This page forms part of the Transcultural Health resource, published in 2004, and is preserved as a historical document for reference purposes only. Some information contained within it may no longer refer to current practice. More information

Section five: Service delivery and customer care

In the context of a national agenda to modernise government, the Department of Health and the NHS envisages significant change to the level of primary care through the establishment and development of Primary Care Trusts (PCTs).  PCTs have an important role to play in ensuring that their polices and practices do not discriminate against people because of their culture or ethnic origin, and that culturally competent services are delivered.

The change agenda presents a major opportunity to ensure that diversity issues are ‘mainstreamed’ in the development of organisational policies, processes and professional practice, rather than ‘bolted on’ as an afterthought once new - potentially discriminatory practices have already become established.

Primary Care Trusts, Primary Care Development Plans and Health Improvement Programmes are setting the context for the development of primary care.  Effective primary care can play a significant role in reducing inequalities in health and improving the health and health care of Black and Minority ethnic groups.

The new arrangements present significant challenges for PCT Boards, health and social care professionals and community based organisations working with Black and Minority ethnic populations that may have multiple problems, be socially excluded, and have distinctive health needs.  PCTs have the potential to reduce inequalities in health, or, if they fail to take advantage of the opportunities, to exacerbate the inequalities that already exist.

The opportunities that present themselves require a re-thinking of health and health care: and a recognition that employment, living and working conditions, housing, transport and the environment are significant contributors to health. The renewed emphasis on multi-agency working, partnership arrangements and cross-functional working is central to improving the health of Black and Minority ethnic communities, and, by extension, all communities.

In this complex environment, what can PCTs do to improve the health of these communities? The post MacPherson era determines that new approaches are needed to those that have been tried in the past.  This module is based on a in-depth awareness of wide ranging work that has been undertaken over the last two decades to identify Black and Minority ethnic health needs, to identify good practice in relation to specific conditions and to develop projects in the hope they may, at some stage, be taken on in the mainstream of the service. Despite all this work, there is a widespread perception in these communities that their needs are not being met and little of substance has changed.

Why is it so difficult to bring about significant perceived change in this area despite all the work that has taken place? Development work has often been either too general to be useful (e.g. NHS agencies are expected to have formal equal opportunities polices but the content may vary widely), or too specific (e.g. what is good practice in a specific geographical area and in relation to a specific population may not be generalisable).

In struggling with the question of what might be the most useful guidance and advice for health professionals and students, this module seeks to steer a middle course between:

  • identifying the underlying assumptions and guidance that might be used to influence the thousands of decisions made every day at a local level , which determine the appropriateness of service to Black and Minority ethnic communities; and
  • specific ways forward that can fundamentally alter the relationships between health agencies - in this case PCTs, and Black and Minority ethnic communities.

Guidance and advice

This advice is not meant to be a tightly prescribed guide that offers a blueprint for how all PCTs should address Black and Minority ethnic health issues.  Rather, it is a framework that can facilitate PCT Board Members and health and social care professionals in orienting their service and beginning to think about what is offered in more fundamental ways.

At its core is a set of Underlying Assumptions and Guidance, illustrated by real stories.

This advice is relevant to the delivery of appropriate services to all communities. It focuses on Black and Minority ethnic groups because of the national importance of the issue, and because we believe this provides a good ‘litmus test’ of the capacity of the service to provide appropriate services to a whole range of groups that may have distinctive needs. We believe that if the ‘Underlying Assumptions and Guidance’ are employed routinely in organisations, it makes it more likely that higher quality care will be provided for all population groups.

The second section, ‘Ways Forward’, considers how the work might be taken forward at the level of the PCT Board and in health and social care practice.

This advice and guidance is based on work undertaken by Mann Weaver (an organisation and management development consultancy) with the Overseas Doctors Association (ODA) and the Kings Fund on behalf of the Department of Health in 1999.

In addition, a series of workshops was facilitated in different parts of Britain with a mixed group of participants, asking them for their stories of giving and receiving care in relation to Black and Minority ethnic groups. The participants included GPs, district nurses, social workers, health service managers, health visitors and workers in community based organisations. The only requirement was that the stories be accounts of vivid personal experiences - they could be good or bad.

Why use stories?

The intention was to base the advice on what people are experiencing, rather than on what they thought should happen in an abstract way. Secondly, personal stories have a distinct power to influence because of their authenticity, and the fact they can give us a sense of how meaningful a particular behaviour or action, however small, can be for others.

