Tackling racism: moving beyond rhetoric to turn theory into practice

Racism and health

Racism draws on an ideology where physical difference is linked to cultural and social difference. This allows ethnic groups to be identified and to be given meaning and value—a process described as racialisation.7 Racialisation has its origins in historically determined, but ongoing, systems of domination that allow for the subordination, marginalisation, and exclusion of those considered to be inferior.89 Inequalities that are consequent to these processes do not arise from the inherent properties of ethnic groupings; rather, they are a result of historically embedded and culturally and politically shaped meanings ascribed to ethnic identities.

A full understanding of ethnic inequalities therefore requires understanding of the ways in which identities are racialised and how racism consequently affects the lives of ethnic minority people. To achieve this, it is useful to consider how racism operates through three broad and closely related processes: structural racism, interpersonal experiences of racism, and institutional racism.10

Structural racism leads to disadvantage in accessing economic, political, physical, and social resources.11 It also has ideological dimensions that involve the denigration of ethnic minority groups, which serves to rationalise this uneven distribution of resources.9 Within the UK there are deep rooted ethnic inequalities across almost all socioeconomic dimensions—income, employment, residential location, housing, and education. These have persisted both over time and across generations121314 despite the introduction of equality legislation, which has been in place in the UK for more than 50 years.15

Interpersonal racism (ranging from discrimination, to everyday slights, to verbal and physical aggression) is a form of violence that emphasises the devalued and fundamentally insecure status of those who are targeted and those who have similarly racialised identities. Such experiences emphasise the denigrated aspects of racialised identities.916 Research shows the centrality of interpersonal experiences of racism and discrimination to the lives of ethnic minority people, impacting across life courses and on health.17 Importantly, studies show that levels of racial prejudice and experiences of racism and discrimination have not changed meaningfully over time.181920

Institutional racism refers to how the norms, policies, and practices of institutions negatively shape the experiences of members of racialised groups within them.21 Institutional settings provide a context within which structural forms of disadvantage and interpersonal racism are concentrated and amplified.92223 The outcomes of institutional racism can be seen through ethnic minority people having a higher likelihood of more negative pathways through care, poorer access to effective services and interventions, and poorer outcomes. This is present in education, health and social care, housing, arts and culture, politics, criminal justice, and mental health.12

The stark ethnic inequalities seen in the impact of the coronavirus pandemic, along with the murder of George Floyd and the subsequent resurgence of the Black Lives Matter movement, have raised awareness of the substantial ethnic inequalities across social, public, and private institutions in the UK. Questions have been asked about everything from deaths in custody, unequal health outcomes, and failures of education systems, to the ways in which histories of colonisation, slavery, and empire are embedded in our cultures and celebrated by our monuments and in the commemorations of our history. Indeed, numerous private, public, and governmental organisations have made public statements in support of race equality. However, the lack of a robust framework to understand ethnic inequality has resulted in little concrete action, with policy continuing to focus ineffectively on proximal and intermediate factors.

The need to focus on institutions

So how might we rethink our approach to addressing racism? The central place of institutions in bringing together and amplifying structural and interpersonal racism, and making them more salient through the provision of services that shape our lives, suggests a policy agenda focused on disrupting the ways in which inter-related institutions produce and reproduce ethnic hierarchies and consequent inequalities. As major employers and providers of essential services, public sector “anchor” institutions show why this focus is important and how it might work.

In 2021, the NHS directly employed 1.38 million people, 22.4% of whom do not classify themselves as a member of a white ethnic group. This is a higher proportion than the 13% average across all employers.24 Other public sector bodies employ many more staff, again typically with an over-representation of ethnic minority people. Public sector bodies also subcontract services from a large and diverse range of private employers, which they can directly influence through the contracting process. The public sector therefore has great potential to drive local and national employment conditions. This presents an opportunity to implement positive and equitable employment practices—for example, in relation to annual leave, sickness absence, study leave, maternity leave, job security, job flexibility, guaranteed hours, limits to unpaid overtime, promoting autonomy and control, and, importantly, pension rights. The people likely to get the most benefit from these changes are those on lower employment grades and with more precarious employment conditions, groups with an over-representation of ethnic minority workers.

Public sector employers could also rethink their institutional structures and practices to reduce ethnic inequalities within their workforces. This could involve developing inclusive recruitment and retention strategies to achieve diverse representation throughout the workforce, understanding and addressing ethnic pay gaps and inequalities in career progression, actively embedding inclusive work cultures, and nurturing the next generation of ethnic minority leaders. In effect, this means lessening the effects of institutional racism on the workforce.

Approaches to institutional reform should also consider how institutional racism negatively affects the outcomes and experiences of service users. This requires fundamentally challenging the focus and actions of institutions and will be extremely difficult to achieve unless leaders are willing to rethink how the services they provide, and how they are provided, relate to the generation and maintenance of racial injustice. The decolonisation agenda provides the tools to do this as it requires us to reflect critically on how historically informed ideologies around race not only shaped the functions and actions of institutions in the past, but continue to do so in terms of who is valued, what forms of knowledge and understanding are recognised, how outcomes are prioritised, and how the history of the institution is commemorated and critiqued.2526 This requires work across a full range of institutions, including professional bodies, politics, and government. However, it is most important to recognise that this cannot be done in isolation. Placing those with lived experience at the centre of this redesign work will be crucial to success.