Inequalities in service provision: an examination of institutional influences on the provision of district nursing care to minority ethnic communities.

This paper reports on the selected findings from a larger ethnographic study of the provision of district nursing care to patients from different ethnic backgrounds. The two-stage study was undertaken in an English community National Health Service (NHS) trust serving an ethnically diverse population. The first stage comprised an organizational profile in order to analyse the local policy context, including specific responses to ethnic diversity. Data were collected by means of in-depth interviews with managers. The second stage entailed a participant observational study focusing on six district nursing teams. Purposive sampling was used to identify four teams with high minority ethnic caseloads and two teams with predominately white ethnic majority caseloads. Interview transcripts and field-notes were analysed by drawing upon the principles of dimensional analysis. The paper focuses upon institutional influences on the provision of care to minority ethnic communities. An analysis of the allocation of district nursing resource to different general practitioner (GP) practices identified marked inequalities in the district nursing provision which impacted upon the services provided to minority ethnic patients. Single-handed, inner city GP practices with a large minority ethnic practice population received a much smaller allocation of nursing staff than single group practices serving a smaller and predominately white practice population. The reasons why this situation existed are explored and an explanation offered as to why it had not been rectified. Observation of caseload management indicated that despite differences in the size of the practice populations served by the respective teams, all patients referred for nursing care received it. However, several covert processes appeared to limit the caseload size of those teams with large practice populations so that it remained manageable within the limited nursing resource available. It is concluded that although nurses at an individual level did not appear overtly to disadvantage minority ethnic patients, institutional forces conspired to perpetuate the disadvantage experienced by minority ethnic communities.