The stories contain many insights and clues to what makes for good and bad care. Some of these were beliefs and assumptions - statements with which many might agree, but which are not specific enough to guide action in particular circumstances.  At the other extreme there were actions that were specific to particular circumstances but may or may not be appropriate in other circumstances.  Between these two was guidance that seem helpful in guiding the many choices and actions we have to take every day. The guidance fleshes out each of the beliefs in ways that help in making choices and taking specific actions.

In reading and trying to apply the assumptions and guidance, it is important to remember that it is not one belief or principle that will ‘fix’ this complex issue. Rather, it is the application and interaction of all the beliefs and principles that will help deliver appropriate services for all.

Underlying Assumptions And Guidance

Underlying assumption 1:

Ethnicity and cultural background has a significant impact on health and the experience of health care.

We see this as an underpinning belief that makes ethnicity and cultural background a significant issue for PCTs and the NHS as a whole.  At one level, many people would agree with this statement, and certainly many of the workshop participants, who were of Black and Minority ethnic origin, would.

However, the key word is significant.  In many NHS settings, it is still not uncommon for people to agree with this statement, but act as if ethnicity or cultural background makes a difference only at the margins of health care, or can be addressed by ‘special projects’ aimed at ‘special conditions’.

In the absence of signing up to this underlying assumption, there can be little motivation for making changes in practice that can address the issues for Black and Minority ethnic groups. Because it is an underpinning belief, offering a reason for considering the issue at all, we have not offered guidance related to it directly; the guidance principle is related to the beliefs that follow.

Underlying assumption 2:

Individuals of different ethnic origin and cultural background are entitled to equal access to good health and health care.

The NHS was built on the principle of equal access. Again, at one level this might be signed up to by many people in the service. However, health service staff are not immune from wider social beliefs that may cut across this, including a belief that some individuals or groups may be more or less ‘deserving’ than others of access to health and health care.

Guidance:

Be aware of the Black and Minority ethnic and cultural groups in your area, and avoid assuming these groups feel able to access health services.

"I was doing some research on the needs of African-Caribbean elders and their carers and spoke to a senior manager in a local health centre because I wanted to interview some district nurses. They suggested there were no Blacks in the area and no need to participate in the research. I discovered from a local voluntary organisation there was a significant Black presence in the area and I was angry how can you set up culturally appropriate services when you are blocked by people like that in a senior position?"

Data is available from a wide variety of sources; including public health, local authorities and voluntary organisations.

Avoid equating low numbers with ‘low priority’.

"I was talking to a health service professional who said to me that there were very few Black families in their area and the issue was not a high priority. I felt like saying if there are so few it shouldn’t be difficult to meet them and find out what there health needs were."

This is such a common response to attempts to highlight Black and Minority ethnic health issues that it needs to be addressed directly. A useful parallel can be drawn with small numbers of people that might suffer from a rare condition. It would be rare for a health or social care professional to argue that because the number of sufferers locally were small, or indeed even if there was only one, that they should not receive appropriate health care.

Take proactive measures to widen access to health and health care

"Even though the population of Black and Minority ethnic communities is relatively small (3%) we have been proactive in seeking to identify and address the health needs of Black and Minority ethnic groups. The development of networks with providers and community groups helped ensure development of a strategy that was widely welcomed. Work has been undertaken to improve child surveillance, and Medical Advisors work with GP’s to respond to the findings of an access to primary care exercise. Race awareness training has been undertaken for all staff and an Equity of Service Provision policy has been developed."

Underlying assumption 3:

Good primary health care is about treating people as unique individuals, not about treating them equally.

There is still a common belief in many parts of the NHS that equitable treatment is about ‘treating everybody as if they were the same’. This fails to take into account people’s uniqueness, part of which is their ethnicity and cultural background. Treating them ‘as if they were the same’ may lead to poor experiences of health care.

Guidance:

Appreciate how individuals from a Black and Minority ethnic background may experience health care in a way different to that intended.

"I was in a health care setting and all I could hear was this screaming. It turned out the doctor was trying to put eye drops into the eyes of a patient. The patient didn’t understand what was happening or why. She was absolutely terrified."

"I took a relative along with me to a consultation. I felt the doctor resented their presence and felt he should only have to deal with me in a private or confidential way. I don’t think he realised how important it was for me that my family was aware of what was going on after all they were the people caring for me when I was at home."

Appreciate the cultural context for the person.

