At the time, I didn\u2019t have the language to describe what I had seen. But I knew it mattered.<\/span><\/p>\n 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.<\/span><\/p>\n Why inclusion is a clinical issue, not a values statement<\/b><\/p>\n We often describe NHS leadership in terms of strategy, performance, or transformation. Increasingly, inclusive leadership must be understood as a clinical imperative.<\/span><\/p>\n Framing inclusion as an aspiration or value is no longer enough. It is fundamental to patient safety, workforce wellbeing, and system sustainability <\/span>(Schulson et al 2022)<\/span><\/a><\/p>\n 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?<\/span><\/p>\n 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.<\/span><\/p>\n For those of us across clinical care, education, and service delivery, this shows up in everyday decisions.<\/span><\/p>\n Leadership beyond job titles<\/b><\/p>\n 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.<\/span><\/p>\n These experiences taught me that leadership is less about hierarchy than influence, accountability, and values in action.<\/span><\/p>\n Inclusive leadership is enacted daily through how we respond to bias, support others, and challenge what does not feel right.<\/span><\/p>\n The values that shape inclusive leadership<\/b><\/p>\n Four values have consistently guided my approach:<\/span><\/p>\n 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.<\/span><\/p>\n What this looks like in practice<\/b><\/p>\n Inclusive leadership is visible in behaviour.<\/span><\/p>\n In practice, this means:<\/span><\/p>\n These behaviours matter because psychological safety underpins learning and patient safety. If people cannot question decisions or raise concerns, risks remain hidden (Kline 2025)<\/span><\/p>\n Why progress can feel slow<\/b><\/p>\n Despite broad agreement, moving from intention to action is not straightforward.<\/span><\/p>\n Common barriers persist; fear of saying the wrong thing, discomfort discussing racism or inequity, \u201ctick-box\u201d perceptions, and pressure in busy clinical environments.<\/span><\/p>\n 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.<\/span><\/p>\n Inclusive leaders can reframe this, normalising discomfort as part of learning and linking inclusion to clinical outcomes.<\/span><\/p>\n When inclusion is positioned as an \u201cextra,\u201d it struggles for priority. As a patient safety issue, its relevance becomes unavoidable.<\/span><\/p>\n What actually makes a difference<\/b><\/p>\n Evidence and experience point to approaches that improve engagement:<\/span><\/p>\n In practice, these are simple interventions: fair access to opportunities, inclusive supervision, and intentional leadership and teaching (<\/span>George and Masey 2020).<\/span><\/a><\/p>\n Creating cultures where people can speak up<\/b><\/p>\n Psychological safety is central to inclusive leadership (Kline 2025).<\/span><\/p>\n Healthcare hierarchies can make it difficult to raise concerns, particularly for marginalised groups. Inclusive leaders work against this by:<\/span><\/p>\n Psychological safety is built over time, through consistent, observable actions.<\/span><\/p>\n Representation as a patient safety issue<\/b><\/p>\n One tangible example of my work in action is the Reframe Image Library<\/a>, created to address the lack of diversity in clinical imagery.<\/span><\/p>\n 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.<\/span><\/p>\n Reframe offers a practical solution: over 3,000 diverse images supporting more accurate diagnosis, better education, and increased patient trust.<\/span><\/p>\n It demonstrates a key point: inclusion must translate into practice. Representation is not symbolic; it is central to clinical competence.<\/span><\/p>\n A call to action<\/b><\/p>\n The implications for NHS leadership are clear:<\/span><\/p>\n So, my challenge is this: reflect on your own practice.<\/span><\/p>\n Where do people speak up, and where do they hesitate?<\/span> 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.<\/span><\/p>\n It requires courage: to challenge, listen, and keep learning, even when uncomfortable, because that is often where meaningful change begins.<\/span><\/p>\n References:<\/b><\/p>\n George, V. and Massey, L. (2020) Proactive strategy to improve staff engagement. Nurse Leader, 18(6), pp. 532\u2013535. Available at: https:\/\/doi.org\/10.1016\/j.mnl.2020.08.008 (Accessed: 22 July 2026)<\/span> Author<\/strong><\/p>\n Sarah Todd<\/strong><\/p>\n 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<\/a>.<\/span><\/em><\/p>\n Declaration of Interests<\/strong> 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\u2019t have the language to describe what I had seen. But […]<\/p>\n\n
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\n<\/span>Whose voices are heard?<\/span>
\n<\/span>What small change could make your team more inclusive tomorrow?<\/span><\/p>\n
\nKline 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<\/span>
\nSchulson 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.<\/span><\/p>\n![\"\"](\"http:\/\/blogs.bmj.com\/bmjleader\/files\/2026\/08\/Screenshot-2026-08-25-160835-204x300.png\")
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\nNo interests to declare.<\/p>\n","protected":false},"excerpt":{"rendered":"