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NHS Covid 19 and health care worker deaths: questions that need asking

Substantial numbers of key workers are being infected by Coronavirus. A substantial proportion of those dying from it are from Black and Minority Ethnic (BME) backgrounds. We don’t know the answers but we do know some of the questions that should have been asked but apparently were not.

Where were the risk assessments for key workers?

The Management of Health and Safety at Work Regulations (1999 as amended) requires employers to ensure there is a work environment that is, as far as reasonably practicable, safe and without risks to health. The resultant Covid 19 risk assessment should have set out what systems of work and what protective equipment might be needed, when, where, and on what scale, and for primary care and social care not just hospital care, not to mention all other workplaces where staff might be at greater risk of catching infection (e.g. bus drivers, supermarket till workers). This was even more important given that we entered the pandemic with too few doctors, nurses and hospital beds, with the PPE stockpile run down, and given the known exponential likely spread of infection.

Alongside that there should also have been an Equality Impact Assessment to determine whether particular groups of staff might be especially at risk (e.g. pregnant women, older workers) and whether particular groups or communities might be at risk such as the poor (greater likelihood of chronic health conditions) or those from particular communities.

Much was made of patients dying with “underlying health conditions” but little was heard about workers with underlying health conditions. After all it was known before the pandemic struck in force in the UK that those with pre-existing respiratory conditions (asthma for example) and heart conditions were at risk.

These two risks assessments are a crucial part of the employers’ duty of care during this pandemic. I could find no mention of steps to be taken for groups of staff with pre-existing conditions who might be asked to work with Covid 19 patients for healthcare, social care, public transport workers or cleaners? If they had been done, would occupational health doctors have advised top quality protection was essential or that such workers should be transferred to other duties?

By contrast the CQC signed off their EIA on March 24th 2020. Where are the assessments for health care, social care or public transport workers, for example?

How important is the disproportionate presence of BME staff on the front line staff?

There are more BME nurses (56%) on the lowest nursing pay band (Band 5) than all the other nursing grades together. Less than 2 % of BME nurses are in the top 5 pay bands (8a to 9). Nationally, 28% of nurses in Band 5 are from BME backgrounds falling off to 4% at Band 9. In London 53% of Band 5 nurses are from BME backgrounds. It is the lower banded nurses on Bands 5 and 6 who are doing the bulk of the hands on nursing and are therefore most at risk. In medicine the proportion of White consultants is higher than that of BME consultants but amongst the lower graded doctors 60% are from BME backgrounds.  A high proportion of public transport and cleaning staff are from BME backgrounds. For example, at least 28% of ‘operational staff’ (includes: Station Supervisor, Train Operator,

Customer Service Assistant, Track Operative, Dial-a-Ride Driver, Bus Station Controller, Pier Controller) working for Transport for London are from a black and minority ethnic background. It is important to note that bus drivers are usually employed via a private company and would not appear in these statistics.  

Ethnicity is not only important because BME deaths are disproportionately high. The BME staff who are disproportionately on the front line, and therefore most at risk, are also those most concerned (in the NHS at least) about the consequences of raising concerns about risk. Sir Robert Francis (2015) found that Black and Minority Ethnic staff felt especially vulnerable about raising concerns at work and these staff also remain more likely to be bullied at work than White colleagues.

Is the inner circle of Government leaders and key experts sufficiently diverse?

Public sector leaders at every level accept that diverse, inclusive teams make better decisions. The diversity that helps make better decisions is not simply that based on gender, race, age or disability. Effective diverse teams also draw on a diverse range of disciplines and institutions in their decision making. But the gaps in decision making suggest the circle of experts advising government was insufficiently diverse. Which of the small inner circle of decision makers and experts has any detailed understanding of how such a pandemic might impact on the elderly, on the poor, or on care homes? Did any of these experts consider how workers’ “underlying health conditions” or the health challenges of specific communities or occupations might make some health and social care workers more vulnerable?    

John Ashton, former regional director of Public Health England, says the government’s advisers took too narrow a view and clung to limited assumptions. He says they were too “narrowly drawn as scientists from a few institutions” whereas there was a need for a broader approach so that “in the future we need a much wider group of independent advisers.”

Greater cognitive diversity (of the sort John Ashton advocates) and demographic diversity are distinct but they substantially overlap and both improve decision making. Yet those leaders making the health and social care workforce decisions on Covid19 look anything but diverse. At Ministerial level Boris Johnson, Michael Gove, Dominic Raab and Matt Hancock seem to be making the key NHS and social care decisions alongside what is (in public at least) an inner circle of senior equally white male advisers – the Chief Medical Officer, the Chief Scientific Officer, the Head of Behavioural Insights and the lead mathematical modeller– not to forget Dominic Cummings.

Whilst other key NHS leaders like Dido Harding and Prerana Issar do understand that leading with compassion and inclusion are crucial to providing good care, and that diversity in leadership is part of that, it is unclear whether Ministers do.

Once the pattern of disproportionate BME deaths started shouldn’t an urgent investigation have started?

We don’t yet know the consequences of any delays resulting from the focus on the flawed “herd immunity” strategy and the apparent absence of risk assessments that might have identified some staff (BME, older, pre-existing  conditions), some communities (poorer, BME) or locations (care homes) as being potentially more vulnerable. However once it became clear (very early on) that a disproportionate number of the front line staff dying were from BME backgrounds, why did Ministers not immediately trigger urgent investigation and mitigation if at all possible? We don’t know if it is the workplace or other factors creating this trend but surely we need to find out urgently to try to mitigate it. We cannot wait for some future inquiry or even the excellent initiative from the Parliamentary Women’s and Equality Committee.

Have diversity and inclusion been discarded at the first sign of crisis?

We know inclusive diverse leadership is better leadership. Yet, not only are national decision makers disproportionately white and male, but symbolically, the senior leadership of the flagship Nightingale Hospital in London is overwhelmingly White too even though half of London’s NHS workforce is from Black and Minority Ethnic backgrounds. What message does that send to BME communities disproportionately bearing the brunt of Coronavirus both as patients and as staff, especially when we know overall progress on recruiting BME staff even when shortlisted is still hopelessly skewed and made no progress last year?

I do not doubt the skill and commitment of those leading national and local responses to the crisis. But was it really the case that the leadership teams (including at the Nightingale) could not have been even better if they had been truly diverse? Diversity and excellence are not alternatives. The contrast between those dying and those making decisions seems very sharp. We should already be trying urgently to find out what is going on.

Otherwise won’t more people be asking, as one nurse put it to me very recently, “are some black staff only visible when they die?”

Roger Kline is Research Fellow at Middlesex University Business School