An Open Letter to Stephen Barclay on diversity by Roger Kline

Dear Mr Barclay.

Good Government is built on evidence-based strategy. Your department and its media allies’ call (1) for NHS organisations to spend money on patient care and frontline services“ rather than “diversity and backroom bureaucracy” assumes equality, diversity and inclusion (EDI) work is an alternative to patient care.

However, your predecessor Sajiv Javid commissioned General Sir Gordon Messenger to consider leadership in the NHS. He found that “acceptance of discrimination, bullying, blame cultures and responsibility avoidance has almost become normalised in certain parts of the system, as evidenced by staff surveys and several publicised examples of poor practice. This exists at the micro-level, in individual workplaces, and across sectors, where the enduring lack of parity of esteem, conditions and status between healthcare and social care remains a blight on effective collaborative working.”  (2)

There has been some (in my view, glacial) improvement in the last 5 years but the latest NHS staff survey shows staff well-being, engagement and the willingness to raise safety concerns deteriorating, whilst bullying remains rife and discrimination is ubiquitous. (3)   The latest WRES data shows it is still over twenty (20.5) times more likely that a White Band 5 nurse will become a Director of Nursing compared to a Band 5 BME nurse

The NHS Constitution stresses NHS workplaces and patient care should be free of discrimination. Research strongly suggests how staff are treated (including whether they face discrimination) impacts on patient care, staff well-being and organisational effectiveness. Inclusion is the extent to which staff believe they are encouraged to contribute to the effectiveness of that group and where all staff believe they are valued members of the work group, and in which they receive fair and equitable treatment. Specifically, where diversity, including at senior levels, is underpinned by inclusion, it benefits staff engagement, retention, innovation, productivity and the safety and quality of care.  Inclusive teams are more likely to be ‘psychologically safe’ workplaces where staff feel confident in expressing their true selves, raising concerns and admitting mistakes without fear of being unfairly judged[i] enabling efficient, productive and safe care. (4)

There is a wealth of relevant research:

  • In hospital settings, managing staff with respect and compassion correlates with improved patient satisfaction, infection control and mortality rates, Care Quality Commission (CQC) ratings and financial performance.[ii] (5)
  • High work pressure, staff perceptions of unequal treatment, and discrimination against staff all correlate adversely with patient satisfaction. (6)
  • Organisations with more diverse leadership teams are likely to outperform less diverse peers with good correlations between leadership diversity and financial performance. (7)
  • Inclusive leaders who promote equality and diversity are good for organisations (8)
  • The cost of bullying and harassment of staff alone has been conservatively estimated as costing the NHS £2.3 billion per year[iii] (9). Some workforce groups, notably LGBT+ staff, disabled staff and black and minority ethnic staff, report that they experience particularly high levels of bullying from colleagues and managers. whilst staff who are bullied are likely to be less willing to raise concerns and admit mistakes[iv].

You demand “Value for Money” but in doing so risk confusing efficiency and effectiveness. Abolishing EDI posts would save a few million pounds, but the cost in reduced effectiveness is likely to far outweigh any savings. For example, consider the consider cost of at least 150,000 NHS staff choosing to solely work as bank or agency staff, many because they feel they were treated unfairly in their substantive roles – especially black and minority ethnic workers, and women seeking flexible working arrangements. (10). It is unclear what “value for money” means when measuring the levels of harassment and even poorer career progression for ethnic minority staff, worse treatment of international recruits, higher agency costs, and teams where staff are less willing to admit mistakes, raise concerns or work collaboratively – the likely consequences of less attention to EDI.

There has been some progress on equality – for example the numbers of disciplinary cases involving ethnic minority staff have fallen substantially since 2017. Boards have become more diverse in recent years but the pipeline of more diverse senior managers remain precarious. Some organisations have developed more flexible working patterns to adapt to the changing needs of their workforces.

But in all these areas of progress, specialists in equality, diversity and inclusion alongside leaderships who understand and act on this evidence have played a crucial role in highlighting problems and signposting solutions.  The cost is minimal and the benefits substantial.

You refer to equality being everyone’s business. I agree, but research is resoundingly clear that progress depends on inclusive leaderships explicitly paying attention to EDI:

  • Support from top management is key in determining the success of diversity programmes. (11)
  • Where diversity interventions lack the involvement of top managers and fail to address overall work processes, their long-term effectiveness in transforming organizational culture is likely to be limited (12).

In every other challenge facing the NHS we know we need expertise that leaderships can draw on. Unless there are specialists and senior leaders who understand and challenge discrimination, who model the behaviours they expect of others, who pay sustained attention to these issues, then patient care, staff retention and engagement, innovation, creativity and staff well-being will suffer as will progress on challenging inequality in healthcare provision. Such evidence-based leadership is a cornerstone of the service improvement we all seek. There is certainly work to be done in ensuring work to improve equality, diversity and inclusion is always evidence based, but that requires precisely the expertise you demean.

Your office suggests we cannot afford such “luxuries”. The evidence powerfully suggests we cannot afford to not pay attention to it.  (HBR 2019)

Yours sincerely

Roger Kline OBE, FRSA, Research Fellow, Middlesex University

[i] Shore LM, Cleveland JN, Sanchez D. (2018) Inclusive workplaces: A review and model Human Resource Management Review; see also Edmondson, A (2018) The Fearless Organisation: Creating Psychological Safety in the Workplace for Learning, Innovation and Growth. Harvard Business School: Whiley


[ii] Dixon-Woods M, Baker R, Charles K, et al. Culture and behaviour in the English National health service: overview of lessons from a large multimethod study. BMJ Qual Saf 2014;23:106–15.doi:10.1136/bmjqs-2013-001947 See also M West (2021) (West M (2021) Compassionate Leadership: Sustaining Wisdom, Humanity and Presence in Health and Social Care.

[iii] Roger KlineDuncan Lewis (2019) The price of fear: Estimating the financial cost of bullying and harassment to the NHS in England. Public Money and Management Volume 39 2019 Issue 3

[iv] Lucian L Leape , Miles F ShoreJules L Dienstag, et al (2012) Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Acad Med. 2012 Jul;87(7):845-52. doi: 10.1097/ACM.0b013e318258338d.



Roger Kline

Roger Kline is Research Fellow at Middlesex University Business School. He authored No more tick boxes: a review of the evidence on how to make recruitment and career progression fairer and “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 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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