Deeply ingrained medical misogyny and racial biases are routinely putting people in need of treatment at risk, the government’s patient safety commissioner in England has warned.
Dr Henrietta Hughes was appointed in 2022 in response to a series of scandals in women’s health. She outlined a “huge landscape” of biases in need of levelling, citing examples ranging from neonatal assessment tools and pulse oximeters that work less well for darker skin tones to heart valves, mesh implants and replacement hip joints that were not designed with female patients in mind.
Hughes said: “I don’t see this as blaming individual healthcare professionals – doctors and nurses – for getting it wrong. It’s pervasive in the systems we have – the training, the experience, the resources.
“Anatomy books are very narrow in their focus. Even the resuscitation models are of pale males – we don’t have female resuscitation models, we don’t have them in darker skin tones. This is deeply ingrained in the way that we assess and listen to patients.”
Hughes’s appointment, with a focus on improving the safety of medicines and devices, came in response to the Cumberlege review into vaginal mesh, a hormonal pregnancy test, and an anti-epilepsy medicine that harmed unborn babies. The review painted a damning picture in which women’s concerns were consistently dismissed, leading to avoidable harm.
Hughes said positive progress was being made in the provision of specialist care for victims of complications from vaginal mesh procedures and welcomed the tightening of prescribing rules for the anti-epilepsy drug, sodium valproate, which came into force in January.
However, she said systemic biases were continuing to negatively affect outcomes for female and minority ethnic patients.
She described the realisation that pulse oximeters, used to measure blood oxygen levels, work less well for 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 highlighted concerns about neonatal assessments.
Bilirubinometers, widely used to assess jaundice in newborn babies, are less reliable for darker skin tones and some guidelines for the assessment of cyanosis (caused by a shortage of blood oxygen) refer to “pink”, “blue” or “pale” skin, without reference to skin changes in minority ethnic babies. The Apgar score, a quick test given to newborns that was rolled out in the 1950s, traditionally includes checking whether a baby is “pink all over”.
“Even the names of those conditions – jaundice and cyanosis – suggest a colour. The Apgar score includes P for pink all over,” said Hughes. “There are systemic biases in that if you have a darker skin tone those conditions may not be so apparent.”
Hughes said the development and testing of devices and medicines needed to cater for 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 in the first instance in a woman’s pelvis. It was designed to be used vertically. With the horizontal use, you’ve got 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, can have less successful outcomes in women, whose hearts are smaller on average. Doctors do not always discuss risks relating to hip joints that specifically affect female patients, she said.
“There are certain sexual positions that can adversely affect the success of a hip joint, but it’s an awkward conversation … that orthopaedic surgeons may not particularly want to have. It’s a culture issue.”
Medical textbooks, image libraries and training props also need to be more diverse, Hughes said, noting that people are less likely to do CPR on women in part because first aid courses typically use male dummies.
She said: “They don’t have the experience of working out where to put their hands because the dummies are all men. It impacts on people’s confidence, experience and normalisation.”
Black babies in England are almost three times more likely to die than white babies, according to figures released last year. The death rate for white infants has remained at about 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, according to the National Child Mortality Database.
Hughes said that despite the substantial challenges there had been positive signs of progress. She said there was a growing move towards publishing demographic data of clinical trials and post-marketing surveillance to be able to assess whether devices were working for all groups equally well. There are also good examples of diversifying design, she said, such as a project at Barts Health NHS trust to use CT scans of women’s hearts in a virtual design environment for designing heart valves.
Prof Habib Naqvi, chief executive of the NHS Race and Health observatory, which reviewed neonatal assessments, said its recommendations had been taken seriously and steps had been taken to address the concerns, including changes to NHS England guidelines. Overall he was “optimistic” about the changes under way.
He said: “The disproportionate impact [of Covid-19] on ethnic minority communities and staff has been stark,. During Covid we heard very clearly that we will need to focus on tackling ethnic and racial inequalities in healthcare. Now we’re at that crossroads. We need to make sure that those promises and statements are taken forward.”
An NHS England spokesperson said: “The NHS is working hard to ensure that everyone, regardless of their race or gender, receives high-quality care, and we will review the commissioner’s comments closely.
“Following recent action by the NHS on reducing healthcare inequalities, there have been improvements in the experiences of BME patients for some illnesses, such as sickle cell disorder, while our new three-year delivery plan for maternity and neonatal services aims to ensure safer, more personalised and equitable maternity care for all women, babies and families.
“But we know there is still work to be done on improving the outcomes and experiences for BME and female patients on a number of healthcare issues, so alongside implementing our Core20Plus5 initiative for reducing health inequalities, we are also working with stakeholders to ensure these patients’ voices, wishes and concerns are heard in the design and delivery of health services.”