"I was asked to assess an elderly Asian woman who was still living with her family. The family was very concerned about her behaviour. She became very distressed, shouting and screaming.  No-one there knew what to do. I had already spoken to the local priest because I knew she was a regular visitor to the local temple.  I brought him with me and she calmed down and we were able to start talking about the problems she was experiencing."

Avoid making assumptions based on stereotypes.

Stereotypes are often useful to us in simplifying the complexities we face and as a rapid guide to action. However, if we fail to question assumptions we hold about people based on their ethnicity or cultural background we may deliver a poor service.

Common examples of the stereotypes we heard included;

  • ‘Asian women are repressed and this affects their health.’
  • ‘Caribbean people are likely to be aggressive and challenging.’
  • ‘South East Asians are docile and will do what they are told.’
  • ‘Africans are friendly and won’t complain. 

"We thought my mother was on medication which turned out to be vitamin and mineral supplements. The doctor seemed to assume that many of his Asian female patients were suffering from being a bit run-down. It turned out she was diabetic and this hadn’t been diagnosed for years.  In the end she developed cataracts."

"I went with my sister to a consultation. She was unable to sleep and had acute pains in her arms. She was on a cocktail of medication so we had no idea what was causing it. She was kept waiting for ages and I asked a member of staff how long it would be. They said they didn’t know and heard him say to one of his colleagues ‘They don’t know how to handle pain’.  It made me really angry."

"My white colleagues were always saying that some of the African-Caribbean patients were loud and aggressive, and that this disturbed the other patients. I found it difficult to respond but kept thinking that where I come from that is not aggressive, just because you ask a direct question and expect an answer." 

"I accompanied my father, who is diabetic, to a consultation that we had been waiting months for. I asked the doctor about his condition and he was very abrupt. Part of the role of a doctor is about not making the patient feel they are a nuisance. I felt my father was being disrespected. The doctor implied that the medicine prescribed by the GP was rubbish and he shouldn’t be using it. How is my dad to know that? I found his whole attitude unacceptable."

"The only way I could get my mother to see a GP was if I could find one that spoke Chinese. A long time lapsed before she got medical treatment and she started developing gangrene in her feet because her diabetes was left for so long. I found that personally very difficult and felt there was a need for GP’s in the service that can serve the whole population."

"A carer told me that she had watched a home bather wash an African-Caribbean woman who was 103, using the same flannel on her body and her face. She didn’t want to complain because she was scared she might have to wait weeks for a replacement carer."

Do not assume individuals who talk more loudly or directly are being aggressive

"I was in the surgery and a woman was shouting and the doctor was shaking his head, saying calm down. She was saying I am not upset. She obviously wanted to try and explain the problem for herself. The GP was not patient enough and did not try to understand her…. they saw her as being aggressive."

Do not assume no eye contact or a response in a quiet voice means you have not been heard.

"I went with my mother to a consultation. The doctor was very unsympathetic and kept asking my mother to speak up.  My mother would not look directly at the doctor because it is impolite. I think the doctor thought she was stupid or ignorant and was very dismissive."

Do not assume that a request for a female presence is an attack on your professionalism.

"I was in the surgery with my sister and the doctor wanted to do an examination. He asked my sister to go behind a screen and undress. We couldn’t agree to this and I asked if she could be examined by a female nurse. The doctor got very angry, but what he was suggesting was completely unacceptable to us because of our culture."

If they are unsure of the significance of an individual’s ethnicity or cultural background

Ask

No one can be expected to be an expert on the significance of every Black and Minority ethnic identity or cultural background, but if you are unsure, ask.

"A health visitor visited my mother and asked if there was anything in particular she could do before she went into her bedroom. I asked if she would take off her shoes…it was such a simple thing but it made such a big difference to my mother."

"My father was receiving meals on wheels but the meals would often remain uneaten. This went on for weeks because he didn’t want to be seen as a problem. It was only when a supervisor visited and asked him about it that we realised there was Caribbean food available."

"After looking at local needs we located family planning and sexual health services in an area where we thought a particular group might be able to easily access the services. Very few people used the service and we were puzzled. It was only when I spoke to local people I realised the stigma associated with visiting the service and that we should have been much more discreet."

Respond to people professionally even when you may be under pressure. The experience of using the service can often have a ‘moment of truth’ that creates a lasting impression on the patient.

"I saw a repeat request from a Muslim patient for iron tablets without gelatine for religious reasons. The doctor had written underneath that he didn’t know of any. Someone was going to be deprived of their tablets because in a busy moment the health care professional did not devote enough time to this issue."

