Maslah Amin: How can the NHS tackle the white male dominance of leadership roles?

maslah_aminThe lack of women and people from a black, Asian, or other ethnic minority (BME) background in senior NHS positions is well known. It is in and out of the news and you hear it discussed on the shop floor among colleagues. Yet it continues to persist. Researcher, Roger Kline’s 2014 survey of discrimination in the NHS outlined it very well. The higher you go up the NHS seniority ladder, the whiter it gets, hence the title for his work “Snowy white peaks.” Also the higher up you go, the fewer women there are in those positions. Many other documents have discussed this issue. In the past two years there has been a push to improve the lack of diversity among senior NHS staff. However the latest evidence suggests that results remain poor.

The push to improve diversity in the whole NHS workforce is not just based on the ethical notion that it is the “right” thing to do. Rather it is well known that the delivery of healthcare is better when the workforce closely resembles the population it serves. Currently there is a significant mismatch between our senior NHS colleagues and our patient population.

It is a sensitive topic because people often associate the practice of improving diversity with the policy of positive discrimination. Positive discrimination is a controversial topic. Critics argue that implementing a policy of positive discrimination is favouritism and comes at the expense of others. However, keeping a system which we know disadvantages women and BME staff is also flawed. Positive discrimination is not the answer. I do not believe that providing an artificial leg up for an individual at the selection criteria to “tick a box” is the solution. It is not sustainable and nor does it treat the causative factor. This is a multifactorial problem.

There are lots of women and BME staff working in the NHS. So getting these groups into the NHS is not the problem. The problem lies with the progression of these individuals to senior roles. Which makes me conclude that 1) the selection criteria is poor and/or discriminatory, and 2) not enough women and BME staff are applying for the senior roles. Let’s not making excuses for the first problem, and instead acknowledge it, and address it. Increasing prospective applicants is difficult when evidence suggests to these individuals that they have a small chance of being appointed. We must discourage this belief. However you cannot do this simply through words, you need action and results. Firstly we have to be open about this issue. If there are not suitable candidates, let’s produce suitable candidates. More women than men now study medicine at university. This was not achieved through positive discrimination. Educational opportunities were broadened across genders and because women consistently outperformed men, more women are now accepted onto medicine. The opportunity to progress within the NHS must also be broadened to all staff. It is also important to recognize that BME staff and women experience different issues, with BME women arguably facing greater challenges. Furthermore, the BME term is broad and individuals within this group suffer from varying degrees of inequity.

A healthcare professional’s practices are evaluated in light of poor outcomes and appropriate action is taken. Yet our recruitment processes, which consistently fail to produce the required output, continue to function unchallenged. It is the recruitment team’s duty to achieve a representative workforce. If this means supporting underrepresented groups to these positions then resources must be made available. I am not surprised that two years since Kline’s report, we still have a long way to go. This inequality has developed over many years. It is not going to be fixed quickly. There have been no meaningful improvements. Instead what we have are intermittent reminders through the media. Recruitment processes, from the initial selection criteria, right to the final interview panel, must be evaluated to determine their efficacy. Once women and BME staff believe they have a genuine chance, I suspect applications will increase. A representative NHS workforce is better for our patients and we must not use this knowledge only when it is convenient.

To finish on a positive note, encouraging work is already going on. Health Education England (HEE) is currently reviewing the Annual Review of Competence Progression (ARCP), which is the formalised yearly review of a doctor’s competencies. Through this review HEE will lead the mission to address the differential attainment of doctors from different ethnicities and backgrounds. Training to be a junior doctor is challenging and stressful. I am sure my junior doctor colleagues will welcome the review of the ARCP process to optimise both our professional and personal lives.

Maslah Amin is a National Medical Director’s Clinical Fellow. He is also a junior doctor who has a special interest in leadership and management.

Competing interests: None declared. 

  • Roger Kline

    Maslah Amin’s blog highlight’s a continuing problem. We are currently analysing the data that all NHS providers were required to provide to our team by August.
    When I looked at recruitment from shortlisting in a sample of Trusts in 2013, it was 1.74 times more likely that White candidates across Trusts and professions would be appointed compared to shortlisted Black and Minority Ethnic (BME) candidates. I expect that our current data trawl will reveal something similar .
    There are a myriad of subtle (and sometimes unintended) ways in which discrimination takes place. Unfo9rtunately the traditional means of addressing this – policies, procedures and training for interview panels (including unconscious bias training) – are largely unevidenced and certainly ineffe3ctive in isolation.
    Our small team are currently scrutinising examples within the NHS and outside where an approach rooted instead in accountability appears to be much more effective – especially accountability led by appropriate metrics with clear senior leadership.
    This is not just a moral issue. If discrimination (intended or otherwise) is allowing ethnicity to influence decisions then it risks patients not getting the best staff. That is unacceptable.
    Along with my colleague Yvonne Coghill we’ll be publishing much more practical, evidenced advice on what works in the near future as part of our work around the Workforce Race Equality Standard.

  • Abeyna Jones

    Thanks for this insightful article Maslah, which deserves an open forum.

    Opportunities are improving for women, yet worsening for BME staff. Roger can tell you about the NHS ethnic gradient, and worsening stats at exec board level.

    As an intersectional female black doctor, you can only imagine the extra climb I have ahead of me.

    Although an excellent account,I believe that these additional points need to be considered

    Why it’s important
    1) Lack of workforce diversity stifles innovation

    2) Quality of care and patient safety is linked to the negative impact of inequalities of levels of wellbeing in BME population

    3) The legislative argument under The Equality Act 2010 – NHS is a public sector body hence has a particular responsibility towards tackling discrimination of this kind

    4) Many illnesses which have a high healthcare burden (e.g. prostate cancer, diabetes, hypertension, mental health problems) are experienced largely by ethnic minorities. We need those with experience working with these groups to help tailor and design an appropriate service

    How it impacts the Medical Profession

    1) NHS Hospital and Community Health Service (HCHS) in 2013 showing medical groups with the highest proportion of BME staff are sub-consultant level posts

    2) Statistics from outcomes of GMC investigations reveal that BME doctors were 50% more likely to receive a sanction and more likely to be involved in allegations of criminality or complaints from employers, compared to white doctors

    3) Organisations / specialties demonstrating a lack of diversity in leadership are therefore less likely to appeal to the pool of increasingly diverse doctors in the UK, leaving themselves vulnerable to survival in the future and foregoing / absolving rights responsibilities.

    This isn’t a popular topic for discussion. Nobody likes being called racist, but it’s a practice we all partake in on a daily basis – either consciously or subconsciously. The fact that this issue persists and is acknowledged, yet not much as changed is an example of how we’re supporting this system.

    2 years post WRES implementation – how satisfied are we that it has made any difference? At present, I can only see a white-out.