Speaker1: [00:00:00] Hello, I'm Suhail Mirza and welcome to this episode in season three of Voices of Care. My guest today is Professor Habib Naqvi, the CEO of the NHS Race and Health Observatory.

Speaker2: [00:00:11] Voices of Care, the healthcare podcast.

Speaker1: [00:00:16] Professor Naqvi, thank you very much for making the time to join us on Voices of Care.

Speaker3: [00:00:20] Well, thank you for having me. It's great to be here.

Speaker1: [00:00:21] No, it's a real pleasure. Tackling race health inequality is a huge imperative. But before we go into the detail of that, it would be really interesting to just get a bit of background in terms of the mission and the goal of the Race and Health Observatory, which has been around, I think, since 2021.

Speaker3: [00:00:40] That's correct. Officially since April 2021. But the idea of an observatory has been around for longer than that. The idea of an organisation that brings together the evidence base and looks at policy change and looks at how it can support organisations and leaders to make that change around racial inequality. It wasn't until the special edition of the British Medical Journal in January 2020, that a very strong argument was put forward for the establishment of an observatory, and at the launch of that special edition at the BMA House, the then chief executive of the NHS, Lord Simon Stevens, did say, yes, we need this observatory and we need a body that will do exactly that. And then, of course, a few weeks later we had the outbreak of the pandemic, COVID-19, which again highlighted the harsh stratification in access and experience and outcomes in health by race and highlighted the need for an observatory to be a excuse for a mover. So we are essentially as an organisation, an independent organisation, but close enough to the NHS to make policy change and distant enough to be objective and to be that excuse remover.

Speaker1: [00:02:07] Now, thank you for setting the background. You mentioned Covid. That's been now we've had, of course, Baroness Hallett's first report, which highlights a number of things ranging from unpreparedness, etc. but also, as you say, highlighting the impact, disproportionate impact of Covid from people, from minorities. Now, this whole issue of race, there was a bit of a backdrop to the establishment of the observatory, because I'm going to just take you back to the Sewell Commission, which set out the idea that actually the idea that there was institutional racism may not exist. So I just want to see how you tackled that, because there's quite a controversial background in terms of the pioneering work that you've done.

Speaker3: [00:02:47] Well, one of our fundamental principles in the observatory is not to be drawn into culture wars or wokeism, but to focus our attention on what the data and what the evidence tell us. In fact, one of our very first pieces of work was to carry out a rapid evidence review of the state of play around ethnic and racial inequalities in health and health care. And that review was led by the University of Manchester, with a number of other organisations and institutions supporting them. And in a way, it may well have been a response to the Sewell report at the time, but actually it really scoped the programme of work that we would then follow for the next three years. And that report, that systematic review, rapid systematic review did make the front pages of the newspapers, not because it was another systematic review around racial inequalities in health, because we've had many of those in the past, but because perhaps for the first time in the NHS, we were beginning to talk about racial inequalities and racism within health care and the need to tackle it.

Speaker1: [00:04:00] And if we just tarry there for a second, one of the things I think the article that you mentioned from the BMA article, you talked about this earlier. It talked about the idea that institutional racism does exist, but it also said that actually and sometimes this might sound counterintuitive to people. Racism doesn't just affect the people who are negatively impacted. It affects everybody.

Speaker3: [00:04:24] Absolutely. That's absolutely the case. And in fact, tackling racial inequality and inequality in general not only saves money but saves lives. And we know that these inequalities exist. They exist from birth to end of life and at critical points in between those two milestones and what we've seen over the last 4 or 5 years now, particularly during the Covid-19 pandemic, is the disproportionate impact of Covid 19 on ethnic minority communities and the health and care workforce. So there is an urgent need for us to focus on this agenda and in a way, our country, our society should be well equipped to deal with that level of urgency. We have a long history of migration in this country, which goes back not just decades, but centuries. We've got fairly robust legal frameworks and the Equality Act and the health inequalities duties, and we've always had very good investment in healthcare research. In fact, the Covid vaccine is probably just one example of a very long list of innovation that has emerged from this country with regards to medicine and healthcare. But at the same time, it can also be argued that our collective responses, societal and healthcare responses to these challenges around race and inequality have been somewhat fragmented, costly and confused. And whereas specific organisations in the past have been set up or specific interventions have been established, they have largely focused on what we call surface-level issues. Rather than tackling the causes of the causes of the inequalities that we see play out.