"My cousin had acute abdominal pains and we called the doctor out several times in the week. He gave him some painkillers and berated my aunt and uncle for wasting his time. On the Saturday they called again and the locum immediately had him admitted with appendicitis. He was very fortunate."

Recognise that family and friends may be a resource, not a problem. Indeed, family and friends may be able to give information that helps the diagnosis.

"My father had become irritable in his behaviour and stopped eating while he was in hospital. It was completely out of character and we were insistent that medical staff were not diagnosing this case correctly. Eventually they rushed him into surgery with an ulcer. The doctor came back and said he was OK; within moments he had a heart attack and died. The family were stricken and I asked a nurse for tissues. She said we haven’t any. It is difficult for us because we wonder what we could have done to make them listen."

Different cultures will have different rituals for marking significant life events, e.g. birth and death.

"When my first son was born 9 years ago, I was made to feel uncomfortable in hospital about the food and the things my mum wanted to bring in for me. When the time came for me to go home a number of people came to fetch me and you could sense this was frowned upon - that only so many people were allowed to visit. When I ask friends about their recent birth experiences, I get people saying the same things. It seems nothing has changed and I find that very sad."

"When my father was dying it was important for us to have a priest there well before the end. We invited him and he gave readings. The staff would come in at inappropriate times and ignore him as though he wasn’t there.  I’m sure this would not have been the case had he been a Roman Catholic priest or a vicar."

Recognise the value of additional spoken languages.

"I was in hospital with my own child in intensive care and was asked to do some translation for another mother. I was feeling vulnerable but I knew if I didn’t do it the woman wouldn’t get the information she needed. People think they can call upon people who just happen to be around including patients, for support in language and I think this shouldn’t be the case."

"Healthcare professionals sometimes seem to feel speaking a Black and Minority ethnic language is demeaning them. People who come from ethnic minorities should be encouraged to bring their experience forward, not negate it. Even if their native language skills are limited, they could be offered courses that would bring it up to a level where they feel comfortable."

"There seems to be a big difference in attitude in health and local government. In local authorities additional language competence and a willingness to interpret is often reflected in additional pay. In the health service it doesn’t seem to be valued, certainly not in what is rewarded."

Underlying assumption 4:

All forms of organisations have routines that are (often inadvertently) discriminatory.

Organisations are created for purposes. In the NHS, many organisational policies, processes and routines have been built up over a period of years to attempt to deliver a ‘standard’ service to a ‘standard user’. Many of these processes and routines may inadvertently discriminate against people of different ethnic or cultural backgrounds.

Guidance

Review how organisation standard operating procedures and routines may be discriminatory.

In the light of the Lawrence Inquiry, some public service institutions are undertaking wide ranging ‘equality audits’ aimed at identifying how polices and practices may be discriminating against people of Black and Minority ethnic origin.

"We would book in patients, and staff would be annoyed when they didn’t turn up. It turned out that some of those dates coincided with a religious festival or important event, and though the patients had tried to change the appointment they had no success. We didn’t have a list of important dates for other faiths. We wouldn’t do this with anyone else; asking people who are non-urgent to come in on Christmas day for example."

Protocols may ignore ethnic difference and be discriminatory.

"I was doing some cultural awareness training for sixteen nurses in their final year. All they talked about was how they perform their standard protocol. One of them said ‘As far as we are concerned if we treat patients equally we will be doing our job.’  I found it insulting because we were discussing some real issues."

"When we visit our family in hospital it’s because we see it as helping them to get well. This is normal for us, and its important for as many members of the family to be there as possible. But we are told that its not visiting hours, or only one or two people are allowed to see the person at one time. They don’t understand how important this is for us."

Human resource practitioners should make use of positive action.

"We have a sickle cell / leukaemia counselling service with an Asian and white worker. I wanted to recruit an additional counsellor of African-Caribbean background to work with the African-Caribbean community and put in a requisition to personnel. I just could not get them to do it as positive action - they just kept saying ‘this is the procedure’."

Review the effectiveness of interpreting and translating services provision.

"I referred a patient with a specific request asking for a Bengali speaking interpreter. Two months down the road a letter came back from the consultant saying they could not communicate with the patient and we would have to re-book. I have personally been raising this issue for the last 7 to 8 years locally and the system is still failing."

