Following on from the powerful blog “After the speeches…” that outlined actions needed to reduce discrimination, we are delighted to publish a ten part blog series by Roger Kline with suggestions on how to tackle structural racism in the NHS.
In 2018, internationally known recruitment consultants told an NHS organisation I was advising that “inclusion” should not be a core competency for a senior leader appointment on the grounds that many potential candidates might not meet it. Fortunately, their advice was rejected.
What was remarkable was that such a proposal was even made. After all, two years previously, the NHS had adopted a leadership development strategy which stated the NHS needs “to ensure we have ‘compassionate, inclusive and effective’ leadership at all levels in health and care……..[it is] crucial to achieving continuous improvement in care for people, population health and value for money” (1).
Such leadership is especially important now as COVID-19 has emphasised the scale of discrimination faced by Black and Minority Ethnic staff and the glacial sped at which the Snowy White Peaks are melting.
We know that inclusive and compassionate leadership helps create a psychologically safe workplace in which staff are more likely to listen and support each other resulting in fewer errors, fewer staff injuries, less bullying of staff, reduced absenteeism and (in hospitals) reduced patient mortality (2).
We know that in such an environment, team creativity improves, innovation is more likely, information is processed more carefully, risk awareness improves, and turnover declines. Where organisational leadership better represents the diversity of staff, there is more trust, stronger perceptions of fairness and overall better morale of staff (3). We know there is evidence of deep links between compassionate leadership and innovation (4).
I have met Chief Executives, Board Chairs, Finance Directors, Chief Nurses, Medical Directors and Human Resource Directors who work hard to create such an environment and who try to balance “relational intelligence” (kindness, emotional intelligence) with “rational intelligence” (regulation, measurement and efficiency) (5).
Such leaders are curious. They listen. They challenge the status quo and do not leave it to those subjected to poor behaviours to challenge them. They try to be aware of, and understand, the perspectives and experiences of staff who may feel like ‘outsiders’, who may face discrimination, or bullying, or are struggling with unsafe workloads.
Such leaders are modest about their own capabilities, admit mistakes, and use the word “we” more than “I”. They create the space for others to contribute. They show awareness of personal blind spots as well as flaws in the system and work hard to ensure fairness in all they do. They demonstrate kindness in everyday small ways and seek to understand those they work with. They place themselves ‘in other people’s shoes’ to understand what life is really like in their organisation, department or team.
Such leaders understand that bullying and discrimination undermine staff self-confidence and that the fair and consistent treatment of team members is crucial to the trust which underpins effective team working. They understand the deep human need to belong that can create effective teams. They understand the anxiety and fear felt when speaking up or sharing ideas in front of others (6).
Such leaders approach discrimination and inclusion as they approach any other factor impeding good patient care. They listen to staff and patients, seek to understand relevant research, and find other organisations successfully tackling similar issues. They adapt or adopt evidenced approaches using real-time data from staff surveys, workforce reports, patient feedback, and clinical risk indicators. They use soft informal staff intelligence as proxy measures of culture…however uncomfortable it may be.
Such leaders understand that demographic diversity is crucial, that careers of Black and Minority Ethnic staff (and others) are blighted by systematic discrimination. They know that inclusion is what helps turn diversity into a bonus in healthcare. When interventions to improve behaviours and culture are proposed, inclusive leaders ask why they are likely to work, since research suggests many proposed interventions are tick boxes or just plain snake oil. They see removing discrimination as a means of improvement not just statutory compliance.
Such leaders understand the decisive importance of their own role and behaviours. When faced with increasingly complex challenges they don’t plot ahead of meetings and present staff with a predetermined solution but instead create a space for collaborative discussion where staff can safely share a range of ideas and potential solutions in the knowledge they will be listened to and respected for doing so.
They know that inclusive teams will also be more likely to recognise that among the most valuable sources of information are the reports and voices of patients, carers and staff. Such teams will be more likely to enable staff to counter pose their professional duty of care to countervailing pressures.
Such leaders understand that ending institutional racism in the NHS (for that is what it is) requires an intellectual understanding of racism and of white fragility because we cannot end that which we are unwilling to see.
They are aware of, and seek to challenge, the countless micro-aggressions that undermine “outsiders” and the pervasive bias that distorts decision making. They acknowledge they must stop turning appraisals, interview feedback and performance discussions with Black and Minority Ethnic staff into “difficult discussions” where the fear of saying “the wrong thing” makes the entire conversation an unsafe one. Such leaders understand that the NHS is symbolic of our shared humanity and of the belief that social justice is good for the public health of all of us. They therefore seek to remove discrimination as a major affront to NHS values and an obstacle to good health care and staff well-being.
Such leaders, in other words, make diversity and inclusion a personal priority.
The 2019 NHS Long Term Plan acknowledges the crucial importance of caring for staff to improve patient care. That will happen when NHS leaders speak truth to power and act on the evidence that challenging discrimination and enabling inclusion is an essential pre-requisite for success, not an optional extra.
That is why those who wish to join the new national NHS Aspiring Directors talent pool are required to demonstrate that they
- Have a deep seated conviction that they cannot achieve their personal goals without creating an inclusive culture
- Give feedback in a non-judgmental way to people who are not demonstrating inclusive behaviour
- Create an enabling environment in which it is easier for people to behave in an inclusive way
Those who cannot do so cannot be entrusted to lead the NHS.
- Developing People: Improving Care (2016) NHS Improvement.
- Carter M, West M, Dawson J. (2008) Developing team-based working in NHS trusts. Report prepared for the Department of health.
- Kline, R (October 17 2018). Diversity and inclusion are not optional extras if the NHS wishes to improve. Health Service Journal,
- West M, Eckert R , Collins R. (2017) Caring to change. How compassionate leadership can stimulate innovation in health care. Kings Fund,
- Unwin J. (2018) Kindness, emotions and human relationships: the blind spot in public policy. Carnegie,
- Edmondson A. (1999) Psychological safety and learning behavior in work teams. Adm Sci Q 1999; 44:350–83.
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.