Session 6: Summary 
Inequalities and discrimination

Introduced by Dr Sonia Adesara
Chair of Panel Michael Mansfield 

 

Witness 1: Dr Mary Ann Stephenson, Director of the UK Women’s Budget Group

Witness statement

The Women’s Budget Group (WBG) analyses economic policy for its gender impact, and also proposes alternative policies to create more gender equality. 

  

Effect of Covid pandemic on women

 

  • At the start of 2021 the WBG had published a report, one of a series on the impact of COVID on women, Where Women Stand, looking back over what had happened since the start of the pandemic, and trying to bring together evidence from their own and others’ work on the gendered and other impacts of Covid.

  • Men have been more likely to die from COVID, but women have been hit harder by the social and economic impact: they have been more likely to be furloughed, to have to carry out increased unpaid work, particularly care work, with the closure of schools and nurseries, but also the crisis in social care. 

  • Women are at greater risk of redundancy, because the sectors they work in are most badly affected by the pandemic, are more likely to be in debt, particularly problem debt, more likely to be living in poverty, and vastly more likely to have experienced an increase in domestic violence. 

 

Could effects on women have been anticipated?
 

  • There has been extensive research into the gendered impacts of previous pandemics, for example, Ebola. Academics such as Dr Clare Wenham at the London School of Economics, raised concerns at the beginning in 2020, and were told ‘London is not Liberia, we won't have the same problems’. 

  • The second thing was awareness of the implications of pre-existing inequalities: women were more likely to be poor, more likely to work in sectors that would have to close, more likely to work in health and social care. Women carried out 60% more unpaid work than men and therefore were more likely to do more of that work. If schools and nurseries were closed. ‘All of that was entirely predictable.’

 

Measures that could have been taken
 

  • The Government and its advisers should have thought about what impact the closure schools and nurseries would have had on women's ability to carry out paid work. 

  • The right to furlough for childcare reasons did come in later but wasn't heavily publicised.  

  • Both parents could have been encouraged to take part time furlough, rather than one partner coming out of the labour market.

  • Statutory sick pay so that people are able to self-isolate should have been looked at more closely: the majority of those not entitled to statutory sick pay are women. 

  • More protection should have been given to people on insecure part-time contracts and zero hours contracts who are more likely to be made redundant than be furloughed

  • In calculation of support given to the self-employed, in the calculation of average earnings over the three years before the pandemic, maternity leave should have been allowed for.

  • More money should have been put into domestic violence services from the start.

  • An equality impact assessment of all the policies should have been carried out and it should have been ensured that advisory groups like SAGE include expertise on gender, and gender and pandemics. 

 

Government response

There had been no response from Government to proposals put forward from early on by the women's sector when they were looking at what was happening in Italy and China. 

 

What needs to be done

  • The furlough scheme ends in September and the end of the £20 uplift to Universal Credit. Dr Stephenson told the panel ‘We're facing a cliff edge’. 

  • An underlying problem, prior to and during the pandemic is the ‘relative lack of generosity in our Social Security system,’ people who've lost jobs have been ‘pushed into poverty.’ The Government needs to introduce a Social Security system that acts as a genuine safety net, a ‘system that is there to protect us’. 

  • The government's ‘Build Back Better’ proposals are all about investment in construction schemes, some of which are important and needed, but unlikely to provide jobs for people who've lost work in retail, hospitality, the beauty sector, for example. 

  • Modelling of investment in social care shows that the same amount of money invested in care could create nearly three times as many jobs as money invested in construction, even if you paid care workers at a higher rate than currently.

  • As with witnesses in past sessions, Dr Stephenson told the Panel that there are issues around test, trace and isolate, and that there are weaknesses in the isolate bit because of the gaps in the Social Security system, and particularly in Statutory Sick Pay, which leaves many people with no choice but to carry on working, even when they’re ill. 

  • More resources need to be put into mental health services and CAMHS to support the effects of COVID on young women in particular

  • To alter the distribution of work in the home we need to change our leave system because otherwise it will be very difficult to get equality outside the home, because that unpaid care is at the root of so much inequality outside the home.

  • Things like impact assessments and gender budgeting, equitable sharing of leave, have taken place in large numbers of Scandinavian countries, in South Africa, and many different countries. This could be a moment for change.

 

Domestic violence
 

  • There were particular issues in lockdown because people were trapped at home with their abusers.

  • A review of women’s organisations from the Women's Resource Centre had showed a 79% increase in demand and over 50% showed an increase for women with complex needs, including violence, but there hadn't been the resources to meet the level of demand.  