Speaker1: [00:06:03] And, I congratulate you on the work that you've done, your progress report from December 2023. I think the introduction was written by yourself and your chair, Marie Gabriel, saying that you're very proud of the work you've done. And just very briefly, it's such a vast area that you cover, whether it's from the race impact or looking at the impact on race for genomics, health education. It's a very broad thing that you're taking on.

Speaker3: [00:06:31] Well, when we talk about the causes of the causes of inequalities, those are the areas that we must focus on education, curriculum, what gets taught within medical nursing degrees, what doesn't get taught, what features in textbooks in terms of photographs and pictures, skin tone. So and then, of course, we know of the long-standing, deep-seated inequalities in health around cardiovascular disease, diabetes, sickle cell disease, the lack of representation in clinical research that then goes on to lead to the inequalities that we see play out. Those are fundamental issues that we must focus on. And I haven't yet talked about workforce because that's another particular issue for not just the NHS, but for major employers across the country to make sure that we get racial equity so that it benefits everyone.

Speaker1: [00:07:24] Absolutely. Now we've had a seminal year: election, new government. And we're going to deep dive into some of them. But if you can just set the scene. You've been very vocal. Your whole career has been one dedicated to this issue. I think you received an MBE for your services to equality and diversity, and that's magnificent. And the Observatory produced a manifesto for the New Government covering a number of things. Can you just give us a very high-level perspective from me, it sounds like the key issue is to look at everything through a race-critical lens, but just wanted to highlight the importance of that manifesto before we dive into 2 or 3 key topics.

Speaker3: [00:08:05] Well, just to the background to the manifesto, we had very clear pledges and commitments from leaders and organisations through the Covid years that actually we must focus on racial inequality, including in health. And our manifesto for the new government sets out some of the fundamental principles and areas of focus that we collectively, as a society, must focus on and is not kind of principles that we've dreamt up. We've carried out an engagement exercise with stakeholders and key players in order to come up with the the seven principles that we outline. And without going into too much detail, the deep seated issues around maternal and neonatal outcomes, it cannot be right that today, in 2024, black women are up to four times more likely to die during pregnancy, childbirth or soon after an Asian women being up to two times more likely. We know of the stark statistics around stillbirths and the ethnic differences there. And it cannot be right that we have a mental health act that is so dated. I mean, we had a review recently just 5 or 6 years ago, that outlined the structural racism and inequalities that exist within the act and how it's operationalised.

Speaker3: [00:09:31] So we must focus upon some of the deep seated issues that we have, but also focusing on making sure that we have the infrastructure to make changes. And that includes ethnicity data recording what how it's recorded and making sure it's recorded for the right reasons and making sure that we have the detail around the evidence that we can kind of focus on as we move forward, but also looking at two other areas that I need to highlight. One is representation in clinical and medical research, which actually if we don't get right, we will get medical devices, medications, clinical assessments that are not fit for purpose for the diverse communities that we're here to serve. And then the second area that I wanted to mention was workforce. This is a leadership issue. We need to get this right. We need leaders to focus on this, and we can go into more depth around that, but also making sure that we have representation at senior levels and not just representation, but inclusion as well. Because representation is not always a precursor to inclusion. And we need to make sure that we get the environment right within our organisations that can benefit everyone.

Speaker1: [00:10:44] And I'd like to dive into 2 or 3 of those in a little bit more detail, because I think it'd be really interesting given the work you've done. But just one framing perspective is that there are a set of principles that you extol and work by, and I think the first thing is to actually name and have the courage to call out racism.

