Misogyny and racial prejudice routinely put patients in England at risk, NHS safety chief warns
Deep-seated medical misogyny and racist prejudice routinely put people in need of treatment at risk, the UK’s patient safety commissioner has warned.
Dr. Henrietta Hughes was appointed in 2022 in response to a series of women’s health scandals. She outlined a “vast landscape” of biases that need to be leveled, citing examples ranging from neonatal assessment tools and pulse oximeters that work less well on darker skin tones, to heart valves, mesh implants and replacement hip joints that are not designed for female patients . mind.
Hughes said: “I don’t see this as blaming individual healthcare professionals – doctors and nurses – for being wrong. It’s ubiquitous in the systems we have: the training, the experience, the resources.
“Anatomy books have a very narrow focus. Even the CPR models are of pale men – we don’t have female CPR models, we don’t have them in darker skin tones. This is deeply ingrained in the way we assess and listen to patients.”
Hughes was appointed in 2022, with a focus on improving the safety of medicines and devices, in response to the Cumberlege review on vaginal mesh, a hormonal pregnancy test and an anti-seizure drug harming unborn babies. The review painted a damning picture in which women’s concerns were consistently dismissed, leading to avoidable harm.
Hughes said positive progress is being made in providing specialist care for victims of complications from vaginal mesh procedures and welcomed the tightening of the prescribing rules for the anti-epilepsy drug sodium valproate, which came into effect in January.
However, she said systemic bias continues to negatively impact outcomes for female and ethnic minority patients.
She described the realization that pulse oximeters, used to measure blood oxygen levels, work less well on darker skin tones as a “real shock to the system” when the problem was highlighted during the pandemic. More recently the NHS Race and Health observatory concerns emphasized around neonatal assessments.
Bilirubinometers, which are commonly used to assess jaundice in newborn babies, are less reliable for darker skin tones and some guidelines for assessing cyanosis (caused by a lack of oxygen in the blood) refer to a “pink”, “blue” or “pale” skin, without reference to skin changes in babies from ethnic minority groups. The Apgar score, a rapid test given to newborns that was first introduced in the 1950s, traditionally involves checking whether a baby is “all pink.”
“Even the names of these conditions – jaundice and cyanosis – suggest a color. The Apgar score includes the P for pink throughout,” said Hughes. “There are systemic biases in the sense that if you have a darker skin tone, these conditions may not be as obvious.”
Hughes said the development and testing of devices and drugs must accommodate a more diverse patient population. Mesh implants, initially used for hernia repairs, were not originally intended for the female pelvis.
She said: “It was never designed to be used primarily in a woman’s pelvis. It is designed for vertical use. With horizontal use you have movement, weight gain, weight loss, the menstrual cycle – the physical impact on the mesh itself and the secondary impact on tissues.”
Hughes cited evidence that heart valves, most of which have been tested more extensively in male patients, may have less successful results in women, whose hearts are smaller on average. And doctors don’t always discuss the risks related to hip joints that specifically affect female patients, she said.
“There are certain sexual positions that can negatively impact the success of a hip joint, but it’s a difficult conversation… that orthopedic surgeons may not particularly want to have,” Hughes said. “It’s a cultural issue.”
Medical textbooks, image libraries and training aids also need to be made more diverse, Hughes said, noting that people are less likely to practice CPR on women, in part because first aid courses typically use male pacifiers.
She said: “They don’t have the experience to figure out where to put their hands because the dolls are all male. It affects people’s trust, experience and normalization.”
Black babies in England are almost three times more likely to die than white babies, according to figures from last year. The mortality rate for white babies has remained at around three per 1,000 live births since 2020, but for black and black British babies it has risen from just under six to almost nine per 1,000. the National Infant Mortality Database.
Hughes said that despite the significant challenges, there were positive signs of progress. She said there is a growing movement toward publishing demographic data from clinical trials and post-marketing surveillance to assess whether devices work equally well for all groups. There are also good examples of design diversification, she said, such as a project at Barts NHS Trust to use CT scans of women’s hearts in a virtual design environment to design heart valves.
Professor Habib Naqvi, CEO of the NHS Race and Health Observatory, which reviewed neonatal assessments, said the recommendations had been taken seriously and steps had been taken to address concerns, including changes to NHS England guidance, and that he is generally “optimistic. ‘ about the changes that are taking place.
He said: “The disproportionate impact (of Covid-19) on ethnic minority communities and staff has been significant. During Covid, we heard very clearly that we will need to focus on addressing ethnic and racial disparities in health care.
“Now we are at that crossroads. We must ensure that these promises and declarations are fulfilled.”