 

  

Professor Kamlesh Khunti

Articles pack for Professor Khunti

 

Professor Kamlesh Khunti is Professor of Primary Care, Diabetes and Vascular Medicine at the University of Leicester. He's a member of the government advisory body SAGE. He is Chair of SAGE Ethnicity Subgroup and a member of Independent SAGE.

 

Covid and inequalities

Professor Khunti explained factors that have contributed to inequalities amongst ethnic minority communities under COVID, using a framework generated by Srinivasa Vittal Katikireddi and others including Professor Khunti:  

  • Differential levels of exposure because people from ethnic minorities because of occupation or housing

  • Differential vulnerability because people are living in an environment that puts them at higher risk, air quality etc, 

  • Greater comorbidities eg more diabetes, cardiovascular disease, high blood pressure leading to greater disease consequences

  • Poor access to care and quality of care potentially. 

  • Differential effectiveness of messaging, because of language, resources, because of, for example, vaccine hesitancy

  • Differential control of working conditions, access to protection, personal protection, and not following advice because of stigmatisation (See article: 1 Unequal impact of COVID-19 crisis on minority ethnic a framework (1).pdf)

  • Professor Khunti told the panel that the impact of COVID has been highest overall in people in terms of age, occupation, and comorbidities but, within those, there has been a disproportionate impact on minorities and that is a complex area.

  • Newer data studies confirm that exposure through living conditions and occupations are playing a significant part in differential vulnerability to infection. In addition, people from ethnic minorities experience a lot more chronic disease – eg diabetes, cardiovascular disease, heart disease – and these are all associated with worse outcomes throughout ethnic minority and white populations. Obesity is a factor as well.  

  • Initially, in early reports from the pandemic in China, Italy and Spain, there had been no reports of ethnic disparities, but in April there had begun to be reports from ICUs in the ICNARC data (ICNARC – Intensive Care National Audit & Research Centre which showed that while overall 14% of the UK population is of non-white ethnicity, 30% of those who are admitted to intensive care units were of non-white ethnicity.

  • Communications had not been tailored enough.to the needs of ethnic minority populations, especially the most deprived. Information needs to be accessible, and to be culturally adapted. All of that didn’t happen at the beginning. The regular news and press conferences were in English, and weren't accessible to most of the minority populations, especially the deprived population who have been hardest hit.

  • Nosocomial infection rates, where people acquire an infection from hospital, could have been improved through good quality Personal Protective Equipment. and regular testing of healthcare staff.

  • The situation had been even worse for black and Latino patients in the US, than in the UK, because of poor access to healthcare in the US. 

 

The future

  • There is a need for a prevention programme for chronic diseases, such as diabetes and cardiovascular disease, that are due to risk factors such as physical inactivity, diet.  

  • Equity of access for newer therapies eg for diabetes should be ensured for people from ethnic minorities, and improvement in terms of screening and follow-up for patients.

  • There needs to be increased funding for research in relation to ethnic minorities as it is more expensive, requiring greater efforts to reach into communities and the need for bilingual support. 

  

Dr Latifa Patel

Witness statement

Dr Patel is Deputy Chair of the Representative body of the British Medical Association (BMA) and a member of the BAME forum. 

 

BAME doctors
Dr Patel informed the panel that:

  • The BMA have done many surveys into the specific needs and disparities of minority ethnic doctors that set them out from their white counterparts. Prior to going into the pandemic these groups of doctors had been more at risk of bullying, discrimination and harassment, and least likely to raise these issues, to be heard, and their concerns to be acted upon.

 

The multiplying effect

  • In one survey done by the BMA, mask shortages were 36 to 43% and there were also shortages on gloves, scrubs and visors, both on the front line and further in the back where there were aerosol generating procedures. Dr Patel told the panel that In the case of a minority ethnic doctor facing these concerns therefore, knowing that prior to the pandemic a doctor may be least likely to raise these concerns, then the effect ‘just multiplies’. ‘You're not really likely to raise your concerns, knowing full well that you're not going to be heard.’

  • These issues have been raised by the BMA with the government who have not responded in the way the BMA would have liked, at a level which would have made staff ‘feel safe and protected’. 

 

Minority ethnic patients

  • Kings Fund and other data shows that minority ethnic patients have very specific needs and have experienced disparities such as poor access to health care in the NHS, and poorer health outcomes. 

