A moment that changed how I saw leadership
Early in my career, I witnessed a senior colleague use racially biased language about a patient, then deliver a lower standard of care. I felt shocked, angry and unsure how to respond.
At the time, I didn’t have the language to describe what I had seen. But I knew it mattered.
That moment stayed with me across nearly four decades in nursing, paramedic practice, ambulance services, education, and leadership. It shaped how I understand inequity and leadership in clinical environments.
Why inclusion is a clinical issue, not a values statement
We often describe NHS leadership in terms of strategy, performance, or transformation. Increasingly, inclusive leadership must be understood as a clinical imperative.
Framing inclusion as an aspiration or value is no longer enough. It is fundamental to patient safety, workforce wellbeing, and system sustainability (Schulson et al 2022)
Health inequalities shape who accesses care, how quickly conditions are recognised, and what outcomes patients experience. These differences are avoidable and unjust. So why do they persist?
The culture leaders create plays a significant role. If staff cannot speak up, challenge decisions, or learn from mistakes, care quality and safety are affected. Inclusion and safety are inseparable.
For those of us across clinical care, education, and service delivery, this shows up in everyday decisions.
Leadership beyond job titles
My leadership developed through practice rather than position. Frontline roles exposed me to deprivation, bias, and inequity. In education, I saw inequities in access, attainment, and opportunity.
These experiences taught me that leadership is less about hierarchy than influence, accountability, and values in action.
Inclusive leadership is enacted daily through how we respond to bias, support others, and challenge what does not feel right.
The values that shape inclusive leadership
Four values have consistently guided my approach:
- Equity – recognising that fairness is not sameness
- Belonging – creating spaces where people can contribute authentically
- Courage – being willing to challenge norms and name inequity
- Representation – understanding that visibility shapes trust and aspiration
In a system as complex as the NHS, these values are practical. They influence strategic decisions and daily interactions: how feedback is given, whose voices are heard, and how difference is approached.
What this looks like in practice
Inclusive leadership is visible in behaviour.
In practice, this means:
- creating psychologically safe environments where people can speak up
- aligning organisational values with everyday actions
- recognising and addressing power dynamics within teams
- modelling openness, humility and a willingness to learn
These behaviours matter because psychological safety underpins learning and patient safety. If people cannot question decisions or raise concerns, risks remain hidden (Kline 2025)
Why progress can feel slow
Despite broad agreement, moving from intention to action is not straightforward.
Common barriers persist; fear of saying the wrong thing, discomfort discussing racism or inequity, “tick-box” perceptions, and pressure in busy clinical environments.
I have learned that resistance is often misunderstood. It is not always opposition; it is frequently uncertainty, fear, or the legacy of poorly implemented initiatives.
Inclusive leaders can reframe this, normalising discomfort as part of learning and linking inclusion to clinical outcomes.
When inclusion is positioned as an “extra,” it struggles for priority. As a patient safety issue, its relevance becomes unavoidable.
What actually makes a difference
Evidence and experience point to approaches that improve engagement:
- Shared learning when leaders learn alongside staff, it signals collective responsibility
- Empowerment trusting teams to innovate and learn builds confidence and engagement
- Recognition celebrating inclusive behaviours helps embed culture
- Alignment ensuring inclusion is reflected in everyday decisions, not just policy
In practice, these are simple interventions: fair access to opportunities, inclusive supervision, and intentional leadership and teaching (George and Masey 2020).
Creating cultures where people can speak up
Psychological safety is central to inclusive leadership (Kline 2025).
Healthcare hierarchies can make it difficult to raise concerns, particularly for marginalised groups. Inclusive leaders work against this by:
- inviting challenge and curiosity
- responding constructively when concerns are raised
- being open about their own mistakes
- consistently reinforcing supportive behaviours
Psychological safety is built over time, through consistent, observable actions.
Representation as a patient safety issue
One tangible example of my work in action is the Reframe Image Library, created to address the lack of diversity in clinical imagery.
Historically, medical education has relied heavily on images of white, able-bodied individuals. Yet conditions can present differently across skin tones; if clinicians are not trained to recognise this, care may be delayed.
Reframe offers a practical solution: over 3,000 diverse images supporting more accurate diagnosis, better education, and increased patient trust.
It demonstrates a key point: inclusion must translate into practice. Representation is not symbolic; it is central to clinical competence.
A call to action
The implications for NHS leadership are clear:
- Inclusion is a patient safety issue
- Leadership is defined by behaviour, not title
- Representation shapes outcomes and trust
- Culture is created every day, in small moments
So, my challenge is this: reflect on your own practice.
Where do people speak up, and where do they hesitate?
Whose voices are heard?
What small change could make your team more inclusive tomorrow?
Inclusive leadership is not an additional task. It is part of safe, high-quality care. If we are serious about outcomes, inequalities, and workforce wellbeing, inclusion must move to the centre of clinical practice.
It requires courage: to challenge, listen, and keep learning, even when uncomfortable, because that is often where meaningful change begins.
References:
George, V. and Massey, L. (2020) Proactive strategy to improve staff engagement. Nurse Leader, 18(6), pp. 532–535. Available at: https://doi.org/10.1016/j.mnl.2020.08.008 (Accessed: 22 July 2026)
Kline R (2025) Not an optional extra. The price of not tackling discrimination in the NHS. London: The Seacole Group. Available at: https://acrobat.adobe.com/id/urn:aaid:sc:EU:d9e38846-0b1d-41cf-85d2-9ff899eb68d2?viewer%21megaVerb=group-discover
Schulson LB, Thomas AD, Tsuei J, Etchegaray JM (2022) Identifying and Understanding Ways to Address the Impact of Racism on Patient Safety in Health Care Settings. RAND Corporation Santa Monica, California.
Author
Sarah Todd
Sarah Todd is a senior education leader at NHS England with a clinical background in nursing and paramedic practice and is a passionate advocate for equity, inclusion, and belonging in healthcare. Sarah has led a range of initiatives aimed at improving representation, learner experience, and culture change, including support for the development and sustainability of the Reframe Image Library.
Declaration of Interests
No interests to declare.