The quality of service is more important than red tape

"My daughter developed really bad eczema. Within a matter of days she had a fully blown case and was pulling her hair out from stress so was admitted to hospital. She was in for six weeks and when the time came for her to leave I was worried about her care. The doctor was very good and said he would cut through any red tape if she needed to come back in. I really appreciated that. When you go to see him, he talks to my daughter first and she says it is her doctor."

Exercise 5.1 Activity

List the four underlying assumptions that determine the appropriateness of services to Black and Minority ethnic communities.
Feedback to these questions can be found in the ‘Feedback’ section at the end of this module.

Ways forward for primary care trusts (PCT)

The Underlying Assumptions and Guidance we have outlined are relevant to all health and social care providers. Are there specific actions that could be taken by PCT Boards and health and social care professionals working within a PCT context to improve the health and social welfare of Black and Minority ethnic communities?

We believe there are some that would indicate whether a  PCT is responding to the issues in a way that was likely to mainstream Black and Minority ethnic health issues in the development of the organisation and not marginalise them.

At the PCT board level, members need to consider:

  • how they demonstrate commitment and a willingness to learn.  Ethnic minority health has been on the agenda of the NHS for decades but progress has been piecemeal and fragmented. In the post Macpherson era, with the acknowledgement of the need to eradicate ‘institutional racism’, the commitment of individuals will be crucial to progress. As new forms of organisations, PCTs have the opportunity to address Black and Minority ethnic needs and achieve significant health gains for local populations.

The effective delivery of a good service is from those who have a commitment. They don’t need to be experts; they need to have an understanding and a willingness to learn.

  • planning for changing population needs.

PCTs should make use of local quantitative information available from both the health and local authority on changing populations and Black and Minority ethnic health and social welfare needs. This should be supplemented by qualitative information available from local Black and Minority ethnic organisations.

Many health agencies still remain unaware of the ethnic make-up of their populations. We know the number of Black and Minority ethnic people in the population is going to increase and we have no excuse for not planning for it.

  • how black and minority ethnic health is reflected in  PCT goals and targets.

PCTs may be uncertain as to the relative priority of Black and Minority ethnic health. The priority afforded to Black and Minority ethnic health is not related to numbers but to a central NHS value of equal access to health and health care. The degree to which Black and Minority ethnic health issues are addressed is a good litmus test of how PCTs are meeting the needs of all local populations.

We are fed up with talking about numbers and priorities. To us this is about social justice. We are also not impressed by having this minority health as a priority in documents. We need local targets for Black and Minority ethnic health.

  • developing their local networks with Black and Minority ethnic organisations, health and social welfare professionals, and individuals.

PCTs need to develop their local networks with Black and Minority ethnic organisations and individuals, including Black and Minority ethnic health and social care professionals inside and outside their own PCT. They can offer community perspectives and specialist expertise.

Too often we can get caught in internal issues and problems. The really interesting work, where you can get energy from, is out there waiting to be tapped.

  • the black and minority ethnic dimension of commissioning and providing services.

PCTs should consider the ethnic minority dimension of commissioning and providing services. This could include commissioning services from Black and Minority ethnic organisations in health promotion and service delivery, e.g. in mental health provision, and in adding value to their own services through the use of advocates and other outreach work that could be undertaken by these organisations.

There are lots of issues on which we could help GPs. They could be referring more people to us, and we see our advocacy role as really helping doctors and nurses do the best for their patients.

Information and communication on Black and Minority ethnic health issues

PCTs need to ensure health information is made available in a variety of local languages, and also use other media e.g. videos, where literacy rates are low (this will often be relevant to significant numbers of the indigenous population).  Where numbers are small, PCTs need to consider what can be done across  PCTs and with the local authority to pool resources.

We always seem to be reinventing the wheel on interpreting and translation services and failing to provide consistent services that meet the needs. This really is an area where authorities could make gains if they pooled resources.

  • accountability arrangements

PCTs need to consider what accountability arrangements will be in place for Black and Minority ethnic health. While Black and Minority ethnic health issues are being built with mainstream strategies there is a need for PCTs to nominate a Board member with responsibility for steering and co-ordinating work.

Ideally you would want to hold the whole Board accountable because Black and Minority ethnic health issues are an integral part of good primary care. It affects everything from the kind of information you need you have, the goals you set, the way services are delivered and by whom. While this is happening it makes sense to have a lead person responsible for putting the issues on all relevant agendas.