  • Dr Patel informed the panel that ‘communication throughout this pandemic from the government has been wholly unacceptable,’ and that when you communicate with patients, you should try and aim it at the most disadvantaged and make that your baseline. This did not happen.

  • Women patients have been affected during the pandemic by the way maternity care was delivered: appointments were suddenly experienced without partners; some women even gave birth on their own. The BMA has been campaigning on these issues.

 

Virtual consultations can discriminate 

  • Virtual communications do not cater to some in minority ethnic groups and low-income families. You need good Wi-Fi, a good understanding of English, a good microphone, a high pixelated camera. 

  • If, prior to the pandemic, translating services were needed to access health care, after the pandemic hit, these were suddenly lost, making disparities worse. 

  • Reliance on mobile phones became more predominant during the pandemic including between GPs, other doctors and their patients. Mobile phone numbers were not available for all patients or were changed more frequently because of pay-as-you-go contracts. Patients were being prematurely discharged from care more frequently because they could not be contacted by phone.

  • Patients missed phone appointments for lack of privacy, and were sometimes making phone calls in cars, toilets, or bathrooms to try and gain privacy, because they did not have the privilege of space in their home, often living with extended family. 

Future improvements

  • A disproportionate number of people from minority ethnic groups are dying, and a disproportionate number are ending up more unwell than their white counterparts. 

  • More doctors, medical students, nurses are needed but the focus should also be on retention. Staff need to feel safe and valued.

  • Risk assessments, which were asked for 12 months ago, are only happening 50% of the time in the case of doctors. There is a difference of 10-15% within the minority ethnic group populations and their white counterparts about how well they've been risk assessed. And risk assessments need to be acted on.  

  • There is a record number of NHS staff reporting burnout, who have mental and emotional concerns, and who are also talking about leaving the NHS. 

 

Vaccine hesitancy

  • Dr Patel explained that to really understand vaccine hesitancy we need to look at the position that the minority ethnic population was in before the pandemic began. There were already concerns and disparities, with a lack of trust in some governmental policies regarding Brexit and immigration, the Windrush generation etc. It is therefore understandable why some minority ethnic people feel a mistrust against the government. 

  • Black and Asian patients are often more at risk within the NHS therefore there is less trust. 

  • To make things better, access, communication and understanding need to be made better.

  • Virtual consultations have not been targeting all populations equally, especially for those who don’t speak English as a first language, 

 

 

Aliya Yule, Migrants Organise
Witness statement

 

Aliya Yule works at Migrants Organise, a charity based in West London, as the access to healthcare migrant organiser. The charity supports around 500 migrants, refugees, asylum seekers and people without status during the pandemic. Predominantly in her work she focuses on the Patient's Not Passports campaign, which is designed to draw attention to the impact of the Government’s hostile environment in the NHS and to campaign against it. They are also in contact with people housed in barracks and who were subsequently moved to London.

 

Their work encompasses both organising and campaigning, as well as the provision of a holistic programme of casework support and activities at their North Kensington office. Most of their activities have moved online since the first lockdown in March 2020.

  

‘Undocumented migrants’ and the ‘hostile environment’

  • Aliya Yule explained to the panel that the term ‘undocumented migrants’ refers to quite a broad category of migrants ie there are many different ways in which somebody can be undocumented. Sometimes people are in the UK legally but can become undocumented through being unable to pay for visas, the refusal of an application. Visa status is sometimes tied to a family member, a spouse or employment. Asylum seekers may be refused but then have the right to appeal and, in this way, they can fall in and out of having regular immigration status. There are estimates that the undocumented population in the UK is from about 800,000 to 1.2 million people.  

  • Aliya Yule told the panel that the hostile environment consists of ‘a whole suite of policies that affects a whole range of sectors, and of services that people need to live any kind of dignified, normal life.’  When people interact with these services, they then become subject to having their immigration status checked. So, by using the NHS, by trying to open a bank account, or trying to get a driving licence, or trying to rent somewhere they can have their status checked. The right-to-rent scheme demands that landlords conduct passport checks on renters. For people who don't have the right to work, employers have to run immigration status checks. 

  • The hostile environment makes life very difficult for people who don't have the right immigration papers, including not just those who don't have legal status, but those who are unable to prove that they do have legal status, such as those from the Windrush scandal. 

  • The NHS, landlords run checks on immigration status, often based on a racialised process eg Overseas Visitor Managers in hospitals look for people with foreign sounding names on bed boards [on NHS hospital wards], and then go to those people and ask them to prove their entitlement to free NHS care. Landlords refuse to rent to people that they think might not have immigration status, because of [to avoid] the hassle of checking them.  

