Following on from the powerful blog “After the speeches…” that outlined actions needed to reduce discrimination, we are delighted to publish part six of a ten part blog series by Roger Kline with suggestions on how to tackle structural racism in the NHS.
The NHS is currently awash with race equality Action Plans but many fall short of standards of rigour and underpinning evidence we would expect of plans on other issues. Too often the annual interrogation of such Action Plans results in the production of another plan, with little analysis of progress – or lack of it – and any lessons for the forthcoming year.
Plans are not compelled to demonstrate why specific interventions might work, or show evidence of effective practice or underpinning research.
So what might help Boards do better?
- Stop thinking you can fatten a cow by weighing it.
This African Proverb sums up our pre-occupation with measurement – our belief that regurgitating data will, of itself, reduce inequality. It is critically important to use data (soft and hard) to help identify the problem, and to know what progress is (or is not) being made, but that is a means not an end.
- Distinguish symptoms and causes
One reason Action Plans are full of actions that don’t (won’t) move the dial, is that they may be tackling the wrong problem. For example, there is little point in prioritising making disciplinary panels more diverse if the real problem is that many cases involving BME staff should never have started. Equally it is pointless identifying the absence of a mentoring programme as crucial if the biggest problem is institutional discrimination preventing the promotion and retention of BME staff (or women, or disabled staff).
- Make sure the plan addresses workplace culture
Research strongly suggests tackling “organisational climate” is crucial. “How we do things round here” is greatly influenced by what leaders, especially senior leaders, do. Do they model the behaviours they expect of others and make diversity and inclusion a personal priority? Do such leaders show curiosity, listen without being defensive, and admit mistakes, recognise and respond to their own privileges and call out discrimination? Kindness is great – but it’s more important that people are treated fairly – they don’t have to be best friends.
Addressing the causes of racism, has never been so important. So unless actions address covert and overt racism – including micro-aggressions, actions will have limited sustainability. “Easy wins” are usually not wins in the long term. Boards must be frank about the impact of racism to tackle its manifestations. Some Trusts do this.
- Beware of excessive reliance on policies and procedures
Policies and processes can easily be subverted and in isolation will not change culture or outcomes. Action planning is often too focussed on policy and process updates but without real evidence (what have you discovered which suggests that the policy needs amending) as to why. Much better to increase people’s understanding and use of what is already in place. Policies and procedures overwhelmingly rely on individuals raising concerns yet research suggests organisations need to proactively tackle challenges like bullying or racism.
- Make sure we learn as we do
We often copy what others are doing before asking for evidence that it worked, or even what “worked” means. Or whether it is likely to work in a quite different environment. If we uplift a healthy palm tree and plant it inside the Arctic Circle it will die. We are seduced into believing that if it sounds like it should work, then it will. Do we still respond defensively when someone suggests race might be a factor in their treatment, thus immediately shutting down discussion and learning?
If what we tried last year didn’t work, do we ask why? Why not? Do we even publicise the fact last year’s plan didn’t work? Do we apply an improvement methodology to work around race discrimination? Action Plans that don’t give an explanation why a specific intervention is proposed, what problem it is trying to solve, what research or best practice it is based on, and what change it is expected to make, should be binned.
- Be proactive not reactive
Do we treat racism as a public health issue? Do we triangulate the hard data and soft intelligence, listening to staff to anticipate problems? If staff survey data is saying there is a problem and no one is raising a concern then there is a double problem. If workforce data says there is a steep ethnicity gradient yet no formal concerns are raised about selection and career progression, it is because it seen as pointless.
- Listen, really listen, to Black and Minority Ethnic staff
Believe it or not BME staff are not responsible for addressing racism in your organisation, no more than women are responsible for rooting out sexism. But they do have a critical role to play in helping the organisation to understand how racism is experienced and in shaping responses. The Board are the custodians of the tackling racism and HR along with senior managers should drive the change. Do not dump responsibility onto an under-graded, under-resourced EDI lead.
- Accountability is crucial
Accountability is key. That might mean asking divisional directors to explain disproportionate patterns in appointments and then expect (with support) to remedy any discrimination. It might mean requiring interview panels to explain to the HR director why women and BME candidates good enough to be shortlisted were not appointed and what support is needed going forward. It might take the form of stopping managers commencing disciplinary investigations unless they can explain why such investigations are appropriate. It should mean setting individual KPIs and organisation-wide goals which the Board holds senior managers to account for, as with other significant proposals.
- If we don’t know if it might work, ask why we’re doing it
When presented with Race Equality Action Plans few Boards ask whether the interventions proposed have a reasonable likelihood of making the difference they are expected to. If those proposing cannot explain why, do not agree them.
- Make sure staff, including front line managers, understand the intended benefits of the Action Plan.
The majority of NHS managers are below Band 8. Too often Action Plans assume these front-line managers will “do as they are told” rather than meet with their own managers to discussion the rationale behind the Action Plan, its implications for them, the support they’ll get and how it will help them manage better and help them provide better care.
- Make sure your efforts are sustainable.
If the Action Plan is dependent on one forceful Board member, then although change might happen it may not be sustained. If the culture leading to unfair disciplinaries is not changed, or if improved representation at senior levels is not accompanied by increased understanding of why inclusion is so important, gains can quickly disappear. Sustained improvement requires an understanding of how racism is maintained and a willingness to dismantle it, creating the psychological safety for staff to raise concerns and helping all staff to recognise their role in building an inclusive culture. If these aspirations are underpinned by evidence, accountability and the courage to do what is right – it can lift action off the page and into the heart of the organisation.
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.
Joy Warmington
Joy is CEO of brap, (www.brap.org.uk ) an equalities and human rights charity that believes that we can be more ambitious in our attempts to close inequality gaps. brap work to use evidence, innovation and evaluation, to make sustainably progress in the area of social justice. She is a faculty member of the NHS leadership Academy and highly regarded as facilitator and coach. She is also a Non-executive Director at Birmingham and Solihull Mental Health Foundation Trust.
Declaration of interests
We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.