Imagine going to work and starting the day by being told that a customer doesn’t want to deal with you because you are black. And the response from your employer is to ask your white colleague to serve them instead. For minority ethnic people working in health this happens more often than you would think.

Recorded racist verbal and physical attacks against those working in the NHS is on the rise; a Freedom of Information request by BBC radio 5 Live found that in 2013, the number of such attacks in the NHS had risen 65% since 2008. And between 2012-13, there were 567 racist incidents involving patients or visitors, 33 involving NHS employees.

Writing in the British Medical Journal, senior NHS doctor Nadeem Moghal was the latest professional to open up about the problem. He described how the parents of a child in a hospital where he used to work refused to have any doctors caring for their child who were other than white. He said: “The clinical director concluded that because of the nature of the disease and the clinical need of the patient, the parents’ request would be enabled.”

In other words, the hospital would uphold the parents' request. And until a board level inquiry reversed the decision – which the parents ultimately conceded to – care was organised so that only a white British doctor attended to the child.

Disturbing events like these aren’t peculiar to the NHS. In 2013, Tonya Battle, received US$200,000 from the Hurley Medical Center in the US, to settle a lawsuit against the hospital for discriminating against her by complying with a father’s request that no black nurses should care for his baby. Battle claimed that a note was posted on an assignment clipboard that said: “No African-American nurse to take care of baby.”

For Moghal, such cases are a part of the “institutional racism” that was described in the McPherson report into the police in 1999, following the murder of Stephen Lawrence. Institutional racism, as the report pointed out, is more than conscious racism. It includes “unwitting prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantage minority ethnic people.” Although racism can be direct in health care, the ways in which it is also “unwitting” are rarely discussed.

When it was published, the McPherson report had a significant impact on public services. There was was discussion and development of initiatives for tackling racism in the NHS. Yet 15 years on, and despite diversity policies and mandatory training, racism continues to infect the health service.

The message that the clipboard note and the hospital’s decision to uphold the parents' request sends out is that it’s OK to accept racist views.

As the Radio 5 FOI showed, racism from patients and those close to them is still very much an experience of our modern health system and in hospitals where people work to help others. It’s also important to remember that black and minority ethnic people are a significant minority of the NHS, where they make up about 18% of the workforce.

Negotiating new forms

What is most often overlooked in discussions of health care racism is how racism can get entangled with illness, complicating what we might think of as “unwitting”. This is not to condone or excuse, but to highlight how legal and policies imperatives can miss the complexity and sheer trickiness of dealing with racism in health settings.

As the psychoanalyst Isobel Menzies-Lyth’s studies in the 1950s revealed, hospitals are not like other organisations. They heave and bubble with a heady mix of emotions – fear, disgust, envy and guilt – that are a consequence of being up-close to human pain and suffering. In Menzies-Lyth’s view, these heightened emotions, combined with the everyday proximity of illness and rude health, lead to anxieties and defensiveness in both patients and professionals.

Where racism is concerned, these intense feelings, together with very different experiences of illness, can mean that racism and dilemmas about how to deal with it, can vary between specialities. For example, a study of nurses in acute mental health services found that they sometimes saw racism from patients as part of a mental health condition and felt that it was inappropriate and ineffective to respond using standard procedures. In other words, their clinical sensibilities affected how they perceived and managed racist incidents.

How to deal with racist comments from people with dementia, is another emerging issue being talked about and by patients' relatives too. Greg, who penned Wits' End a blog about his experiences with his late mum’s dementia, wrote in one post after his mum called staff “negroes”:

I’ve never heard her use that term. The idea that she would even choose to mention the skin colour of the staff member totally dumbfounds and alarms me. My Mother has mixed with people of many different nations and ethnicities in her life – she lived in Pakistan, in Japan, in India and travelled extensively throughout my Dad’s career, taking in every continent. I don’t recall her ever being frightened by a skin colour. All I can imagine is that she reverted to some pre-1950s attitude – maybe the sort of language she heard her own parents use.

In my research into end-of-life care, I’ve found examples of different dilemmas. Doctors and nurses can be especially reluctant to tackle racism because of a sense of the futility of taking dying people to task. What good would it do to challenge someone’s racism in the last stages of their life?

To complicate matters further still, when people are dying their biochemistry can change because of advancing disease, drugs and their side effects. I have seen usually convivial patients become combative, abusive and sometimes violent towards caregivers. If this behaviour takes on racist overtones, what is it we are dealing with: unadulterated racism or disease-induced racism rising from a deep cultural unconscious?

It’s clear that racism can take different forms and that we need to recognise and tackle its variations. While it may be that staff dealing with those with dementia may need more support and preparation, the ambiguity of “unwitting” racism in such cases can’t be an excuse to do nothing. If we miss or ignore how and why racism is still alive and well in our health system - where someone in need of help feels able to demand care based on skin colour - what does it say about us as a society and how we value our doctors, nurses and other health professionals?