COVID-19 risk assessments: shortcomings in the protection of Black, Asian and Minority Ethnic healthcare workers.

Sir,

Over the past few months, various preventative measures that aim to combat the spread of severe acute respiratory syndrome coronavirus-2 have been implemented with good results, including the use of personal protective equipment (PPE) and reinforcing general hygiene practices [1]. However, research by Iqbal and Chaudhuri regarding management strategies for dealing with coronavirus disease 2019 (COVID-19) in the UK concluded that current efforts are ‘not translating to a sense of security’ amongst the National Health Service (NHS) workforce [2]. In particular, mortality statistics have highlighted a disproportionate effect on Black, Asian and Minority Ethnic (BAME) healthcare workers (HCWs). Preliminary analysis of 119 HCWs that have died in the UK with COVID-19 revealed that 64% of them were from the BAME community, despite this community representing only 21% of the workforce [3]. Furthermore, a survey of frontline doctors conducted by the British Medical Association (BMA) showed that, compared with their White colleagues, almost twice as many BAME doctors felt pressured to work in high-risk environments without adequate PPE [4].

Following guidance from NHS Employers (the employers' organization for the NHS in England) and BMA, hospital NHS trusts have responded to these concerns by implementing risk assessments for HCWs that take ethnicity into account. Outcomes of these assessments are then used to provide individualized and specific guidance to staff members, such as by suggesting modifications to their work practices.

However, there are important issues to consider in the design of these risk assessment tools, which can cause considerable concern for BAME HCWs. The latest data from the UK Office of National Statistics (ONS) indicates that being from a BAME background is itself a significant factor that increases the mortality risk of COVID-19 [5]. However, risk assessment systems that require two or more risk factors to be present (one being that the individual is of a BAME background) will not identify BAME HCWs without additional risk factors as being at significantly higher risk. In addition, the grouping of many diverse ethnicities within the umbrella term of ‘BAME’ severely restricts the accuracy – and, by extension, the validity of subsequent advice – of these risk assessments. This approach fails to appreciate that ‘BAME’ refers to a heterogeneous group, overlooking the large variations in mortality risk between different ethnicities [5]. The use of this broad term can also lead to instances of confusion, seen in the way that some risk assessments clearly include mixed race under the BAME category whilst others do not specify. To avoid the consequences of using reductionist labels, we propose that risk assessments should reflect the six ethnic categories as found in the detailed reports published by ONS regarding mortality rates for COVID-19: Black, Bangladeshi/Pakistani, Indian, Chinese, Mixed and Other [5].

Moreover, the lack of standardization between the risk assessments issued by each of over 200 NHS trusts in the UK can result in significant variations in risk stratification between hospitals. This is not a trivial matter, as variations in risk categories will subsequently impact advice around work; an HCW at one hospital may be advised to change to a non-patient-facing role, whereas in a different hospital, they may be advised to continue to work as normal. For some HCWs, these variations in management could be the difference between life and death. Whilst it may sometimes be appropriate for individual NHS trusts to take a different approach to risk assessment, for example based on their regional circumstances, the so-far inconsistent approach has left many staff feeling worried and unsure about what they need to do to best protect themselves and their patients. These feelings have been compounded by recent reports that, to date, only 23% of NHS trusts have completed the process of risk-assessing their staff [6].

In conclusion, these issues highlight the need for standardized and widely implemented risk assessments that use the best-available evidence to assess the risk to BAME HCWs more accurately. Finally, although this letter has focused on HCWs, we stress that similar approaches must be taken for public-facing jobs across any other relevant industries. Moreover, steps to mitigate the short-term risk to BAME staff must continue, in parallel with ongoing investigations into contributing socio-economic or biological factors leading to the racial disparity in mortality rates of COVID-19.

Conflict of interest statement

None declared.

Funding sources

None.