Jacqui Stevenson and Mala Rao investigate why BME people have lower wellbeing levels

Wellbeing – feeling good and functioning well – varies between different ethnic groups in England. Even taking into account the social and economic factors known to influence wellbeing, there appears to be a residual, non-random difference – with people from Black and minority ethnic (BME) communities reporting lower levels of wellbeing than their White counterparts.

This discrepancy had been recognised but not explored in detail – so we researched and produced a report ‘Explaining levels of wellbeing in BME populations in England’. This report investigates the issue of ethnic disparities in wellbeing and possible drivers for this. The aims of the study were to carry out a brief review of the existing data and literature on ethnic disparities in wellbeing and to gather the observations and views of key opinion leaders through a call for evidence, interviews and a roundtable meeting.

We found evidence that wellbeing differs significantly between ethnic groups. Data on wellbeing in the UK is gathered through multiple sources, across which ethnic disparities have been evidenced. For example, the Understanding Society survey findings indicate that life satisfaction is lower for people from BME groups, with a larger effect for people of second generation status. Importantly, it found that difference in life satisfaction holds when controlled for individual characteristics and neighbourhood factors.

The Annual Population Survey carried out by the ONS also gathers ethnicity data, allowing for detailed analysis of wellbeing by ethnic group. In 2012, with respect to life satisfaction, the White ethnic group reported an average of 7.4 out of 10, compared to 6.7 in the Black ethnic group, though some other ethnic groups reported similar or slightly higher averages. On the question of ‘how worthwhile the things they do are’ also, the White ethnic group reported a higher average than all other ethnic groups.

Why does this disparity matter? There is a positive association between higher levels of subjective wellbeing and both health and longevity. High levels of wellbeing can add 4 to 10 years to life, and impacts on child development, living well and ageing well.

If therefore there are lower levels of wellbeing in ethnic minority populations, this has serious implications. That the apparent differences hold when controlling for known factors influencing wellbeing such as employment, housing and household income, suggests that there is a particular association between BME status and lower subjective wellbeing, with implications for health and longevity.

A review of the literature revealed evidence of ethnic inequalities across every dimension of life – which were also reported in both the interviews and roundtable we conducted as part of this research. Discrimination and inequalities in health, employment, law enforcement, education, access to health care and services, including mental health all persist, and are likely to contribute to lower levels of wellbeing in people from BME populations.

In our report, we took as a case study the NHS – which is a large employer with a highly ethnically diverse workforce, as well as a focus on health and wellbeing. Our findings point to the fact that, far from being an exemplar for staff wellbeing, the NHS helps to illuminate the impact and consequences of lower wellbeing in BME staff, as well as specific drivers for differences in wellbeing between different ethnic groups.

Ethnic diversity is not proportionately represented through the NHS hierarchy.  A survey of the ethnic composition of the leadership of the NHS in London exposed the stark contrast between London's demography, with 45% of the population and 41% of its NHS staff being made up of BME people, and BME representation of only 8% of Trust Board members and 2.5% of Chief Executives and Chairs in the NHS leadership. The London picture was reflected in every respect nationally, with BME representation being very low or entirely absent from the Boards of some of the national English NHS bodies.

Ethnic discrimination has also been demonstrated in recruitment and career progression, resulting in an 'ethnic gradient' within the workforce, with BME staff being represented in larger numbers at lower pay grades and lower status roles among medical and non-medical employees. Recognition and reward for work is also inequitably distributed, as shown by a review of one example of performance related pay, or the variation by ethnicity of Clinical Excellence Awards for consultant staff.

Furthermore, racism and discrimination against staff can take other forms. A 65% increase in racist verbal and physical attacks against staff by patients in the NHS was reported by one study in the 5 years up to 2013. A published report of an incident described how a hospital had acquiesced, when parents requested that their child was to be treated by a White doctor only.
Our review also included evidence of inequalities and potential bias in fitness to practice processes carried out by the professional regulatory bodies, and examinations and assessments which are part of specialist training.

Experiences of actual or perceived discrimination, barriers to progression and other inequalities, are broadly agreed to have an impact on staff wellbeing, but the extent of the impact is unclear and less well researched. However, research has demonstrated a clear link between the wellbeing of BME staff and patients' perceptions of care. In organisations where BME staff felt motivated and valued, patients were also more likely to be satisfied with the service they received.

Conversely, the greater the proportion of staff from a BME background who reported experiencing discrimination at work in the previous 12 months, the lower the levels of patient satisfaction in the study, suggesting that attitudes towards BME staff were also likely to be reflected in organisational attitudes towards patients.

In recognition of the fact that patients from BME backgrounds rated their care from the NHS lower than that from the majority population, and that BME NHS staff rated their job satisfaction lower than staff from the majority community, a ten-point strategic NHS Race Equality Plan had been developed in 2004 but a decade later there was little evidence of progress in achieving its goals. In recognition of this, the NHS has agreed a mandatory workforce race equality standard which requires NHS organisations to collect baseline information from April 2015 on indicators of workforce ethnicity and to publish annual updates on these metrics. An Advisory Group which includes the Chairs of all the NHS bodies has been established to provide oversight of this new strategy.

The need to address racism and discrimination within the NHS is incontrovertible. Recognition of these problems has been longstanding, but successful solutions have thus far remained out of reach. This echoes the wider persistence of racial inequality in society.

Jacqui Stevenson is a PhD candidate at University of Greenwich, Programmes and Advocacy at ATHENA Network, formerly Acting CEO of AHPN and Mala Rao is Professor and Senior Clinical Fellow, Department of Primary Care and Public Health, Imperial College London

Further reading:
http://www.bmj.com/content/349/bmj.g4781
http://www.theguardian.com/healthcare-network/2014/aug/01/inequality-black-ethnic-minority-rife-nhs