Speaker3: [00:11:01] Well, we're establishing what we're calling the Race and Health Observatory model of anti-racism and very clear points, a handful of very clear points, the first one of which is to name racism. The first step to any change in any arena is to acknowledge that there is an issue to change. And so to acknowledging racism and discrimination and how it exists and how it manifests within our day-to-day work, for example, is critical for us to make change going forward. And of course, that acknowledgement comes alongside the leadership that we need, the accountability that we need to push the work forward.

Speaker1: [00:11:46] Well, let's start at the beginning of life because I think that's a good place to start your manifesto. You've touched upon it, the idea of maternal and neonatal health equity. You've done some work in your report back in July 23rd. Can you just set the picture? Because I think people still find it amazing that there are these differences. You talked about some stats. What did you find in terms of that analysis and what can we do about this with the birth trauma inquiry that you've commented on recently. So it would be really interesting that this still exists today.

Speaker3: [00:12:18] If you think about examples of racial inequality in society as a whole. There probably isn't a statistic as stark as being up to four times more likely to die during pregnancy or childbirth, or soon after. Absolutely. And we know those inequalities exist. We know the stratification exists with regards to access to maternal care, with regards to experiences whilst you're in maternal care as an ethnic minority. And with regards to the outcomes that we are now sadly too familiar with, the embrace data comes out on a regular basis, highlighting some of the stark statistics around maternal, neonatal outcomes. And so focusing on this statistic, on this challenge is absolutely the right thing to do. And we've got a programme of work within the observatory, um, that does exactly that. And we've got a fantastic advisory group which is made up of fantastic clinicians, nurses, midwives, academics, but also critically so, people with lived experience so that we are able to actually focus on the right things at the right time. And one of the first pieces of work that we actually did was to look at neonatal testing and making sure that we can firstly identify where the racial bias exists. And secondly, do something about it. Yes, the Apgar score.

Speaker1: [00:13:55] 1952.

Speaker3: [00:13:55] I think 1952.

Speaker3: [00:13:56] I mean, the fact that we're still using that. I mean, judging the health of a baby, partly based upon the colour of its skin immediately after birth was not right in 1952, certainly not right today in 2024. And in fact, the Apgar score is not just used in maternal maternity units and maternal health services in this country, but also has been exported to other parts of the world, including in Africa. And so that kind of is astonishing. And so looking at how we can de-bias the clinical assessments, how we can look at, for example, other conditions such as jaundice, and make sure that we can have a more inclusive way of judging the health of a baby is absolutely our kind of goal at the moment. And that's what we are focusing on with other partners and organisations. But we are also aware that there probably isn't a single unified intervention that looks at racial bias in maternal care and neonatal outcomes. And therefore we are working with other organisations, such as the Institute for Healthcare Improvement and the Health Foundation to examine how we can work with integrated care systems that we have now in healthcare as pilot organisations, to do some deep dives around closing the gap in maternal and neonatal outcomes between black and minority ethnic women and white women.

Speaker3: [00:15:35] And we're doing that using those principles of anti-racism. So this isn't just about looking at the clinical metrics that we want to close down and closing them down, but looking at how we are going to get to that stage in a more holistic way. So, for example, identifying that there is an issue to tackle, and then coming up with a holistic plan that includes examination of workforce representation within the maternal unit itself, that looks at the degree to which there is racial bias in the policies and the processes of that service. Looking at the way in which that organisation, that service engages in a meaningful and sustained way with its communities. So looking at all of those things in a holistic way will help us to actually focus on closing down the gaps, not at surface level stage, but in a more sustained and meaningful way over time.

Speaker1: [00:16:33] And that will make a dramatic difference from the experience of all people, from minorities in terms of using those services.

Speaker3: [00:16:39] Absolutely. And it's about designing interventions that actually doesn't leave anyone behind. If you get it right for the most vulnerable, you are likely to get it right for everyone.

