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Racism and sexism are "alarmingly normalized" within the structures and person-to-person interactions across the NHS, and the NHS has delayed acknowledging and learning from the evidence, says a from the BMJ Commission on the Future of the NHS, published in The BMJ today.

There is an ethical imperative for the government and NHS institutions to act now, it concludes.

On a wider scale, discrimination and inequities related to protected characteristics, such as race and ethnicity, sex and gender, age, disability, sexuality, religion and belief have a major impact on the health of the public the NHS serves—and on staff well-being—says the report.

Discrimination and inequities contribute to increased risk of physical and mental health conditions, limit access to care, shape negative experiences of illness and encounters with services, and lead to worse overall health outcomes, including mortality, it highlights.

As well as having a major impact on population health, discrimination and inequity also have huge financial consequences for the UK economy. Every year health inequity leads to productivity losses of £31–£33bn, lost taxes, and increased welfare payments of £20–£32bn, as well as direct health care costs of at least £5.5bn, it points out.

After reviewing the evidence, the report makes recommendations for the UK government, health care leaders, the Care Quality Commission (CQC) and equivalent regulators, and the NHS on tackling discrimination and inequities across the NHS to enhance the experience of patients and staff and improve health outcomes.

For the UK government:

• Hold NHS leaders responsible for achieving the ambitions outlined in the NHS equality, diversity, and inclusion improvement plan.
• Implement the independent on inclusive leadership in full.
• Give the NHS Race and Health Observatory (RHO) statutory responsibility for producing equity based impact assessments of new NHS policies and programs and make it the main repository for all matters related to race and ethnicity in the NHS, including the Workforce Race Equality Standards.
• Mandate national research and health bodies to establish equality standards (especially concerning race, ethnicity, sex, and gender) in all research grants, studies, and approvals of drugs, medical devices, and technologies.
• Ensure that biases in existing advanced technology and artificial intelligence are identified and corrected, preventing the introduction of new biases that discriminate against patients.

For the Care Quality Commission (CQC) and equivalent regulators:

• Add an explicit inspection criterion for staff well-being to identify and tackle racism, sexism, and other forms of discrimination.
• Hold leaders and organizations accountable for failures in addressing discrimination.

For the NHS:

• Collect and report transparent, accurate, disaggregated data on race, ethnicity, sex, and gender in all organizations.
• Prioritize equitable research, with financial support from government research funders like the National Institute for Health and Care Research (NIHR) and UK Research and Innovation (UKRI), and collaboration with charitable research funders. Withhold funding where these principles are not met.
• Implement the starkest findings of research on inequitable clinical care and ringfence funding to support improvements.
• Set national standards for diversity and inclusion to produce culture change.
• Provide statutory protection for whistleblowers and update the NHS England long term workforce plan to include the role of freedom to speak up guardians.
• Make evidence based training focused on reducing bias and discrimination (including intersectionality training which explores how various aspects of a person's identity, like race, gender, and class, intersect to create unique experiences of privilege and oppression) readily available, emphasizing improved interactions with diverse colleagues, cultural safety, and cultural competency. Encourage professionals to develop awareness of clinical interactions and reflect on personal and systemic bias.

For health care leaders:

• Improve working conditions by facilitating flexible and remote working and reducing bullying, harassment, and discrimination.
• Model anti-racist and anti-sexist behavior to encourage similar conduct in employees.
• Monitor staff diversity and track inequity across roles and career trajectories.

The six expert authors conclude: "NHS leaders and the public must recognize that prioritizing health equity is a proven strategic investment that leads to good patient outcomes, and better retention and recruitment rates of staff. It is also an ethical and legal imperative."

Equity in health care is about acknowledging that different needs require different responses with varying resources, and that inequity involves multiple characteristics in many cases. Services should be codesigned with those who struggle the most to access care and have the poorest outcomes to reduce inequality in health outcomes, they argue.

They add, "Inaction represents an unacceptable choice that increases harms to patients and costs in terms of increased staff absences, sickness, resignations, and reduced productivity.

"The evidence and policy options are abundantly clear. Political and institutional leaders must urgently choose to prioritize the elimination of these avoidable, unhealthy, and costly injustices, or face the consequences of a disaffected NHS workforce, and widening inequalities in health outcomes in the general population.

"The recommendations we make, if implemented, will go a long way to making the NHS a happier and healthier place."