Patients report alarming lack of trust in NHS primary care providers
Results of a survey on the level of trust that Black, Asian and ethnic minority patients have with NHS primary care service providers reveal alarming levels of discrimination and mistrust.
Over 2,680 people competed the primary care ‘trust’ survey issued by the NHS Race and Health Observatory in 2022, which sought views on a broad range of areas including overall trust in, and satisfaction with, primary care providers, and levels of satisfaction with remote healthcare services.
Participant responses from ethnic minority groups were compared with White British participants across key health services delivered by primary care, including GP Practices, Community Nurses, Community Pharmacies, and Midwives.
Survey data were analysed by researchers from Oxford University and published, alongside existing research on patient experience, in a new comprehensive report from the Observatory: Patient Experience and Trust in NHS Primary Care. Analyses of data from the annual General Practice Patient Survey (GPPS) are also presented in the report.
Despite primary care services often being the first point of contact with the NHS for patients, the report highlights a worrying lack of trust amongst certain ethnic minority groups of the service or care that they receive. A third of South Asian participants say they rarely or never trust primary care to meet their health needs.
Patient trust is impacted by past experience, and in particular the way that healthcare professionals behave towards and communicate with them. This can directly affect their level of engagement with healthcare services, and lead to health inequities. Only half of participants (55%) trust primary care to meet their health needs most or all of the time.
Experience of discrimination, which can be a key contributor to eroding trust, featured highly – with 51% of participants reporting some form of discrimination. This included alarming rates of racial or ethnic discrimination, with 38% of Asian participants and 49% of Black participants reporting that primary care providers treat them differently due to their ethnicity. The report also showed that compared to white British patients, ethnic minority groups reported worse experiences in their communication with their GP practice and felt taken less seriously.
Frequent complaints from women were raised by many participants who felt that being a woman or a “person of colour” leads primary care providers to ignore, or minimise, the reporting of pain. Concerns also arose around the lack of medical competence, cultural awareness and resources regarding health conditions that disproportionately affect ethnic minority communities – including sickle cell disorder, lupus, and diabetes.
Survey responses highlighted low levels of confidence in the training of healthcare professionals, the provision of appropriate clinical assessment, in medical advice and in diagnoses of skin conditions amongst patients with different skin tones. Advice from NHS 111 to monitor “turning blue in the face” was cited as being inappropriate for people with Black skin.
Today’s publication coincides with a roundtable set to address the report’s key findings. Hosted by Dr Chaand Nagpaul, a GP and board member of the NHS Race and Health Observatory, the roundtable will bring together over twenty key partners, representing local communities, the voluntary sector, government and the wider NHS.
Patient Experience and Trust in NHS Primary Care report
A public survey and interviews captured patient experiences on the following:
- Overall trust in, and satisfaction with, primary care providers
- Trust in primary care as an accurate source of information, particularly about Covid-19
- Provider communication and engagement during consultations
- Levels of satisfaction with remote healthcare services
- Discrimination relating to ethnicity, language, or other personal characteristics.
More than half of Asian and Black participants felt that they were treated differently by primary care providers due to their ethnicity or other personal characteristics, such as gender or socioeconomic status.
Overall, Black and ethnic minority groups were more likely to feel that primary care providers did not listen to their concerns, with Bangladeshi/Pakistani and non-British White participants less likely to feel that their concerns were acted on.
Across all ethnicities, common concerns emerged around difficulties accessing appointments, concerns on the accuracy of remote diagnoses, misdiagnoses, and on the quality of medical care received. Additional barriers to communication were faced by participants whose first language was not English.
Professor Habib Naqvi, Chief Executive, NHS Race and Health Observatory, said:
“We cannot have a two-tier NHS based upon patient ethnicity, background or circumstances. This report reflects the clear need to bring speed and urgency to reform the NHS, so that patients do not face discrimination and systemic barriers when seeking healthcare. Work is needed now to re-build levels of trust and confidence in the NHS amongst diverse communities, and for the Observatory, that work begins by listening to patients, communities and our partners – so that services can be co-designed to meet the diverse needs of our diverse populations.”
The survey also shows that many patients from ethnic minority communities reported high rates of not feeling listened to by midwives. Concerns were also shared in relation to islamophobia, being regarded with suspicion, coupled with assumptions about not valuing health based on religion.
