Ethnic monitoring and equity

Collecting data is just the beginning

From this month collecting data on ethnic group from all patients admitted to NHS hospitals will be routine.1 This ethnic monitoring is intended to enable the NHS to provide services without racial or ethnic discrimination. Currently, the use the delivery of services vary on these grounds, with or without intent,2 which hinders the achievement of equity in the NHS.3

Several recent papers in the BMJ have shown that levels of need or use of services may differ between ethnic groups.4 5 6 Two papers in this week's journal also show the potential of properly conducted ethnic monitoring. One paper, identifying ethnic group on the basis of name, shows excessive referrals of Asian patients for gastroenterological investigation with no apparent clinical justification (p 910).7 This finding was replicated in a different region when a different method of categorisation was used (p 909).8 More detailed information could begin to cast light on the reasons for this.

For other conditions and procedures, systematic monitoring of all users might identify the existence of underuse when profiles of users are compared with those of the population in the area. Collecting information on language and religion, while not formally required, could be valuable to providers of services, allowing greater efficiency in the provision of hospital meals, interpreting services, and spiritual support and in improving preventive interventions.9 10 Several purchasing authorities (Coventry, Birmingham, Ealing) have announced their intention to require these data.

Yet the introduction of ethnic monitoring has been much resisted; some people believe that collecting data might itself be discriminatory. After much debate the “ethnic group question” was excluded from the 1981 census—but not asking the question did not prevent discrimination.11 Within the NHS, discussion has focused on the definitions of “ethnic group” and “race” and the difficulty of asking people to which ethnic group they belong.12

Concerns have been raised about the security and confidentiality of data.1 The NHS Executive, and those who have extensively tested the monitoring procedures, believe that these difficulties are overstated and can be overcome.13 Statistics on race and ethnic group have been collected in Britain for various purposes since the second world war, and their use in the criminal justice system and social services has shown measurable benefits.14 The NHS is used to handling personal data and there have been no objections to including a question on ethnic group in the patient held antenatal records used in the west midlands.

In the United States the collection of data on race is well established and used extensively for epidemiological, clinical, and planning purposes.15 The term race, however, carries connotations of genetic determinism and possibly of relative value, and the current consensus is that the term has no scientific value.16 Ethnic group, the preferred replacement, is a complex academic and legal construct containing elements of culture, geography, ancestry, religion, and history. It is also usually a shorthand term for people sharing a distinctive physical appearance (skin colour) with ancestral origins in Asia, Africa, or the Caribbean. Furthermore, it permits people to assert their own identity, which is in keeping with the new patient centred approach of the NHS.

The question on ethnic group in the 1991 census laid the foundation for ethnic monitoring and provided a baseline against which all other statistics could be measured. Most providers and purchasers will base their questions on the major census groups—white; black Caribbean; black African; black other; Indian; Pakistani; Bangladeshi; Chinese; and other. These may need to be supplemented by other locally important groups (for example, Yemeni or Vietnamese). Guidance from the NHS Executive should help to maintain national consistency and comparability.1

Everyone is a member of (or can claim membership of) an ethnic group, and the ethnic question is for everyone. The proposed monitoring may not meet the needs of all researchers, but a standardised and commonly agreed set of categories is necessary.

Several health authorities have established mechanisms and training for routinely collecting data on ethnic group,10 17 18 and the NHS Ethnic Health Unit is sponsoring development work in primary care along the lines suggested by Health.19 Training in ethnic monitoring gives staff a greater understanding of their role in a multiracial or multicultural society.10 13 Implementing proper ethnic monitoring, after adequate consultation with the community and training of staff, improves relations with clients and customers and the delivery of services.10 13 18 Delay in implementation will result in scepticism among members of ethnic minorities regarding the intentions of the health service towards their needs. We look forward to the replacement of the uncertain results from limited surveys with clear indications of true patterns of ethnic diversity in use and need, which only proper monitoring can provide.20