  • The hostile environment works in the NHS by charging some migrants up to 150% of the cost of care, according to a very complex set of rules and exemptions. ‘Non-urgent’ treatment requires payment upfront. So that means, if someone can't pay, they will not get the treatment; but also, that the NHS can share patient data with the Home Office, particularly around debts accrued due to treatment. If you have a debt to the NHS, your future immigration applications can be prejudiced. 

  • Many hospitals use debt collection agencies to chase migrants who have these debts. 

 


The hostile environment and Covid-19

  • People’s fear of coming forward for health care for Covid-19, even though Covid-related is free, has been seen across migrant communities by organisations who report that people are afraid that when they come forward they will be asked to prove their immigration status, which often they can't do.

  • The Government was urged at the beginning of the pandemic to make it clear to people that treatment for Covid was free but it wasn't publicised particularly clearly, nor was it very clear. This is because the rest of the charging regulations still remain in effect. If someone goes for treatment for coronavirus, for example, but then needs further treatment beyond coronavirus, it is not clear whether people will be charged for the rest of their treatment beyond the coronavirus treatment.

  • Aliya Yule added:
    ‘it's not really possible to have a health system in which you have some parts that are chargeable, and some parts that are not, and be able to communicate that to people clearly. And particularly when at the same time you have this system of sharing patient data with the Home Office sitting behind it. So, meaning that even when testing and treatment is free for people, there is still this fear of coming forward, lest you might make yourself subject to immigration enforcement as a result.’

  • Elvis - a member of the Filipino community
    Aliya Yule told the panel about the case of Elvis, who was part of the Filipino community in London, a cleaner who had lived and worked in the UK for over 10 years with his wife, sending money back to the family in the Philippines. In April of last year, Elvis died alone at home of suspected coronavirus. He had been so fearful that if he presented to the NHS, because he didn't have immigration status (although treatment for Covid was free) he and his wife would become known to the Home Office and then detained and possibly deported.  

  • Ayman
    Ayman is the pseudonym of a Lebanese man who came to the UK about two years ago. He had been detained in Brook House (a detention centre). He had managed with the help of a migrant charity to get out of there and was learning English and volunteering. He had developed Covid symptoms and had been urged to put himself forward for testing and treatment. However, he was so fearful of landing a huge debt with the NHS which he could not pay, which would have meant that he wouldn't be able to regularise his visa. Because of this he sadly died.

  • Black British man sent threatening letter by hospital
    A black British man who had needed treatment for Covid had kidney failure and was in an induced coma. Whilst in hospital his family were sent a threatening letter that said he needed to provide evidence of his eligibility for free NHS care within seven days. They required six months of proof of address or bank statements, and so on, without which they said they would start charging him for his treatment. He had gained British citizenship 2 years prior and had lived in the country for over a decade. This was despite the Government saying that no one should be status checked for Covid-related treatment. The response his family received from the hospital was that it was an automated system, and everybody was receiving these letters.   

 

Military barracks

Several hundred people had been kept in barracks even though the Government has said this would stop. Conditions were completely unsanitary, there was very little possibility for people to socially distance or isolate from each other. There was spread of coronavirus. It had been difficult for people to access GP services when they were ill. Many people have ongoing mental health problems that they need support with and very few receive it. 

 

 Government response and the future

  • Aliya Yule told the Panel that the recently announced new plan for immigration demonstrates a government committed to being even more hostile to migrants, particularly to asylum seekers. They say that unless people arrive here through legal routes - not that the government is committed to providing any - they will further criminalise people who arrived here illegally.  

  • The Government will subject people to even harsher and stricter conditions, despite the growing number of cross-party MPs who have called for the end to various parts of the hostile environment, including in the NHS, and including through the pandemic.  People across civil society have been urging Government, saying that It's not possible to have an effective public health response when you have people subject to such degrading treatment.

  • Aliya Yule told the Panel that this policy is about ‘scapegoating a group of people, essentially’, making migrants to blame for the erosion and defunding of public services. 

  • In the NHS the charging system for undocumented people could be seen as preparing the population for the introduction of wider charging in the NHS.

  • For health workers working in the NHS and paying the immigration health surcharge, this is essentially a double tax: first they have to pay the immigration health surcharge and then through their taxes as well. The surcharge has just gone up to £624 pounds per person per year. This has be paid in its entirety with every visa application, for every member of a family.