Janet Riddell-Heaney, MA, RN, RHV, DipChild Protection, Cert Ed.
Designated Nurse for Child Protection, Harrow Primary Care Trust, Harrow.In our previous paper we laid out some basic issues in child protection, the process involved and its impact on health service staff (Riddell-Heaney and Allott, 2003). In part two, we wish to explain how racism can affect the delivery of health services and, in particular, the child-protection arena.
In our previous paper we laid out some basic issues in child protection, the process involved and its impact on health service staff (Riddell-Heaney and Allott, 2003). In part two, we wish to explain how racism can affect the delivery of health services and, in particular, the child-protection arena.
In the light of recent inquiries, such as those into the deaths of Ainlee Labonte and Victoria Climbie, the social and care professions need to examine professional responsibilities, organisational practice and individual accountability.
A major turning point for all organisations and institutions was the murder of black teenager Stephen Lawrence in April 1993 and the subsequent inquiry (Macpherson, 1999) into the management of the police investigation. It raised issues concerning culture and race throughout the police investigation. The outcome was to introduce changes in working practices and attitudes to oblige organisations to consider their staff and the care of the public or patients, taking into consideration racial issues.
Although the Macpherson report mainly focused on issues of institutional racism towards members of the black community, it has a relevance in promoting anti-racist practice in general.
The Children Act (1989) was the first piece of legislation that specifically required local authorities to consider a child's 'religion, race, culture and language' (Section 22). Incorporating the UN Convention on the Rights of the Child (1989), the Children Act lays the responsibility with the local authorities to consider these issues when there is a child-protection concern.
We live in a multicultural society. There are white ethnic-minority groups as well as black and Asian minority groups. Within minority groups there may also be further differences. As well as addressing the needs of the larger ethnic-minority groups, it is important for the health service to address the needs of the smaller groups to ensure equal provision, justice and equal access for all members of society, regardless of background. This is certainly happening in part. There are organisations in the UK that provide support for people from ethnic-minority groups with particular types of disease or ill health, such as the Sickle Cell Society. However, this does not address the whole issue of service provision.
It is difficult to identify a holistic term to describe racism. It is not only individual acts of hostility aimed at one person, but can also be widespread throughout an organisation or institution. Macpherson (1999) described institutional racism as: 'The collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture, or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantage minority-ethnic people.'
Although this was in specific regard to the Metropolitan Police, it was apparent that it could equally apply to the NHS. Racism within service delivery was an area where further work and development was needed as it had already been identified as an issue.
In 1995 Smaje identified three forms of racism affecting service delivery in health care. These were:
- When patients are treated less favourably because of stereotyping about their ethnic backgrounds
- When service providers assume that equality in service delivery for everyone will ensure equality of care for everyone
- When there is a failure to consider ethnic-minority group needs or perspectives when planning service delivery, or when these needs are considered but interpreted incorrectly.
Madge (2001) cites Gilbourn and Youdell (2000), who identified that racism may be seen through its effects. 'Any set of practices and beliefs that systematically disadvantage members of one or more minority-ethnic group can be defined as racist. This approach allows social science finally to catch up to the pervasive and complex forms that racism can take.'
Racism and the NHS
In terms of cultural sensitivity and equality of service provision, it is clear that barriers within the NHS are blocking organisational change with regard to racism. In a debate held in London by the London Ethnic Health Network in February 2000 (LEHN, 2000), a number of reasons were cited for inequality in the provision of health services to people in ethnic minorities (Box 1).
It was suggested that NHS staff did not see the relevance of the Macpherson report to their workplace or individual practices and that there was a lack of knowledge about how to improve communication services for users of the services who do not speak English.
Suggestions for improvement in tackling inequalities in health service provision are shown in Box 2.
For nurses, it is startling to realise that as health-care professionals we may be unwittingly allowing discriminatory or racist practice as a result of thoughtlessness and lack of knowledge. We are obliged as nurses, midwives and health visitors 'to promote and protect the interests and dignity of patients and clients irrespective of gender, age, race, ability, sexuality, economic status, lifestyle, culture and religious or political beliefs' (Nursing and Midwifery Council, 2002, clause 2.2).
As health-care professionals, we should be striving to attain best practice for all our patients. By omission of examination and review of current practice within our own organisations, we may be condoning racist practice because of lack of thought and lack of knowledge.
Racism and child protection
The report, Childhood Matters (NCIPCA, 1996a, 1996b) examined racism, culture and ethnicity in specific relation to child protection. This was then expanded on in the Framework for the Assessment of Children in Need and their Families (DoH, 1999) and Working Together to Safeguard Children (DoH et al, 1999). All these documents highlight concerns raised with regard to evidence of 'institutional racism operating in the field of child welfare' for over 30 years (DoH, 1999).
