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Interview: ‘The NHS is dependent on medical migration’

Interview: ‘The NHS is dependent on medical migration’
By vfiore
11 April 2018

An OBE is awarded to a small number of people. Even smaller are those who decide to reject the award – Professor Aneez Esmail is one of them.


Despite being professor of general practice at the University of Manchester and director of the National Institute of Health Research (NIHR) Manchester Patient Safety Translational Research Centre (PSTRC), Prof Esmail still finds the time to work as a GP at the Robert Darbishire Practice in Rusholme, Manchester.


An OBE is awarded to a small number of people. Even smaller are those who decide to reject the award – Professor Aneez Esmail is one of them.


Despite being professor of general practice at the University of Manchester and director of the National Institute of Health Research (NIHR) Manchester Patient Safety Translational Research Centre (PSTRC), Prof Esmail still finds the time to work as a GP at the Robert Darbishire Practice in Rusholme, Manchester.


Back in 1993, he started his research into the issue of racial discrimination in the NHS. Together with his colleague Dr Sam Everington, he published a study called ‘Racial discrimination against doctors from ethnic minorities’, through which he exposed shortlisting discrimination against ethnic minority doctors who trained in the UK.


The study included the creation of a CV for six applicants, three with Asian names and three with English names. Despite being arrested for making fraudulent applications (with the charges later dropped), they did not desist and exposed the barriers that were preventing Asian candidates from being shortlisted.


Prof Esmail is nationally acclaimed for his work on racial discrimination, but he believes there is still a lot to do in this area.


What progress has been made on racism in the NHS over the past 25 years?


When I did the study, there was a problem I faced in that I was never shortlisted for a job. I remember working in the NHS at that time and there were very few consultants who were from ethnic minorities. When I was in medical school, I never had a single ethnic minority professor. But if you look at it now, the NHS is totally different.


We have hundreds if not thousands of consultants in all fields who are from ethnic minorities. I don’t think if we did the same study now we would find that there would be a problem of ethnic minorities being shortlisted in the way that I was having difficulty getting shortlisted. So, of course, we have made progress.


The Workforce Race Equality Standard (WRES) demonstrated that black and minority ethnic (BME) background leadership positions are still not proportionate to the number of BME workers at other levels in the organisation. How can this problem be overcome?


To think that the problem of racism has gone away is wrong. I think it’s shifted.


If you look at NHS clinical academics, for example, there are far fewer professors who are from ethnic minorities than there should be. So you look at my university, and although 40% of the lecturers in any field in medicine would probably be from an ethnic minority you won’t get that number anywhere near who are professors. It probably is about 6% or 7%at the moment. So I think that there are still these differences in hierarchy. When you look at the NHS and at how many medical directors are of ethnic minorities, they’re very few and you would expect more from ethnic minorities. If you ask how many people from ethnic minorities work in senior levels in the NHS, you would find they are a minority. I am referring to NHS management positions, such as chief executives. We are a totally different country, we’re a totally different system, and that is a good thing.


Do you think that the introduction of the WRES has helped improve this situation?


We have to think that the WRES has only been going for two years. Therefore, we shouldn’t give it too much credit. The most important thing about the WRES is that it became a mandate; a requirement. It is the first time in the history of the NHS.


What is WRES doing? It is asking the NHS to actually report on and do something about the information you have on what happens to ethnic minorities. For example, it is looking at the issue of bullying and harassment. When we first set it up, I remember the first conversation I had about it with [NHS England chief executive] Simon Stevens, who I met together with my colleague Roger Kline. It was very clear that he was committed to doing something about it, and we argued that unless we had some sort of mandate we would just be going in the same old way again and again.


I think he recognised that and acted up on his leadership to push for the development of the WRES. Now we have to wait and see how it works out – but I’m confident that, if it sticks to its original purpose, it will have an impact.


Do you think it could improve the challenges ethnic minorities currently face to hold leadership positions within the NHS?


I hope so because that’s one of the areas we’re going to look at. So one of the metrics, for example, was to look at how many posts are being shortlisted at grade eight and nine. I could just use the same thing in my university. When I was involved in doing something at the university at a management level, one of the areas we looked at was how many professors who were women or from ethnic minorities were being appointed. We were looking at their promotion processes, and if we were finding that women weren’t being appointed at professor level, we would go back to the heads to ask why. They would justify themselves by saying that there were not enough women, for instance.


We would then ask what they were doing to favour access to professorship for women. So when you begin to have that conversation, you force people to actually confront the problem. If that process happens in the NHS it will be inevitable that things will change and more people will apply. It’s not going to happen overnight, but you need to see progress. One of the good things is that we are working very closely in the WRES with the CQC [Care Quality Commission].This means that when they go around inspecting, they want to see data proving how well the institution they are visiting is doing on equality, to decide whether they deserve a ‘well led’, which is one of their criteria. We managed to get the CQC to ask more pertinent questions about the issue of equality. There is some really good talent out there who could do a huge amount for the NHS, and if they are denied an opportunity, they will never be able to shine and the service will suffer.


Can you describe the current state of the NHS? Do you think it needs to be reformed?


I really fear the word reform. I have worked in the NHS for well over 35 years now and I have seen huge numbers of reforms. It’s almost a déjà vu that I would call ‘the British disease’. I am sick of reform actually at any level whether it’s in higher education or in the NHS.


