Recording Quality Ethnicity Data - PRIMIS

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              Recording Quality Ethnicity

                        Dr Kambiz Boomla
                  Queen Mary University of London

Fifth Annual Conference 11 – 12 May 2005
Piecing Together the Future
    Recording Quality
     Ethnicity Data
Dr Kambiz Boomla
Senior Lecturer
Centre for General Practice & Primary Care
Queen Mary University of London
Content of presentation

• policy background and legislation
• racism direct and institutional/the
  McPherson report
• local contexts and targets
• why record ethnicity
• group exercise
• how to record
The policy context – why collect
ethnic category information?
• The Race Relation Amendment Act
• The NHS Plan
• NHS workforce
• To track changes in morbidity and
• Improving public health by developing
  services appropriate to the needs of
  different ethnic minorities
 Why we have to do this:

• Race Relations Act 1976 says:
• Direct racial discrimination is treating a person
    less favourably than another on the grounds of
•   Indirect racial discrimination means applying a
    requirement or condition which although applies
    to all, can only be met and benefited by a
    considerably smaller proportion of a minority
    group and cannot be justified other than on
    racial grounds
The Race Relations (Amendment)
Act 2000
• Came into force on 1st April 2001
• Duty on all public bodies including GP practices
    to promote race equality and have due regard to
    race equality in carrying out their functions
•   Extends the provision of the act to cover indirect
    discrimination (failure to provide equitable
    services to black and minority ethnic groups)
•   Places a statutory duty on the public services to
    eliminate unlawful racial discrimination and to
    consider the race equality implications in all of
    the policies that shape their operations
The Human Rights Act 2000

• Prohibits inhuman and degrading
  treatment and prohibits discrimination
• Likely to apply to inability of patients in
  the health service to communicate
  effectively with practitioners, or to do so
  in inappropriate ways, e.g. using children
  to interpret during a consultation
 Direct discrimination/direct racism

• Refusal to provide a service (Section 20 of
  the race relations Act 1976) makes it unlawful
  for anyone concerned with the provision of
  healthcare services to discriminate on racial
  grounds by refusing or deliberately omitting to
  provide the services; or as regards quality; or
  the manner in which, or the terms on which,
  they are provided.
Institutional racism and the
McPherson report
• ‘The collective failure of an organisation to
    provide a proper service to people because of
    their colour, culture or ethnic origin.
•   It can be seen or detected in processes,
    attitudes and behaviour which amounts to
•   This is through unwitting pressure, ignorance,
    thoughtlessness and stereotyping which
    disadvantage minority ethnic people.’
Questions arising from the
Macpherson report
• Are we acting fairly?
• Does the service we provide reach all the
  communities it’s meant for and does it meet
  their needs?
• Are we providing the same professional standard
  in every situation?
Topical example: death of Rocky
Bennett in psychiatric unit
• Sir John Blofeld’s report:
    – “The views of our witnesses were unanimous, institutional
      racism is present throughout the NHS. Final responsibility lies
      fairly and squarely with the Department of Health”
    – Staff themselves not racist, and were found kind, taking Rocky
      to football matches, but were unaware of the “corrosive and
      cumulative effect of racist abuse on a black patient”, seeing
      black patients as “more aggressive, alarming and difficult to
• Out of 100,000 black people, 28 end up in secure units
• Out of 100,000 white people, only 4 end up in secure
•   Without ethnic monitoring, these figures cannot be
    revealed and explanations cannot be sought
Local contexts
• By November 2003 each PCT meant to have
 Ethnic Monitoring Action Plan
  – Identify various pilot projects and
  – Have a robust and extensive staff training
    plan based on DH “Ethnic Monitoring Training
       and follow link at bottom of this page

     • Clear objectives set for use of information within
       service planning and delivery
targets, targets, targets – east
• by March 2004, 50% of all directly
  provided and GP practices must reach
  75% valid ethnic coding – not met
• by March 2005, 100% of practices must
  reach 75% valid ethnic coding – not met
• by March 2006, 100% of practices must
  reach 95% valid ethnic coding
House of Lords definition of ethnic
Essential features
• A long shared history
• A common cultural tradition

In addition, some of the following may be present:
• A common geographical origin from a small number of
  common ancestors
• A common language
• A common literature
• A common religion
How ethnicity differs from
culture and race
             Characteristics           Determined by..

 Ethnicity   Refers to aspects of      Group identity, social
             shared history,           pressures from the
             language and culture,     group linked with a
             a group identity          psychological need to
             defined from within       belong
 Culture     Ideas, beliefs, values,   Social experiences
             knowledge,                and education
             behaviour, attitude,      through upbringing
             traditions shared by a    and choice
 Race        Visible physical          Genetic ancestry
Inequalities in health
• 46% increased CHD mortality in South Asian
•   110% increased of CVA mortality in African-
    Caribbean women
•   Suicide amongst young South Asian women
    300% greater than majority population
•   300% increased prevalence of, and mortality
    from Diabetes in Asian population
But -

• Above view also present ethnic minorities
  as the disadvantaged problem ethnicities
• Many disease more common in whites
  – Breast cancer and some other cancers
Why keep records of a patient’s
ethnic group?

