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As a long-term advocate of Ethnic Record Keeping and Monitoring (I
wrote an editorial with Paramjit Gill in 1995: 'Ethnic monitoring and
equity: Collecting data is just the beginning' BMJ 310 :890.) I was
interested to read the editorial by Pollock and King (21 March BMJ 2009;
338 :b357) highlighting the value of data from obstetric surveillance
systems, as displayed in the linked article by Knight & colleagues
from UKOSS (BMJ 338 :b542).
We have know for a long time that ethnicity (or membership of a
minority 'ethnic group') is a marker of poor health outcomes, and a
diversity of inequalities, and recognise that it is not only a complex
variable in its own right (as I explore in an article on the NHS Library
site of the Specialist Library for Ethnicity & Health: www.library.nhs.uk/ethnicity ) but also that it is correlated with many
other deprivation factors. Correlation is not, of course, causation, and
we need to collect and examine such data carefully at the finest level
available, to identify the salient elements and effects. Religion,
culture, family structures, location of communities, language and other
issues are all important. As also are the responses and knowledge or
skills of the health care teams and their 'cultural competence'.
There are two problems. One is (as suggested by the authors) that we
do not ask enough questions. For example, we cannot disaggregate the
'migrant' effect by asking about citizenship status, length or residence
etc. The other problem is that asking these questions is not a trivial
task. It risks not merely controversy but also unwanted effects that
themselves may create or worsen inequalities. For instance, many practice
staff are hard pressed and may even resent having to ask 'ethnicity'
questions of all their users - and the 'majority' users may feel that they
are being marginalised or misunderstand the reasons for the questioning:
forgetting that we ALL have an ethnic identity, which needs to be taken
into account. However, NHS record systems are not good enough to ensure
that one can 'ask once and not again'.
The Department of Health has taken some steps to include incentives
for ethnicity data collection in its Quality Outcomes Framework and
Directed Enhanced Schemes, but this will not alone create the database
that the NHS needs nor answer all the technical and organisational
problems that exist. I and colleagues from all over Europe will be
debating some of these issues at a forthcoming meeting of the EU 'COST'
(Commttee on Science and Technology) Action IS0603 "HOME" (Health of
Migrants in Europe)workshop in Utrecht after Easter, and hopefully we may
be able to work towards some solutions and better understanding at a
European level as well as appreciating the insights and support from
Australia offered by Pollock and King.
Making Ethnicity Count
As a long-term advocate of Ethnic Record Keeping and Monitoring (I
wrote an editorial with Paramjit Gill in 1995: 'Ethnic monitoring and
equity: Collecting data is just the beginning' BMJ 310 :890.) I was
interested to read the editorial by Pollock and King (21 March BMJ 2009;
338 :b357) highlighting the value of data from obstetric surveillance
systems, as displayed in the linked article by Knight & colleagues
from UKOSS (BMJ 338 :b542).
We have know for a long time that ethnicity (or membership of a
minority 'ethnic group') is a marker of poor health outcomes, and a
diversity of inequalities, and recognise that it is not only a complex
variable in its own right (as I explore in an article on the NHS Library
site of the Specialist Library for Ethnicity & Health:
www.library.nhs.uk/ethnicity ) but also that it is correlated with many
other deprivation factors. Correlation is not, of course, causation, and
we need to collect and examine such data carefully at the finest level
available, to identify the salient elements and effects. Religion,
culture, family structures, location of communities, language and other
issues are all important. As also are the responses and knowledge or
skills of the health care teams and their 'cultural competence'.
There are two problems. One is (as suggested by the authors) that we
do not ask enough questions. For example, we cannot disaggregate the
'migrant' effect by asking about citizenship status, length or residence
etc. The other problem is that asking these questions is not a trivial
task. It risks not merely controversy but also unwanted effects that
themselves may create or worsen inequalities. For instance, many practice
staff are hard pressed and may even resent having to ask 'ethnicity'
questions of all their users - and the 'majority' users may feel that they
are being marginalised or misunderstand the reasons for the questioning:
forgetting that we ALL have an ethnic identity, which needs to be taken
into account. However, NHS record systems are not good enough to ensure
that one can 'ask once and not again'.
The Department of Health has taken some steps to include incentives
for ethnicity data collection in its Quality Outcomes Framework and
Directed Enhanced Schemes, but this will not alone create the database
that the NHS needs nor answer all the technical and organisational
problems that exist. I and colleagues from all over Europe will be
debating some of these issues at a forthcoming meeting of the EU 'COST'
(Commttee on Science and Technology) Action IS0603 "HOME" (Health of
Migrants in Europe)workshop in Utrecht after Easter, and hopefully we may
be able to work towards some solutions and better understanding at a
European level as well as appreciating the insights and support from
Australia offered by Pollock and King.
Competing interests:
None declared
Competing interests: No competing interests