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.