Six years ago The Snowy White Peaks of the NHS ¹ highlighted the scale of race discrimination in the NHS, the UK’s biggest employer of Black and Minority Ethnic (BME) staff. COVID-19 has shown so much more needs to be done.

300 health and social care staff have died so far from COVID-19, a disproportionate number of BME heritage. We know NHS staff infection was overwhelmingly due to occupational exposure ² whose causes are varied but include the disproportionate BME staff role in patient-facing services, their poorer access to appropriate PPE, the greater reluctance of BME staff to raise concerns, disproportionate deployment into “hotter” roles, and the greater presence of BME colleagues amongst agency staff. BME staff have been largely absent from decision-making.

The NHS response to the risk of staff infection largely failed to acknowledge the importance of the discriminatory treatment of BME staff which placed them at greater risk ³ instead focussing on the health conditions which made those risks more dangerous.

The COVID-19 impact on BME staff, and Black Lives Matter, has prompted promises to tackle racism more resolutely ⁴. So what should NHS leaders do to ensure faster progress to tackle workforce race discrimination? Here are ten suggestions for Boards and Integrated Care System (ICS) system leaders – there will be others.

Firstly, equality, diversity and inclusion must finally become core Board business. No one should be a member of any NHS Board if they cannot confidently explain to staff and managers (and interview panels) why tackling race discrimination is important for the NHS and demonstrate what they are doing personally to achieve this. It must not be an optional extra. To gain the insight required to act requires difficult face to face discussion, reading, and listening and acting on lived experience.

Secondly, every leader must seek out and understand their local challenges, looking for risk not comfort. They must be familiar with Workforce Race Equality Standard (WRES) data and other equality data such as turnover, exit interviews, and absenteeism rates disaggregated by site, occupation, and service. Those challenges include patient and community experience. The repeated refusal of individual Boards (and national bodies) to be honest and open with equality data is a serious shortcoming that must end.

Thirdly, Boards should stop signing off “action plans” unless those proposing them can demonstrate why they are likely to work. In considering clinical interventions, we look for such evidence. Why on earth do Boards rarely ask the same of those proposing interventions on discrimination?

A typical NHS “action plan” on race discrimination consists of improving policies and procedures, introducing better training, and some positive action. Yet research found ‘attempts to reduce managerial bias through diversity training and diversity evaluations were the least effective methods of increasing the proportion of women in management’ ⁴. Similarly, Unconscious Bias Training, may improve cognitive understanding but has limited impact on decision-making ⁵. A primary focus on ‘policies, procedures and training’ will not change institutional discrimination any more than it would vanquish bullying ⁶.

Fourthly, Boards must be proactive and preventative. If they don’t use research and data (including lived experience) to drive interventions, inserting accountability at every stage, they will fail. Rather than adding a BME member to a disciplinary panel, for example, managers must not start a disciplinary investigation unless they can demonstrate it is the appropriate and fair response to an alleged offence and not discriminatory in itself.

Fifthly, Boards must embed accountability. Start by setting clear measurable time-limited goals, ensuring managers and staff understand why, and then holding themselves (and their managers) to account. There should be consequences and/or incentives when agreed diversity goals are not met, as for any other key performance indicator (KPI). It doesn’t mean “beating up” managers but rather helping build their capacity and confidence at every level, recognising that requires investment of time and determination by leaders.

In recruitment, for example, ask managers to explain patterns of apparent discrimination in appointments and access to “stretch opportunities”. If there is no credible explanation, then insist outcomes must change and support managers to achieve them. Stop relying on individual staff to challenge individual appointment decisions.

Research suggests it is much more effective to debias processes, not individual managers. We know “stretch opportunities” (acting up, secondments, involvement in project teams) are the most important contributor to career progression, but these are mainly accessed via a “tap on the shoulder.” Just look how ICS roles and COVID-19 roles have largely been filled. Instead, insist every “stretch opportunity” is filled in a transparent manner, using a “positive action” approach.

Sixth, Boards and teams must prioritise psychological safety so they become inclusive, welcoming the difference that BME staff bring, recognising that when they are really included and valued, able to bring themselves to work, there are immense benefits for all ⁷. Boards must understand that whilst improved BME representation is crucial, the benefits are limited without inclusive behaviours and culturally sensitive psychological support.

Seventh, Boards and leaders must model the inclusive behaviours they expect of others, with consequences if they do not. Culture is largely shaped by what leaders do and don’t do. Good leaders put themselves in the shoes of others, listen, enable, polish the skills of others, and are honest about mistakes. They make diversity and inclusion a personal priority, not leaving it to those subjected to poor behaviours to challenge them. Demonstrable values should be a core part of appraisals.

Eighth, equality, diversity and inclusion are drivers of service improvement so must stop being primarily a matter of compliance delegated to junior staff.

Ninth, the focus of NHS work around race equality must change. Remorselessly challenging racism must go hand in hand with supporting those who want to eliminate discrimination, question their own privilege and be allies. Such support must tackle the bizarre absence of a properly resourced national good practice repository on diversity and inclusion.

Finally, it is time to step up national accountability. Good governance has accountable metrics. Why, for example, are Trusts that cannot demonstrate serious progress on race equality still receiving a CQC Good or Outstanding rating?

Strong statements on racism are helpful. But in 2020 anything less than decisive practical action is unforgivable.

References

1. Kline, R. (2014). The “snowy white peaks” of the NHS: a survey of discrimination in governance and leadership and the potential impact on patient care in London and England. Middlesex University Research Depository.
2. Stephanie Evans, Emily Agnew, Emilia Vynnycky, Julie V Robotham (2020) The impact of testing and infection prevention and control strategies on within-hospital transmission dynamics of COVID-19 in English hospitals May 20 2020 doi: https://doi.org/10.1101/2020.05.12.20095562
3. Kline, R. (2020) The NHS response to BME staff’s Covid deaths was late and lopsided. Health Service Journal June 8 2020
4. Personal message from Sir Simon Stevens on Black Lives Matter and health inequalities (9 June 2020). https://www.england.nhs.uk/2020/06/personal-message-from-sir-simon-stevens-on-black-lives-matter-and-health-inequalities/
5. Kalev A, Dobbin F, Kelly E. (2006) Best practices or best Guesses? assessing the efficacy of corporate affirmative action and diversity policies. Am Sociol Rev 2006;71:589–617 doi:10.1177/000312240607100404
6. Atewologun D, Cornish T, Tresh F. Equality and human rights Commission research report 113 unconscious bias training: an assessment of the evidence for effectiveness. EHRC, 2018. https://warwick.ac.uk/services/ldc/researchers/resource_bank/unconscious_bias /ub_an_assessment_of_evidence_for_effectiveness.pdf
7. Justine Evesson, Sarah Oxenbridge, David G Taylor. (2015). Seeking better solutions: tackling bullying and ill-treatment in Britain’s workplaces ACAS.
8. West M, Eckert R, Collins R. (2017) Caring to change. How compassionate leadership can stimulate innovation in health care. Kings Fund https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Carin g_to_change_Kings_Fund_May_2017.pdf

Roger Kline

Roger Kline is Research Fellow at Middlesex University Business School. He authored “The Snowy White Peaks of the NHS” (2014), designed the Workforce Race Equality Standard (WRES) and was then appointed as the joint national director of the WRES team 2015-17. Recent publications include) the recent report Fair to Refer (2019) to the General Medical Council on the disproportionate referrals of some groups of doctors (co-authored with Dr Doyin Atewologun) and The Price of Fear (2018), the first detailed estimate of the cost of bullying in the NHS, co-authored with Prof Duncan Lewis.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.