Speaker1: [00:16:49] Absolutely. Thank you for that. The other area I wanted to touch upon was the broad issue around mental health. This has come to the fore. I mean, it was there before the pandemic, but the effect of the pandemic on mental health is, in the literature, far and wide. I wanted to focus, in particular, the work that you're doing, because it's part of the manifesto of accelerating the work. Mental health equity and the work that you've done around the access to talking therapies, because this is an initiative that the NHS, I think began back in 2008. It was called Improving Access to Psychological Therapies at that time because it's really, really important. And some of the findings, again, I think should be widely known.

Speaker3: [00:17:31] Absolutely. We commissioned an independent review of the IAPD program and published the report in 2023.

Speaker1: [00:17:44] Are you looking at ten years of data? I think something.

Speaker3: [00:17:46] Yeah, absolutely. We're looking at ten years of data. We were looking at issues around access and experience and of course, outcomes. But the data tells us what we've known for a very long time, the fact that actually particularly black men are less likely to be referred to talking therapies. They're less likely to self-refer, as well. And yet the evidence shows us that actually when they are referred, they have good outcomes. So this makes it even more important for us to get right. What is it that's stopping the referrals or what is it that is leading particularly Black, African and Caribbean men to enter the mental health system through certain routes and not other routes. And so we must focus on these issues and de-bias the policies and the processes that we have. Reforming the Mental Health Act will be one way in which we not only make progress on chipping away at the structural racism that we have that plays out through the operationalisation of the act itself. But in a way it will help support kind of debiasing healthcare more generally, as an example.

Speaker1: [00:19:10] And that's now on the policy commitment from the government, of course, in terms of the Mental Health Act. But going back to the talking therapies, if I may, just there you talked about the idea. I think in summary black and ethnic minorities have poorer access and poorer outcomes. But the truth is, am I right in saying that if the access improves, the outcomes can also then improve?

Speaker3: [00:19:35] That's what the data tells us. The data tells us that actually, once you receive talking therapies, you are just as likely. And in fact, for some groups, no better than the majority population to have outcomes that are that are positive and therefore increasing access is absolutely critical and decreasing or kind of eradicating the barriers to that kind of come up in terms of access is really important.

Speaker1: [00:20:04] And that's going to be a let's look at solutions there a little bit because that I mean, the other point that struck me looking at this is that some of the models, even people who are not familiar with this area, I mean, CBT, for example, cognitive behavioural therapy, some of the models that are offered are very well-intentioned with good outcomes for some people may not be suitable for people from different backgrounds. That's also an interesting finding from the data.

Speaker3: [00:20:30] Absolutely. And we have other resources and guides and toolkits that can help support practitioners on the ground to deliver a more inclusive service, particularly when it comes to CBT. As you mentioned, when it comes to talking therapies, and we need to amplify those tools and those examples of good practice so that we can have a more inclusive service for all.

Speaker1: [00:20:58] And I guess, again, looking at the solutions to moving ahead, that it's not going to happen overnight, but partly will be designing services which are reflect ethnic diversity. But there's also a training issue here and co-designing getting people from lived experience, those backgrounds to be part of the design of the therapies and intervention.

Speaker3: [00:21:19] That's a fundamental principle of the observatory. In fact, we set up a stakeholder engagement group that helps us to co-design and make those decisions not just on our own, but in collaboration With representatives of those that we're here to serve, we are more likely to get, uh, outcomes, interventions that are suitable for everyone if we co-design and co-produce our interventions.

Speaker1: [00:21:49] And I guess this takes us neatly to the next area that I wanted to cover, which you did touch upon in that helpful summary in your manifesto to make the changes in maternal and neonatal services, to make the changes in the talking therapies, in terms of structure and presentation, is all going to require a significant empowerment to leadership and also enhancing accountability amongst the workforce. So that's a big, big topic. And I wanted to touch upon that in this sort of final section of our conversation. Firstly, how important is ethnicity in terms of the NHS workforce? I think the statistics might be slightly out, 26% of the workforce is from a minority background. And if you go to various clinical groups, occupation groups, that dramatically changes.