Let’s take the case of Manchester. When I arrived in Manchester, we used to have the family health services, health authority, and district health authorities. Then the internal market came in, and we rejuggled things, and people had to re-apply for their jobs. Later, we created a regional health authority that became a strategic health authority. We went back to a Greater Manchester health authority. Then we transitioned to much lower down to the CCGs and then we went up again. When the media is saying, ‘Is this the beginning of the end for CCGs?’ I suddenly think that we need some strategic thing. I think the NHS is far too centralised. Now that’s good for general taxation, and I’m not one of these people who believes there should be no politics in the NHS. The NHS and health is a deeply political issue, and I think it’s really important that politicians are involved. I would despair if politics came out of the NHS, because health inequalities are because of politics. The funding is because of politics, and we cannot have a system where we just say we want more and more money. So it is a deeply political thing. But at the same time, we have a situation where there is too much central control, because in our country the regional level is not well developed, and local politics is not as great as it should be. That does not mean that we shouldn’t have more politicians involved at a local level, for example. I would love to see a situation where the people of Greater Manchester and the politicians of Greater Manchester had a say on how to run themselves in Greater Manchester. It is not right that only doctors or nurses or others know how best to run the NHS. Developments like CCGs were good, but again it just became too bureaucratic. In Manchester, we used to have three CCGs; now we’re coming back to one. Then someone’s going to say well actually shall we just call it strategic health authority again, or some other name. So I despair. I don’t think the NHSimpacted on by ill health and so on, but the solution is not just in more tests, in more hospital appointments and in hospital treatment. The solution might be in helping people cope with what they’re doing in their own home, with someone like the GP and the practice team being central to that process. I feel that for too long we have pushed more and more into hospitals. I don’t deny we need specialists to work with it, but I conceive specialists as ‘partialists’ and not specialists, because they know a lot about something very narrow and very small, which can be very important at times. But in terms of how patients live their lives, how they come to terms with illness and suffering, that needs a holistic approach. And I think general practice is best placed to deliver that.


If you could have a second meeting with Simon Stevens, what would you ask him to do?


There are two things in particular.


I think our out-of-hours system is just nonsense. It’s all fragmented. You have walk-in centres, you go to A&E, you have the ambulance staff coming and then we have the arguments about who holds the records. Our technology allows us to have the records. Therefore, the logical thing is for the specialist in family medicine to be doing that, because usually the problems that people suffer with on a day-to-day basis tend to be managed by the specialist in family medicine, or the general practitioner, and it doesn’t all have to go to the A&E department. A book called ‘A Fortunate Man’, by art critic John Burger, describes the GP as a chronicler of a patient’s life. But I think our fragmentation of care has changed that, and it’s a great pity, really. We can create systems which enable more of that to happen rather than just send them off to the ‘partialist’, who sends them off to another ‘partialist’. We need to change GPs and give them confidence to deal with more complex cases. We need to stop haranguing them about everything they do is unsafe and only the specialists can deal with it, and if you’re in doubt refer it and so on.


The other thing I would ask him is to do more about our chronic elderly. I’m struck by how much of elderly care we have forfeited in general practice. I think that we need to be able to do more about a group of people who aren’t just a health problem and we need the skills of a GP to be able to look after them better.


How do you think hard Brexit will affect the quality of care provided in GP practices?


We have recently published a paper on this a few months ago, suggesting that there is a problem. If you look at deprived areas, they have the highest proportion of doctors who are from the EU or international medical graduates. The NHS is dependent on medical immigration to make it function, both from Europe, the sub-continent, and former-areas of the Commonwealth. I think that a hard Brexit would have an impact on general practice because it’s going to put quite strict immigration controls, but it will not only have an impact on EU doctors. I fear what could happen if foreign GPs working in deprived areas start thinking, ‘What’s the point?’ And they will leave those areas, with no one stepping up to replace them. British graduates aren’t incentivised to go work there, as they’d rather be in a nice inner-city area, or a nice suburb near to the theatre. I think it is definitely the case that we are a national health service, but we are also an international health service. We are unusual. The NHS is probably the largest employer of ethnic minorities, and many of the ethnic minorities come from abroad. It is the way the NHS has chosen to function, and I fear for its future if we go down that route.


Back in 2002, you were offered but declined an OBE for your contribution to primary care and race relations. Why did you decline it?


I believe that firstly, healthcare is a team effort. I don’t think it’s about an individual and I don’t think it’s right that we recognise just individual merit. I think there’s clearly some people who do a huge amount of work, they are unique individuals and we should acknowledge and recognise them. But I always felt that, firstly, I was doing my job. They wanted to award it to me for improving race relations and for primary care but I believe that it is my job to improve primary care. If my team got the OBE I would have said, ‘Yeah, I’ll be part of that.’ But that wasn’t the system. I think we should recognise teams, we should recognise excellence and everything else.


Last year, you won The Pulse General Practice Lifetime Achievement Award. What did this mean to you?


I was really humbled about it. I do feel that it’s a great accolade, and I’m really proud of it, because it’s given by your peers. I feel it’s a great recognition by my colleagues and my peers who mean a lot to me. You succeed for many reasons, and very critical to my success is my family really. Without my family’s support I could not have achieved what I achieved and it allows me to acknowledge that. My mother, she came here as a single parent, as a refugee, and that was really important. The negative is that I’m not finished yet. I’m glad I got a lifetime achievement award but I have many more years of life to fight for this great NHS of ours.


Valeria Fiore is a reporter at Healthcare Leader


Picture credit: Neil O’Conner 

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