The NHS employs 1.6 million people,¹ with 42 integrated care systems (ICSs) and 215 trusts across England, but it has less than ten chief executives from minoritised communities.¹ There is also less than 13% representation of minoritised executive directors and very senior managers, despite 24% of the workforce being from minoritised backgrounds. One in three trusts has entirely White boards (HSJ, 2020; NHS England, 2023). There are 35 NHS Trusts in London and only three minoritised CEOs. Yet over 50% of London’s population and health and social care workforce comes from minoritised communities. They face the highest percentage of racism in the sector. Black women are almost four times more likely to die in maternity services in the UK than White women. Black people are five times more likely than White people to be sectioned under the Mental Health Act 1983 and less likely, together with Asian people, to receive treatment and support from mental health services and therapy). I can think of only one good example of transcultural board leadership off the top of my head: East London Foundation Trust, the only mental health Trust in London with an outstanding CQC rating, which I believe is not coincidental. Out of the ten Executive Directors, six are visibly from minoritised backgrounds. With psychological safety, representation, and innovation from the top down, it showcases hope, trust, and inspiration for all staff.

Personal perspective

Having worked in the NHS for about 11 years now, I have personally experienced and witnessed nepotism, racism, discrimination, silent leadership, and lack of accountability of managers and others. In my view it is widely recognised that NHS managers currently have no real sense of accountability to a regulatory body and can quickly move on from one NHS organisation to another. This can have the effect of limiting the voices of individuals who have perhaps been impacted by them and their actions.

There is ample opportunity to lead by example here. We have yet to have a Black Chief Nursing Officer, while the reality is that the NHS would not have existed without nurses from the West Indies and the Commonwealth, and we continue to rely on an international workforce. White people from the host community mainly occupy positions that impact policies, commissioning, research bodies, management, and leadership roles. It would be better for NHS managers to have a regulatory body for health and social care management, and individuals in such roles who understand the non-White workforce and their contexts. This may not solve all the problems, but it would be a positive start to acknowledge the difficulty that exists for a single minority voice to be heard. There are no safe spaces for individuals who have been caught up in some complexity in their working life and regulations and are experiencing moral injury. I feel that many may have lost faith in Freedom to Speak Up Guardians acting equitably and fairly; meanwhile, we continue to see inappropriate promotion of people who are not always worthy or the kindest leaders to lead those they do not represent.

Transcultural leadership

The NHS has an international workforce which requires transcultural leadership, as leadership is about serving. According to Smith (2013), “being transcultural is to purposely interact with people by transcending cultures’ natural barriers with the sole objective of bringing the ‘many’ to one in vision, purpose, and action.”

It is suggested that transcultural leaders:

• are open-minded, respect different beliefs and are life-long learners.
• instil trust and adapt socially through flexibility, patience, an even disposition, navigating ambiguity, humility, locus of control, and initiative.
• focus on global networks, driving performance and building team effectiveness.
• enjoy new challenges, strive for innovative solutions to social and situational issues and learn from a variety of sources.
• can build and maintain trusting relationships that are intersectional and across cultures.
• are inclusive in social situations, demonstrate a genuine interest in other people, and exhibit a good sense of humour.
• see through vagueness and uncertainty, do not become frustrated, and figure out how things are done in other cultures.
• remain calm without being critical and demonstrate respect for the political and spiritual beliefs of other cultures. Transcultural leadership is about anti-racism, with starts with oneself, un-learning and re-learning about biases, discrimination, and racism, including anti-blackness, misogynoir, Islamophobia, antisemitism, caste systems, etc.

Transcultural leadership can embed anti-racism and psychological safety for all. Transcultural leaders can navigate situations which could otherwise exclude individuals from minority populations as they can recognise, respect and mitigate differences due to being knowledgeable about their own culture and challenge confirmation bias whilst having skills to interact generally in a multicultural work environment² However, Brown (2007) reported this does not mean that transcultural leaders profess to know it all. Transcultural leadership is about positive influence to create an inclusive environment and cooperation. The impact is that we can have diverse perspectives, a smarter workforce, innovation, better productivity, and profitability.³

Overall, leadership should create various leaders of different backgrounds, to ensure not only representation but individuals who create psychological safety, prioritise equality and in all reality want to put it into action.

