It helps to know “why” before you do “what” by Roger Kline

Following on from the powerful blog “After the speeches…” that outlined actions needed to reduce discrimination, we are delighted to publish part eight of a ten part blog series by Roger Kline with suggestions on how to tackle structural racism in the NHS.

In the Second Wave of COVID-19 the NHS is committed to avoid its shortcomings towards Black and Minority Ethnic staff in the First Wave. This time round individual staff risk assessments should be in place (even for agency staff) and there is some (not enough) effort to draw organisational lessons from the individual assessments. There is greater awareness of the risk of disproportionate deaths of NHS staff (especially BME staff) not least since it seems very likely that “occupational exposure” was a key cause and that discriminatory treatment (intentional or otherwise) played a key role.

This time round there is greater awareness that equality, diversity and inclusion are not optional extras (suspending WRES and WDES collection) but are crucial contributors to the best possible patient care, staff retention, and organisational effectiveness. There are national targets for leadership diversity and BME representation built into The NHS People Plan.

Research suggests that the ability of leaders to understand, articulate and act on the evidence about race discrimination is decisive in whether equality, diversity and inclusion improve. Any NHS leader not committed to social justice (enshrined in the NHS Constitution) and unaware of the immense waste of talent caused by race discrimination has been asleep. Any leader who is not aware that treating all staff well improves patient care and safety, staff retention and organisational effectiveness and that this especially applies to BME staff has homework to do. Similarly bullying, which disproportionately impacts BME staff, undermines teamwork and safety and deters BME staff in particular from raising concerns. Racism has a cumulative impact on the health and well-being of BME staff.

Research lays out the institutional and structural underpinning of racism both within NHS employment, in health service provision and in the factors that drive ill health including the impact of Covid 19, as the Fenton Review summarised.

Crucial to a successful NHS strategy, therefore, is the evidence that diverse and inclusive leadership, which understands this is crucial, and that such leadership must reflect on its own privilege and address the institutional and structural obstacles we face. But Ministers and their advisers disagree.

The Equalities Minister sought to hide the recommendations of the Fenton Review and “hit back at claims ‘systemic injustice’ is the reason ethnic minorities are more likely to die from coronavirus in England”. In similar vein the head of the No 10 Policy Unit dismisses the concept of institutional racism claiming “a lot of people in politics thinks it’s a good idea to exaggerate the problem of racism”.

Meanwhile, Dominic Cummings, no less, argues that people

“talk a lot about ‘diversity’ but they rarely mean ‘true cognitive diversity.’ They are usually babbling about ‘gender identity diversity blah blah.’ What [we need] is not more drivel about ‘identity’ and ‘diversity’ from Oxbridge humanities graduates but more genuine cognitive diversity.

The previous Equalities Minister, Liz Truss, argued too much ground had been ceded to the Left on issues of identity:

“We need to reassert the value of individual and character above the particular type of group you might happen to be a member ofI think there’s been too much identity politics in Britain”

She was also dismissive of “identity”. But these claims about “diversity” are also wrong and need to be addressed. So what do we know?

Diversity can enable differences in knowledge, information, models of thinking, heuristics which may give better outcomes on tasks such as problem solving, prediction, innovation and creativity, evaluation, verification and developing strategies. Both demographic diversity (e.g. gender, disability, age, race, sexual orientation, social class) and cognitive diversity (i.e. people who have different ways of thinking, different viewpoints and different skill sets in a team or business group) can make a very significant difference to performance – and although they are not the same they do substantially overlap (think Venn diagram).

Demographic diversity (which is also likely to draw on upbringing, education, work and life experience) will specifically contribute to the differences in performance of those engaged in non-routine cognitive. Non-routine cognitive work would include solving a problem, planning a solution, predicting an outcome, developing a policy, evaluating options, undertaking research etc. A large proportion of NHS staff engage in non-routine cognitive thinking.

Moreover, counter-intuitively, the best teams engaged in non-routine cognitive work do not consist of the group with the best individual performers but are diverse ones consisting of both good performers with other varying cognitive (and often demographic) performers. Counter-posing the “best” candidate and one who adds diversity is a false dichotomy. The best teams need both good performance and diversity – the latter is crucial to ensure a good mix of knowledge bases, analytical tools, mental models, different perspectives, experiences and information. That is why a diverse team is likely to be better (will be better) than a team of ten composed of the best performers (1).

Evidence for this? Firstly, there are numerous large scale correlative studies linking workforce and leadership diversity to organisational performance though a substantial number of these analyses are not peer-reviewed.  Secondly there are large numbers of smaller experimental evidence studies showing that teams give better performance than individuals and that diverse teams generally (no0t always) produce better results than homogenous ones. Thirdly, there are analyses of very large data sets such as multiple analyses demonstrating that team based, and research papers by diverse teams, are substantially more impactful and much more.

Where diversity is underpinned by recruitment and career progression that ensure all talent is drawn upon and developed, and there is an inclusive work environment where difference is valued, respected and where team members trust each other, then significant performance improvement is likely to follow.

Diversity alone does not necessarily improve performance. Indeed diversity may reveal prejudice which may undermine performance if it is not managed effectively since there are potential conflicts and tensions in diverse teams that may not exist within homogenous ones. But when leaders put in place the preconditions for inclusion – including psychological safety– and make clear their belief diversity and inclusion are essential and can improve how teams work, it can make a significant difference.

The meta-analyses of the correlative evidence have generally come to mixed conclusions i.e. there is evidence of positive impact of diversity but not in all situations. It is how teams and organisations, including diverse teams and organisations, are led and managed that seems crucial.  And there is another benefit of demographic diversity. The introduction of demographically different people may make a difference by their mere presence since it causes us to think harder and differently – generating more ideas and complex arguments.

The dominant and lop-sided paradigm dominating Government thinking on diversity risks undermining progress towards a diverse inclusive NHS leadership. It needs to be openly engaged. It is wrong and we should explain why.


  1. Scott E Page (2017) The Diversity Bonus: How Great Teams Pay Off In The Knowledge Economy.

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.

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