for these differences to be understood. [2] There has also been considerable attention given to possible biological explanations for the disproportionate effect of Covid, but a recent paper from the ethnicity subgroup of SAGE argued that these are “unlikely to explain the ethnic inequalities”. [3] As the Royal College of Nursing highlighted in a submission to this review:

”Biology can also be a distraction and discussions around Vitamin D deficiencies do not fully explain the disparities between Black, Asian and minority ethnic groups contracting and dying from Covid-19; the true picture will not be understood by biology alone.’’

IPPR and the Runnymede Trust estimate that co-morbidities lead to the Black population being only five per cent more likely to die from Covid-19 than the white population, arguing:

“The majority of the additional risk of death from Covid-19 experienced by minority ethnic communities is unexplained… Genetics cannot explain why every minority ethnic population, given huge genetic diversity within and between these groups, has a higher risk of death from Covid-19 than the white ethnic population. Instead, this inequality is likely to be driven by structural and institutional racism… and differential access to healthcare.” [4]

One of the drivers of health inequality is the Government’s failure to implement targeted public health strategies. Since 2015, £800 million has been taken out of public health grants to local authorities and this summer the Government announced Public Health England would be scrapped. These cuts have fallen most heavily on areas with high levels of deprivation and the negative relationship between deprivation, ethnicity and health outcomes is well documented. We consistently heard that targeted, culturally appropriate public health strategies to combat chronic conditions such as obesity, heart disease and diabetes, which feed more serious health complications, should be a priority for Government.

The NHS is our most treasured institution, and the heroism of doctors and nurses during this pandemic has cemented this fact in the hearts of people across Britain. The NHS was founded 75 years ago, as the Windrush arrived, and its story has always been entwined with Britain’s growing diversity. Today, Black, Asian and minority ethnic people make up 20 per cent of its workforce.

But despite the huge contribution of our NHS, 64 per cent of Black Britons think the NHS does less to protect their health than that of white people, a perception substantiated by the health outcomes they experience. [5] Maternal mortality is five times higher for Black women than white women, and twice as high for Asian women. Black mums-to-be are eight times more likely to be admitted to hospital with Covid-19 than white pregnant women. [6]

We also heard that Black, Asian and minority ethnic people often experience barriers to accessing healthcare, including mental health services. This can often be caused by a lack of cultural and language appropriate communication, as well as digital exclusion. One submission reported the remarks of a junior doctor working in intensive care:

“Language barriers for people who can’t speak English, especially when you can’t say if you’re in pain or short of breath, can have a huge impact.”

For migrants, requirements to show passports when seeking care and information passing between the NHS and the Home Office has created a significant barrier to accessing even emergency healthcare. [7] We heard that the ‘no recourse to public funds’ condition that prevents many migrants accessing social security and other state assistance was a factor in health inequalities experienced by many. In the context of Covid-19, the Coalition of Race Equality Organisation’s submission highlighted that the vast majority of migrants were unaware of the Covid-19 exemption from charging and immigration checks, meaning many were avoiding seeking medical care out of fear.

Many submissions raised the lack of training for healthcare practitioners to enable them to fully understand inequalities in health outcomes, cultural differences and any unconscious bias. We heard that some Black, Asian and minority ethnic people are not being taken seriously when seeking care, or facing untrue stereotypes about pain thresholds which affect clinical decisions. Black Ballad highlighted some examples:

“We’ve spoken to doctors and midwives who don’t even know that Black women are five times more likely to die from pregnancy complications. If there is no awareness in the first place, and people don’t know about it, then what can be done?” [8]

There is also a lack of medical training on the different presentation of medical conditions among different ethnicities, and a lack of Black, Asian and minority ethnic participants in medical trials. Scientists for Labour reported to us, for example, that:

“Medical professionals have reported a lack of training on diagnosis of conditions for those with darker skin tones.”

Finally, there is a lack of diversity in senior levels of the NHS. Black, Asian and minority ethnic staff make up around 20 per cent of the overall NHS workforce but just 6.5 per cent of senior managers. In London, almost half of NHS employees are Black, Asian and minority ethnic, but 92 per cent of NHS Trust Board members are white. [9] During a roundtable with NHS providers, Trust leaders highlighted the “critical need” for more diversity in decision-making positions, with nursing and management structures being particular examples of where the ‘glass ceiling’ needed to be broken.

Several respondents mentioned the NHS Workforce Race Equality Standard (WRES), which was introduced in 2015 to improve the diversity, progression and treatment of Black, Asian and minority ethnic staff. The Seacole Group, the network for Black, Asian and minority ethnic non-executive directors in the NHS, told us that the requirement for healthcare organisations to provide WRES data was an important first step to reveal the scale of inequality and discrimination. However despite five years of data there has been no substantial change. They suggested improvements must be made to hold senior management to account on progress. A respondent said:

“We have the data to prove inequality but we are not moving forward to see tangible improvements. As we approach the second wave it will be unforgivable if we have the same level of deaths.”

This review also heard concerns about the impact on mental health as a result of the pandemic, particularly in light of the poor mental health outcomes Black people face and the barriers to accessing mental health services. For instance, a 2018 review into modernising the Mental Health Act found that “those of Black African or Caribbean heritage are over eight times more likely to be subjected to Community Treatment Orders than those of white heritage”. [10] Dr Jacqui Dyer, Chair of Black Thrive, a London based partnership for improving Black mental health, stressed that “post treatment and bereavement counselling to support individuals in our community will be key”.

To understand the disproportionate impact of Covid-19 on the UK’s ethnic minority communities, we must look beyond Covid-19 to longstanding health inequalities and their causes. A number of organisations, including the Royal College of Nursing and the British Medical Association, called for a cross-governmental strategy to tackle health inequalities in their submissions to us. As the British Medical Association argued:

‘’Over the longer term there must be a determined focus on interventions to narrow the longstanding health inequalities that Covid-19 has brought to the fore.’’

But the truth is the Government already knows this. Ten years ago the Marmot Review warned that a strategy was needed to reduce healthcare inequalities, but the Conservatives’ record has been shameful. Austerity and a failure to provide for ever-increasing demand has seriously undermined our health service. The 2020 Marmot Review into Health Inequalities found that: [11]

“Austerity has taken its toll in all the domains set out in the [first] Marmot Review. From rising child poverty and the closure of children’s centres, to declines in education funding, an increase in precarious work and zero hours contracts, to a housing affordability crisis and a rise in homelessness, to people with insufficient money to lead a healthy life and resorting to food banks in large numbers, to ignored communities with poor conditions and little reason for hope. And these outcomes, on the whole, are even worse for minority ethnic population groups and people with disabilities.”