Therefore, allyship is essential to transcultural leadership, because:

• We cannot say we are leaders when minoritised staff do not have a seat at the highest table.
• We cannot say we are leading when we cannot inspire those who are not represented and whose voices are not being heard.
• We cannot say that we are anti-racist when Black nurses are more likely to be referred by employers to regulatory bodies, and 63% of Black nurses are referred by workplaces to the NMC with no case to answer.⁴
• There is no leadership when most Black nurses stay stagnant at lower bands due to systemic racism, discrimination, and nepotism. Where a Black senior nurse is not safe to work at NHS England due to racism.⁵
• There is no leadership when there remains a “snowy white peak.”⁶ So who will represent the best interest of minoritised and underrepresented communities?

The NHS needs anti-racist, culturally inclusive and compassionate, humble, and transcultural leadership and health and social care services. We must have diverse CEOs and leaders to deliver and sustain a better, psychologically safe organisation. For all those NHS Trusts and leaders saying they are becoming anti-racist, I would like them to report yearly on the actions and reflections to achieve this and see the improvement in data results of staff surveys, WRES, exit interviews, and companies’ review websites. And, of course, the NHS needs diversity and representation from the top down. After 75 years, how much longer will it take for meaningful change-making in the NHS? Where everyone believes in a system of fairness, equality, and inclusion? Where there is no room for bad or silent management? The key to leadership is to ensure everyone can develop and grow. It is not about the few but the many.

References

1. NHS. NHS Long term plan. NHS Engl. (2019).
2. Simons, R. L. et al. Discrimination, segregation, and chronic inflammation: Testing the weathering explanation for the poor health of Black Americans. Dev. Psychol. 54, 1993–2006 (2018).
3. Brown, J. F. The global business leader : practical advice for success in a transcultural marketplace. INSEAD Bus. Press Ser. xvii, 134 p. (2007).
4. West, E., Nayar, S., Taskila, T. & Al-Haboubi, M. The Progress and Outcomes of Black and Minority Ethnic (BME) Nurses and Midwives through the Nursing and Midwifery Council’s Fitness to Practise Process. 1–35 (2017).
5. Kline, R. Paradigm lost? Reflections on the effectiveness of NHS approaches to improving employment relations. BMJ Lead. (2023) doi:10.1136/leader-2022-000729.
6. Kline, R. The ‘snowy white peaks’ of the NHS: a survey of discrimination in governance and leadership and the potential impact on patient care in London and England. (2014).

Authors

Mushtag Kahin

Mushtag is a Registered Nursing Associate, a NHS Governor, undertaking her MSc student in Mental Health Studies. She is volunteer at the Hayaan project (Mind in Harrow), and a disruptor. Mushtag is passionate about transcultural leadership and care, anti-racism and coaching.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None

 

Dr. Nagina Khan, BHSc, PGCert, Ph.D. 

Dr Nagina Khan is a Senior Postdoctoral Researcher, Cultural Psychiatry & Health Inequalities (CHiMES), Department of Psychiatry, Oxford University. Nagina’s research is focused on social justice, equality, and fairness, in culturally appropriate mental health care and complex interventions. She is working on the staff data analysis of Experience based investigation and Co-design of approaches to Prevent and reduce Mental Health Act Use: (CO-PACT) study. Nagina has worked as a Scientist at Centre for Addiction and Mental Health (CAMH) on the mixed method study focused on the Cultural adaptation of CBT for Canadians of South Asian Origin. She was a Medical Research Council (MRC) Research Training Fellow, her research was centred on complex interventions for people with depression, University of Manchester. Her post-doctoral studies were undertaken at the NIHR School for Primary Care Research, UK focusing on First episode Psychosis in Young People Using Early Intervention services. Other research interests include, Social Justice in medical education, Professionalism in undergraduate medicine and Incentivisation Schemes (P4P) in healthcare for HICs and LMICs. Nagina is an Editorial board member of the BioMed Central Medical Education Journal. She is also the BMJ Leader Editorial Fellow.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None