Speaker3: [00:22:40] Absolutely. And I guess if we're in the business of tackling ethnic inequalities in health and health inequalities in general, which we are, then we need a workforce that's representative of the people that we're here to serve. And that's not always the case at all levels, leadership levels. We know that there is a lot of work to do in order to get that representation at senior levels, and yet we know of the evidence. The evidence tells us that a happy workforce leads to happy patients, and that, in fact, I came across that relationship way back in 2009 when we were developing something called the Equality Delivery System for the NHS, and it was a piece of seminal piece of work carried out by Professor Michael West and Professor Jeremy Dawson. At the time at the they were at the Aston Business School, and they found that direct relationship that, you know, if you look after your staff, you're likely to have better outcomes for your patients. And we asked Michael and Jeremy to repeat that analysis for us again a few years later, which they did with even more data from those two sources, the staff survey and the inpatient survey. And with even more sophisticated data analysis techniques. And they found that that relationship was as strong kind of eight years later than their first report.

Speaker3: [00:24:06] But there's a very, very important line in their report which is kind of pertinent to this topic. They argue that the way an organisation treats its staff and its minority staff in particular, is a good barometer for the overall culture of care within an organisation. And that's really important. We need to make sure that we focus on what our staff survey tells us, what the NHS, workforce, race equality standard data tell us and have been telling us now for many years. The fact is that there are higher levels of discrimination, victimisation, bullying and harassment amongst experienced amongst ethnic minority staff and there is a lack of opportunities with regards to progression at senior levels. So we must focus on getting that right and we must focus on having the accountability to get that right. And that includes perhaps developing a holistic accountability framework that includes very clear objectives for leaders on this topic and holds them to account for delivering on them. But also includes, you know, setting targets which are, you know, which need to happen in a meaningful way, of course. As well as the incentives that need to be associated with this agenda, just as they are with any other critical agenda across the NHS.

Speaker1: [00:25:49] Obviously, the NHS has taken a step in this direction with its publication of its EDI improvement plan early this year, last year to help representation at senior level amongst minorities and other initiatives. But what's interesting about what you say there, Professor Dawson's work, Professor West's work is the long-term workforce plan for the NHS seminal document January 2023. One of its predicates for it to work and deliver is there has to be quite a seismic shift in productivity amongst the workforce. I guess this initiative that you're talking about. Proper representation and equity would play a big part in that.

Speaker3: [00:26:33] Absolutely. And that's exactly what the data and the evidence tell us. In fact, just a few years ago, we asked the King's Fund to carry out a piece of work for us, looking at the relationship between staff engagement and agency staff spend. And we know, for example, that for every increase one standard deviation, increase in staff engagement. So the more that an organisation engages with its staff, a hospital trust can on average save £1.6 million per annum. And that was then. That was kind of six years ago. So getting this agenda right not only saves lives, but can save the NHS money as well. And why wouldn't we want to focus on equity for everyone.

Speaker1: [00:27:19] Including people who are now in a very different labour market than perhaps was in existence? Certainly when I started work, people working flexibly, flexibly in bank and energy agency to be engaged, as you say, correctly.

Speaker3: [00:27:33] Absolutely. And also looking at, I guess, some of the reasons why people do want to work in agency and in bank, rather than having a substantive contract with a organisation or a trust. And some of the work I've done in the past has looked at some of those challenges that organisations have. So making sure that we are able to be flexible in the way that we work, in the way that we offer people leave to go on long haul holidays or holidays or gets, you know, um, you know, going back to their families to visit, to take time off for example, for Ramadan and fasting, and making sure that we are compassionate organisation and employer and making sure that we support all staff with regards to their needs.

