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.
“We know – intellectually – that confronting an issue is the only way to resolve it. But any resolution will disrupt the status quo. Given the choice between conflict and change on the one hand, and inertia on the other, the ostrich position can seem very attractive.”
Margaret Heffernan, Willful Blindness: Why We Ignore the Obvious at Our Peril
Data is an essential source of evidence for good management decision-making Mary Dixon Woods distinguishes problem solving and comfort seeking behaviours.
“Problem-sensing involved actively seeking out weaknesses in organisational systems, and it made use of multiple sources of data—not just mandated measures, but also softer intelligence…….” https://qualitysafety.bmj.com/content/23/2/106
For NHS race discrimination, problem-sensing leaders seek out and interrogate both “hard” and “soft” data. They use workforce data (notably Employee Staff Records), staff surveys, turnover data, exit interviews, Datix records, grievances, absenteeism patterns, alongside information from Speak Up Guardians, BME networks, union and professional representatives, focus groups and corridor conversations, as well as patient survey data and complaints.
Such leaders at Board, division, profession, service, site and team level triangulate such data and seek to anticipate “surprises”. They do so through a “learning lens” paying particular attention to the lived experience of those whom data suggests are subjected to discrimination. They pay attention to comparisons with similar organisations and national intelligence. Such leaders are constantly alert to discomforting information and understand the importance of creating safe spaces to raise it. They are wary of reassurance and pay attention to data patterns, individual concerns and everything between.
“comfort-seeking behaviours are defined here as being focused on external impression management and seeking reassurance that all was well; consequently, what was available to organisations was data, but not intelligence. https://qualitysafety.bmj.com/content/23/2/106
Robert Francis had such behaviours in mind when he concluded:
“there lurks within the system an institutional instinct which, under pressure, will prefer concealment, formulaic responses and avoidance of public criticism…an institutional culture which ascribed more weight to positive information about the service than to information capable of implying cause for concern.” https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/279124/0947.pdf
That “instinct” is exacerbated by the difficulty we as White people have in discussing race discrimination, where data and intelligence “comfort seeking” takes several forms.
Wilful blindness. One Trust’s recruitment data with showed 80% of staff shortlisted were White whilst 20% were from Black and Minority Ethnic (BME) backgrounds. At appointment, 90% of White interviewees were appointed and 10% of BME interviewees. When I said this meant they had a serious problem I was met with looks of surprise. I was told “it’s not brilliant but the change from 80% White staff shortlisted to 90% appointed is hardly catastrophic”. In fact, this meant it was more than twice as likely (20/10 x 90/80 = 2.125) that White interviewees would be appointed from shortlisting as BME ones.
Avoidance. I shared one Trust’s (dreadful) data on workforce race equality with a Board. One NED asked where ‘my’ data came from. I explained it was from the Trust’s own website. The Board had not been told about this data, almost certainly because it did not reflect well on those who owned it.
In another Trust it was clear that Workforce Race Equality Standard (WRES) data was essential context for deciding whether two junior managers had a case to answer for race discrimination. The HR director redacted that information from the investigation report as “not relevant”.
Similarly, the external independent report into the tragic suicide of Amin Abdullah managed to do so without once questioning whether race discrimination might have been a factor. https://www.linkedin.com/pulse/sound-silence-roger-kline/
Denial. In most NHS organisations prior to the WRES, the annual Workforce Reports consistently claimed the numbers of staff being disciplined were too small to draw any conclusions about whether BME staff were disproportionately disciplined. Yet it was consistently clear that more BME staff entered the disciplinary process than White staff.
Defensiveness. In one high profile Trust, every nurse and midwife Fitness to Practice referral to the Nursing and Midwifery Council was BME staff. When a very senior BME nurse suggested the Senior Management Team explore why, the Chief Nurse asked her if she was calling her a racist. That ended the discussion and her career went downhill thereafter.
Disbelief. Some senior leaders have assured me their BME network is not “representative” and that most BME staff were positive about the Trust even when staff survey and turnover data said the opposite. Similarly, during Covid, on three separate occasions when I told Trusts that nurses were telling me redeployment decisions for BME staff made them feel like “cannon fodder”, such accounts were simply not believed.
The 2015 Francis report on Speaking Out found BME staff were much more concerned even than White staff about the consequences of speaking out http://freedomtospeakup.org.uk/wp-content/uploads/2014/07/F2SU_web.pdf yet prior to the staff survey data analysis, the DHSC assured me there was no evidence of this.
Selective use of data. One trust proudly told me there was not one BME staff grievance about bullying the previous year yet their staff survey reported that 39% of BME staff felt they were bullied by colleagues or managers. In fact, they had a double problem since the absence of any grievances also suggested staff either felt there was no point complaining or feared that doing so would make things worse.
Rose tinted spectacles. National bodies are not immune from comfort-seeking. For example, the national WRES report for 2019 states that
“White applicants were 1.46 times more likely to be appointed from shortlisting compared to BME applicants; a similar figure to that reported in 2018, and an improvement on the 1.60 times gap in 2017 and 2016……. (The) WRES indicator ……. on beliefs regarding equal opportunities in the workplace (has) not changed for both BME and white staff”. https://www.england.nhs.uk/wp-content/uploads/2020/01/wres-2019-data-report.pdf
Had this been local NHS Trust data, a problem sensing Board might instead expect something like this
“The likelihood of White staff being appointed from shortlisting compared to BME applicants was 1.46 times higher, slightly worse than 2018, with only slow improvement over the previous three years. There was a deterioration in whether BME staff felt there were equal opportunities for career progression or promotion”.
Let’s commission another report. Most NHS organisations already have oodles of data and intelligence at their fingertips. What is needed is not yet more commissioned data but making sense of, and acting on, existing data.
COVID-19 and Black Lives Matter seems to have galvanised NHS leaders, a growing number of whom understand that an open, honest, problem-sensing approach is crucial if new national goals on race equality are to be reached. The time for comfort seeking is over.
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.