Feedback on levels of trust in healthcare advice for Covid-19 showed lower levels for many Black and Asian ethnic minority groups (excluding Indian) and for non-British White participants in comparison to White British groups.
General Practitioner, Dr Chaand Nagpaul, an Observatory Board Member, said:
“Trust is the bedrock of the relationship between a healthcare professional and the patient – even more vital in primary care where patients seek first point of contact help for the health needs, and where measures can be taken to prevent ill-health. It is deeply concerning to hear of poorer experience, racial bias and discrimination faced by patients of ethnic minority groups and the negative impact this has on their engagement with the health service and the care they receive.
“It is essential the primary care sector use this insight report from patients to improve communication and health care delivery for our diverse population of patients who need support and compassion to equitably support and treat their health needs.”
Several patient insights are included in the report. One woman, described as mixed ethnicity, shared her experience of being misdiagnosed for over 26 years and not being listened to. Once finally diagnosed with endometriosis, she was left infertile. Many others complained they weren’t believed about the levels of pain they were experiencing, or that their pain was not taken seriously.
Research Fellow in Moral Psychology, and report co-author, Dr. Joanna Demaree-Cotton, Oxford University, said:
“Listening to patients is a cornerstone of ethical medical practice. It involves taking seriously information they share about themselves and their symptoms. It also means taking effective action to help resolve their needs in a way that is meaningful and acceptable to them. Patients need to feel they are part of a healthcare system that cares about their welfare regardless of ethnicity, gender, or other group characteristics. When they do not experience this kind of care, it can be especially alienating and damaging to trust, dignity, and mutual respect. An equitable healthcare system is one with the resources to listen to its patients and to respect them as individuals.”
The Observatory will now undertake further evaluation of the survey and is exploring methods to help improve access and delivery of primary care in local communities, this work will initially centre on East London with a focus on vaccine uptake. The independent health organisation will also publish its new corporate strategy next week.
Dr Shona Arora, Director of Health Equity at the UK Health Security Agency, said:
“After clean water, vaccination is the most effective public health intervention in the world for saving lives and promoting good health. Improving vaccine uptake in areas of low coverage is therefore a key public health goal and we want to ensure that all communities are benefiting equally from the effective vaccination programme we have in this country. Strong and trusted local health services are essential to achieving high levels of vaccine uptake and we are pleased to support the RHO and local partners to explore how we can reach this.”
Key Recommendations include:
- Integrated Care Systems should work with local communities to improve levels of trust in accessing primary care services in local communities, with a focus on areas where data indicate challenges, e.g. vaccination uptake. (NHS England and Integrated Care Systems)
- Raise awareness amongst healthcare professionals about racial and ethnic disparities in patient experience of primary care, and its impact on health outcomes including through existing resources and interventions where these exist. (NHS England, Royal College of General Practitioners, Royal College of Nursing)
- Independently led and co-produced practical guidance for healthcare professionals, including those within primary care settings, on undertaking sustained and effective engagement with ethnic minority communities. (In conjunction with NHS England)
- Continue investment in cultural competency and cultural safety training and development for primary care professionals, both within healthcare educational curriculum and within professional developmental courses. Including building on existing programs and interventions to enhance inclusivity, accessibility, and representation across the curriculum. (NHS England, Royal College of General Practitioners)
- Disseminating guidelines and resources that address structural barriers in accessing primary care services, such as access to interpreters and translated materials, longer appointments for non-English speaking patients with interpreters, and improved digital access and enablement. (NHS England)
- Development and implementation of practical tools to increase culturally appropriate communication on perinatal health in primary care settings. (NHS England to lead and the Royal Colleges to support)
- Development of aframework to assess, evaluate and hold healthcare providers accountable for addressing ethnic health disparities, such as trust metrics, patient feedback loops, and transparency within performance metrics. (Care Quality Commission, NHS England)
- Improve the quality of ethnicity coding for patients in primary care, including:
a. Ensuring the latest guidance is being implemented
b. Routinely monitoring the quality of ethnicity coding
c. Continuously identifying how ethnicity coding can be improved and putting in place actions to achieve this. (NHS England)
9. Further research on the development of evidence-based strategies to improve trust between ethnic minority communities and the healthcare system. (National Institute for Health and Care Research).