Speaker1: [00:28:23] It's a fascinating topic because the level of flexibility of work now, I think is recognised, of course, in the NHS people promise. We've had that. But as you say, quite rightly, Professor Naqvi, people from ethnic minorities are disproportionately represented in agency and there may be a reason for that which relates to the culture changes that need to take place. So I think that's really important work. I wanted to end the conversation, if I may, just to take a broader picture. You've set out some of the manifesto imperatives for the new government. We shall see. Hopefully they will listen very clearly. They're very compelling. And it's just to broaden the view around one of your imperatives at the observatory, which is not just to draw upon work in the UK, but foster international collaboration and share good practice here. Can you just expand upon the international remit of the observatory?

Speaker3: [00:29:13] Sure, yes. One of my key aims for the observatory has always been for it to be a global player. With regards to tackling these issues. Because racial inequality is a global, system wide structural challenge that requires a global, system wide structural response. And we cannot be working on this agenda within our own geographical borders. We need to learn from other societies, other countries on how they're making progress and have that exchange of good practice and replicable good practice with those countries. And that's exactly what we've been doing over the last three years. We were fortunate to have a fantastic twinning relationship with the Center for Disease Control and Prevention in the US on the back of the then G7 summit. And we've also established a fantastic international experts group with race and health experts from as wide as Australia and New Zealand, South Africa, Guatemala, Canada and the US. And of course, from here in the UK, coming together as we do to think about what is it in maternal health that's working in New Zealand with the indigenous population? Or what is it that you know is working well in Canada with regards to mental health and the ethnic minority communities that we can learn from and vice versa? So it's about how we can bring together good practice, exchange of ideas, data and evidence in order to progress on this journey as we're moving forward, and not just to highlight the scale of the challenge, but to come up with solutions to those challenges as well.

Speaker1: [00:30:58] And I think that allows all systems to actually learn from each other and actually be able to be a beacon of hope for this nation and the wider nations. One very final point. You've had your funding extended to 2027. You've been in these type of roles for a long time. You must be very proud of the work you're doing at any particular priorities that are coming up for you in terms of your work over the next couple of years. I mean, you cover so much.

Speaker3: [00:31:27] Well, health and equalities is a long term mission to get that right, isn't it? And 2027 is only around the corner. We need sustainability from the system to focus on this agenda for the longer term. In order for us to make those sustainable changes. And we've got a fantastic programme of work, um, which is looking at as I mentioned before, the causes of the causes with regards to mental health, with regards to sickle cell disease, with regards to maternal and neonatal outcomes. Looking at education, looking at the global, aspects of all of this as we come together. And I'm excited about the future. I'm excited about what we can do together within this country and beyond this country to make a real and meaningful difference to some of the most vulnerable people, patients and healthcare staff in our country.

Speaker1: [00:32:26] And one of your goals is obviously to empower vulnerable communities. And you've talked we've talked about race equality here. It sits within this bigger picture around all health inequalities and tackling them. And of course, you know of course, you know, Professor Marmot and the seminal work that he's done. I guess your work and the observatory's work plays a key role in turning the dial on those bigger determinants.

Speaker3: [00:32:49] Absolutely. And one of the fundamental principles that we observed, I guess, so vividly through the Covid years has been the concept of trust and trust with our communities and the trust or the lack of trust that our communities have in systems and organisations and structures. There is, I guess we're probably at a crossroad now where we need to build and rebuild levels of trust with our communities. And trust is about truth told consistently over time. And we need to begin to tell the truth around some of the inequalities, some of the causes of the causes, and begin to work upon those with our communities in order to focus on those determinants, those determinants of health in a more sustained and meaningful way.

Speaker1: [00:33:43] On that note of hope, Professor Habib Naqvi, thank you very much for your time and for your passion.

Speaker3: [00:33:48] Thank you so much.

Speaker1: [00:33:49] My pleasure. If you've enjoyed this episode of Voices of Care, please like, follow or subscribe wherever you receive your podcasts. And if you want to learn more about how we're turning the dial on health and social care debate, please visit newcrosshealthcare.com/voicesofcare. In the meantime, I'm Suhail Mirza, thank you very much and I look forward to seeing you on the next episode.

Speaker2: [00:34:08] Voices of Care, the healthcare podcast.