At the level of health and social care practice, professionals in PCTs need to consider how they:

  • acknowledge and respond to the person rather than stereotypes

I was in hospital receiving care after the birth of my second child. What made the difference was the only Black nurse who sat down and talked to me for five minutes or so about God and life. While all the equipment was important, the difference it made in terms of the quality. I really remember her face and that is four or five years ago. Reaching out for the individual really makes a difference.

  • take a holistic approach.

We came across an elderly Caribbean women living on the top floor of an empty council house. She had stopped eating, and taken to smoking and drinking. The council had offered to re-house her miles away - she would have died there. We offered her a housebound befriending service and got the GP to give her dietary supplements; she responded to someone who cared.

  • explore their own values, assumptions and prejudices.

I came here and qualified as a nurse and health visitor. It wasn’t until I became a manager of a health centre I realised the importance of access and standards. I was into blaming Black and Minority ethnic cultures and began to critically evaluate and question myself about my own attitudes. I developed a passion for getting the organisation to realise that when delivering services to minority groups they need to take a different view. That led me to establish a resource centre to provide a translating and interpreting service and to train staff to engage with the issues. The professionals and community working together raised the funds.

  • enhance their communication skills.

When you go down to the individual level many of the stories relate to generic skills of communication; empathy with the patient, giving time to the patient. Maybe it is more difficult for a healthcare professional to demonstrate those skills to ethnic minorities than other patients. I suspect there are many groups that have the same problem.

  • recognise and respond to other groups that may also have problems with access to health.

A single mother with several children requested a home visit for a child with a cold. She had no transport and couldn’t afford a taxi. The healthcare professional said she smoked 40 cigarettes a day, had satellite television and drank; if she could afford all those things she could afford to bring the child to the surgery. The child ended up not being seen.

My father suffered a stroke and started to experience heart failure in hospital over several weeks. I could not get a straightforward answer to why they were not transferring him to the specialist coronary care unit. All they did was ask my brother whether he had been a drinker - he hadn’t - and referred to his age - he was in his 60’s at the time.

  • show respect for and respond to religious beliefs.

My nephew was dying and we wanted him baptised with living water. The staff made enquiries and arranged for an ambulance to bring the baby to the baptism site. They had to physically remove the baby and make sure he could still breathe. We got our ministers to come down to the river. We were so surprised. That really helped us to come to terms with the situation.

  • work across organisational boundaries and share resources.

You have to get other parties involved. If addressing racism is on the agenda of health agencies but not on the agenda of others - or vice versa - then the whole package that is needed - falls to pieces. It does not make sense to have individual workers and projects when we could be sharing resources across boundaries.

  • involve community based organisations.

We came across a mother of four who had been in a difficult marriage and when she left she had no friends and family left, only social services. Her eldest child who was 13 was giving her a hard time and her GP referred her to a psychiatrist. The mother came in my own home and he is now very supportive of his mother.

A young women with a child left her extended family after her husband died and had no experience of living independently. She was neglecting her own health. We helped her to secure benefits and go to college. We empowered her while maintaining her dignity. And most importantly we maintained her relationships with her extended family, because they are her real support in the long run.

  • develop capacity in communities.

A lot of African-Caribbean carers I was working with did not have an assessment and the relevant community care package. I felt I was able to refer them to relevant services and benefits as well. I felt I was able to empower a number of carers to actually take on the carers group, do the training, organise the respite and the activity. We now have a number of carers in the group who are doing just that, so they are actually empowered and taking issues forward.

  • recognise and respond to different living patterns.

I had a patient with mysterious pains and it was several months before I knew his family was going to be homeless and he had been refused re-housing. I wrote to the council saying you have to respect the values of the person’s culture; though the family had grown-up children, they want to live in an extended family. I managed to get them re-housed.

Exercise 5.2 Group activity:  Putting it into practice

Bring together as mixed a group as possible for a half-day session.  Take turns telling your own stories about caring for Black and Minority ethnic people.  When you have listened to these, check out whether the ‘Underlying Assumptions’ are believable for you, and whether the ‘Guidance’ is helpful.  If these are helpful, perhaps with some modifications of your own, explore what actions you or your organisation would need to take to integrate such practice in your everyday work.  Similarly, consider existing practice (and planned initiatives) and map out the range of work being undertaken.

Then consider your plans in the light of some of the identified ‘Ways Forward’.
(i) Are there any significant gaps?
(ii) How might these be addressed?

When these discussions have taken place, select a small group of people to be responsible for taking the action forward.