Following the first government child death inquiry into the death of Maria Colwell in 1973 (Department of Health Committee of Inquiry, 1974) studies have been undertaken to assess the numbers of children entering the care system.
Before the implementation of the Children Act (1989), many children were taken into care as a result of abuse. However, concerns about the numbers of ethnic minority children within the care system is now new. Childhood Matters (NCIPCA, 1996a, 1996b) summarises some of the studies undertaken in this area (Adams, 1981; Rowe et al, 1989; Barn 1993). All these studies, going back over many years, repeatedly highlight that the number of ethnic minority children entering the care system was higher than the rates for white children during the same time frame or that there was an over-representation of black children in the care system. More recently, Childhood Matters and the Framework for the Assessment of Children in Need (NCIPCA, 1996a, 1996b; DoH, 1999) identified the same concerns - 28% of black children were in care within four weeks of a referral, compared to 15% of white children. They also identified the reticence that some social workers might have in engaging black families in preventive and supportive work to reduce the chances of their children being taken into care.
Black children were far more likely to have parental responsibility assumed by the local authority than white children. As discussed last month (Riddell-Heaney and Allott, 2003), safeguarding children is every individual's responsibility. All staff involved are required to undertake their roles with professionalism and integrity.
The NSPCC highlighted in Protecting Children from Racism and Racial Abuse (1999) the clear lack of evidence available from black, Asian and other ethnic-minority people.
Whose Child? The Report of the Panel of Inquiry into the death of Tyra Henry 1987 (London Borough of Lambeth, 1987) suggested that the lack of support provided by the social services department to help this black child's grandmother care for her was influenced by gender-based racial stereotyping. An over-idealised view of African-Caribbean women was cited as influencing social work practice with the family. As a result of this lack of support, Tyra returned home to her parents, where she was subsequently killed by her stepfather.
The report noted: 'There is a 'positive', but nevertheless false, stereotype in white British society of the Afro-Caribbean mother figure as endlessly resourceful ... essentially unsinkable. It may have been an unarticulated and unconscious sense that a woman like Beatrice Henry would find a way to cope no matter what, that underlay the neglect of social services to make adequate provision for her taking responsibility for Tyra' (London Borough of Lambeth, 1987).
In the case of Sukina Hammond, a child of mixed parentage who was killed by her father, the report of the circumstances leading to her death (The Bridge Child Care Consultancy, 1991) states: 'We know agencies that are moving towards trying to be more sensitive and understanding to the racial and cultural needs of their client group do risk failing to recognise the particular needs of an individual child. In addition, white professionals who have undergone anti-racist training can sometimes over-compensate out of fear of being accused of racism.'
Lord Laming's inquiry into the death of Victoria Climbie will be published some time in 2003. It will be interesting to read if consideration is given to the issue of racism. Did this possibly contribute to the lack of intervention from health and social care staff at certain points during Victoria's short life in England?
Race and equality
Just as culture, religion, gender and age demand respect, so does ethnicity. Race is part of the whole picture and cannot be separated from any one individual. Some may argue that race should no longer be an issue, as everyone should be treated in the same way. The Social Services Inspectorate Report They Look After Their Own, Don't They? (1998) states: 'In general authorities are making more efforts to consult service users and carers and provide information in relevant languages and involve interpreters in assessments ... The evidence reviewed also suggested that those agencies who responded by saying 'we treat everyone the same' have either not considered the needs of the black communities or have taken a decision to ignore them.'
Equality does not mean treating everyone in the same way. It could be argued that equality in service provision is ensuring that everyone has the opportunity of equal access to the services. If a child and family require interpreters to access the service, these should be made readily available. Otherwise it is not equal at all.
The needs of individuals vary in any given situation. In safeguarding children, race has to be considered as part of the child's whole family and situation, as it may well give rise to issues that require special attention. As health-care professionals we should be able to incorporate this philosophy as individuals as well as in the systems in which we work.
'Racism persists because of the failure of an organisation openly and adequately to recognise and address its existence and causes by policy, example and leadership,' the Macpherson inquiry into the death of Stephen Lawrence found.
'Without recognition and action to eliminate such racism, it can prevail as part of the ethos or culture or the organisation. It is a corrosive disease' (Macpherson, 1999).