We want to ensure that we are providing an
 appropriate and accessible service for the whole
 of the community

By …

   • Assessing who is using the service now

   • Identifying the health needs and patterns
       of illness among all ethnic groups

   • Highlighting any gaps in service provision

  • Measuring the outcome of the service
      response to these highlighted gaps

  • Developing staff awareness of, and response
      to, the individual needs of different ethnic
Equality vs equity in service
• Providing a service that treats everyone equally
    assumes everyone is the same
•   Equity in service provision means delivering a
    service that recognises, respects and meets the
    needs of the individual
•   Providing an equitable service is not about
    giving people the same service, it is about them
    receiving a comparable service that meets their
Ethnic monitoring categories
(1991 Census)
       0   White                9S1

       1   Black Caribbean      9S2

       2   Black African        9S3

       3   Black – other        9S4

       4   Indian               9S6

       5   Pakistani            9S7

       6   Bangladeshi          9S8

       7   Chinese              9S9

       8   Other ethnic group   9SJ

       9   Did not answer       9SD
Ethnic monitoring categories
(2001 Census) 16 + 1
     White                    British                      A   9i0
                              Irish                        B   9i1
                              Any other White background   C   9i2
     Mixed                    White and Black Caribbean    D   9i3
                              White and Black African      E   9i4
                              White and Asian              F   9i5
                              Any other mixed background   G   9i6
     Asian or Asian British   Indian                       H   9i7
                              Pakistani                    J   9i8

                              Bangladeshi                  K   9i9
                              Any other Asian background   L   9iA
     Black or Black British   Caribbean                    M   9iB
                              African                      N   9iC
                              Any other Black background   P   9iD
     Other ethnic groups      Chinese                      R   9iE
                              Any other ethnic group       S   9iF
     Not stated               Not stated                   Z   9iG
Code conversions
Some but not all of the 9S codes can safely be converted to
  9i codes
•   9S1 White to 9i0 British/mixed British
•   9S10 White British to 9i0 British
•   9S11 White Irish to 9i1 Irish
•   9SB5 Black Caribbean and White to 9i3 White and Black Caribbean
•   9SB6 Black African and White to 9i4 White and Black African
•   9SB2 Other ethnic, Asian/White origin to 9i5 White and Asian
•   9S6 Indian to 9i7 Indian or British Indian
•   9S8 Bangladeshi to 9i9 Bangladeshi or British Bangladeshi
•   9S7 Pakistani to 9i8 Pakistani or British Pakistani
•   9S2 Black Caribbean to 9iB Caribbean
•   9S3 Black African to 9iC African
•   9S41 Black British to 9iD2 Black British
•   9S9 Chinese to 9iE Chinese
•   9SC Vietnamese to 9iF0 Vietnamese
•   9SD Ethnic group not given to 9iG Ethnic category not stated
Why can data quality be poor
• Patchy use of race information at local level – so
    people think the information they record is not
    being used
•   Patients not wanting to categorise themselves
    because of uncertainty about why information
•   Data collectors feeling uncertain and thinking
    collecting information emotive issue
Good practice in collecting data

• Senior management signed up to
• All staff trained
• Principles of self classification recognised
• Staff comfortable and can answer patient
• Data only collected once
Special issues
• The very young
     – Parent can respond
     – Baby not automatically categorised same as mother
• Permanently confused
     – Relative can assign
• Those not understanding English
     – Form translation, use of linkworkers/advocates

So how to do it?
• New patient ethnic profiling form
• Include ethnicity field in new patient check
•   Include ethnicity field in chronic disease
    management templates in QOF of new contract
•   Include audit of 9i codes
•   Persuade your local PCT to set up a local
    enhanced scheme for patient profiling
Tower Hamlets Local Enhanced Scheme for
patients who have health needs related to
ethnicity and language

• Aims
  – To enable practices to provide longer consultations to
    those who have difficulty communicating in English
  – To enable practices to profile ethnicity and language
  – To enable practices to employ more staff to deal with
    the above
  – To fund the training of practice staff
  – To help provide language appropriate health
    information for patients
Payment for scheme
• Level 1
  – Payment equivalent to 6 QOF points for
    recording ethnicity on sliding scale of 25-80%
  – Payment equivalent to 6 QOF points for
    recording language on sliding scale of 25-80%
• Level 2 (not being funded this year)
  – Providing a service for patients who have
    difficulty communicating in English £xx per
    consultation having interpretation/advocacy
Practice facilitation
• Team of facilitators going round practices to
  load up templates
  – Keith Prescott
  – Jo Tissier
  – Gladys Fordjour
• To provide training to practices
  – Multidisciplinary
  – Package of training material
• To ensure audit
2003/4 data
• Overall ethnicity recording across three PCTS
    19% in ¾ million patients ( practice range 0-
•   But in disease groups mean recording level
    – CHD 69%
    – Diabetes 78%
    – COPD 59%
• Next year’s data may show dramatic
    improvement once recording incentivised
    Recording Quality
     Ethnicity Data
Dr Kambiz Boomla
Senior Lecturer
Centre for General Practice & Primary Care
Queen Mary University of London

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