In July 2000 the Department of Health published its report of Inspection of Services for Ethnic Minority Children and Families: Excellence not Excuses (DoH, 2000a). The inspectorate worked closely with eight social services departments and examined the quality of services provided to ethnic-minority groups and the extent to which the groups were involved in planning and decision making. Although good practice was found and praised, several issues were highlighted, which are summarised in Box 3.
In Understanding Difference (Madge, 2001), issues concerning the detection of sexual abuse within black and ethnic minority groups are discussed. Madge cites several studies that demonstrate the referral rate for black and ethnic-minority children who may have suffered sexual abuse is lower than that for white children. For example Gibbons et al (1995) found a referral rate of 20% for black and ethnic-minority children, whereas the rate for white children was 31%. Madge states that Moghal et al 1995) reached similar conclusions about sexual abuse in Asian children. Madge suggests that professionals need to develop a higher suspicion index for black and Asian children with regard to sexual abuse so that children do not become 'lost' to the safeguarding and protection system.
Humphreys et al (1999) undertook a study looking at 20 Asian families who were involved in child-protection processes. This found that a series of factors conspired to create oppressive (or racist) situations for the families involved.
It is clear that in this research, the considerations for the families involved with regard to religion, race, culture and language were not prioritised. Humphreys et al's results, some of them alarming, are outlined in Box 4.
Conclusions drawn from this study are that the child-protection process highlights the structural problems that can impede and hinder anti-racist practice within the social-care and NHS systems. Although individual professionals appeared to work with the families in most cases, the infrastructure upon which they so heavily relied fell short, which meant that oppressive practice was occurring.
In summary, Childhood Matters (NCIPCA, 1996a, 1996b) states: 'Despite the apparent acceptance of institutional racism in child-care services and apparent acknowledgment of the evidence provided around practice with black children, there has been no co-ordinated institutional response to counteract some of the effects that racism continues to have ...'
Working Together to Safeguard Children (DoH et al, 1999) suggests: 'The issue of race cannot simply be added to a list for separate consideration during an assessment. It is integral to the assessment process.' When undertaking assessments of black families professionals should be mindful that:
- From referral through to core assessment, intervention and planning, race and culture have to be addressed using the assessment framework (DoH, 1999)
- Racial and cultural stereotyping of black families can lead to inappropriate interventions in families as well as a failure to protect black children from abuse
- Professionals should guard against myths and stereotypes - both positive and negative - of black and ethnic-minority families
- Anxiety about being accused of racist practice should not prevent the necessary action being taken to safeguard a child
- Careful assessment made in the context of the wider social environment is required. This should be based on evidence of a child's needs and a family's strengths and weaknesses. This will help to avoid any distorting effect of these influences on professional judgements.
Those of us working in the health service can learn from the research that has been carried out on racial issues for children and apply them to our working environment.
Box 5 sets out some pointers for NHS staff and Box 6 describes training in the area of preventing racist practice. Box 7 sets out the particular role of managers within the NHS.
Having a diverse workforce at every level makes a vital contribution to being able to provide an effective, accessible and culturally sensitive service to diverse communities.
As stated in Improving Working Lives (DoH, 2001) all NHS employers should be required to set local targets for increasing the representation of black and ethnic-minority staff in sectors of the workforce where these groups are currently under-represented, to ensure that they better reflect the community they serve. In conclusion, racism is not an issue that health-care staff can ignore. It is up to all of us to ensure that we as individuals, as well as our organisations, tackle racist attitudes in the context of child protection and across the whole NHS.
- The third paper in this series, to be published in the March issue of Professional Nurse, will examine cultural issues and practices that may present in both children's and adult services. This will impact on young people aged 14 to 18 needing health care who are sometimes cared for in adult settings.
Reflect on how some of the criticisms levelled at social services in the Department of Health report Excellence not Excuses (2000a) may be applied to your department or organisation. What measures could be initiated to try to resolve some of the issues evident in your work environment?
Changes for children and families of ethnic origin require active intervention. Reflect on what widespread changes could be made in the health service to enable intervention to take place appropriately. What would the specific objectives be and how could they be measured?
Reflect on how the management of changing practice in safeguarding children could be considered in your organisation so that all members of the workforce are included.
What arrangements have been made in your department/organisation to ensure that the concerns and priorities of the local black community are embraced? Reflect on what you could do to enhance the situation.
Do ethnic minority workers in the NHS feel valued and empowered? Consider how you would identify what supportive measures are required and how they would be implemented.
Read a copy of the report into the death of Tyra Henry (London Borough of Lambeth, 1987). Reflect on how you may have acted at the time and how you would act now.
Training and resource packs on tackling racism are available on the Department of Health website: www.doh.gov.uk/ raceharassment
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