A new report on race discrimination in the NHS suggests workplace race discrimination in Britain’s biggest employer of black and ethnic minority staff is as widespread as ever. Research Fellow Roger Kline sets out the context and summarises a radical new approach being taken to bring about improvement.
The latest report on race discrimination in the NHS confirms again that the workplace experience of black and minority ethnic staff in the NHS is worse than that of white staff. It suggests little progress since my paper ‘The Snowy White Peaks of the NHS‘ held a mirror to the UK’s largest employer of black and minority ethnic (BME) staff in 2014 and summarised evidence demonstrating that BME staff were treated less favourably than White staff in recruitment, Boards membership, career development, disciplinary processes, and bullying.
When Robert Francis described patient care in Mid Staffordshire Hospitals as existing within “an institutional culture which ascribed more weight to positive information about the service than to information capable of implying cause for concern” his words could equally apply to the response to widespread evidence of systemic race discrimination. Many NHS employers were neither collecting data, nor analysing it, nor acting on the extensive evidence of race discrimination.
Yet we know now that such discrimination adversely impacts not only BME staff but on the effectiveness of healthcare providers and the care and safety of all patients, not just BME patients. It risks patients not getting the best staff, higher turnover, absenteeism, lower discretionary effort, grievances, disciplinaries and tribunals. It makes NHS staff ill. The higher levels of bullying of BME staff increase the risk that staff may not admit mistakes, raise concerns or work in effective teams. Unrepresentative leaderships are likely to be less innovative and engage in “group think”.
Research has found powerful correlative evidence strongly linking the treatment of BME staff to patient experience and care, concluding that “the staff survey item that was most consistently strongly linked to patient survey scores was discrimination, in particular discrimination on the basis of ethnic background”.
Discrimination adversely impacts not only BME staff but on the effectiveness of healthcare providers and the care and safety of all patients.
The NHS, after much debate, decided that the previous voluntary efforts launched in 2004 after the McPherson Inquiry had failed to produce the required improvement. It introduced the Workforce Race Equality Standard 2015 which replaced the focus on improving policies, procedures and training, coaching and mentoring. Despite good intentions it had not worked, due to the lack of measurable outcomes, incentives or sanctions, benchmarking and research underpinning.
The NHS Workforce Race Equality Standard was rooted in the research evidence on effective change in workforce equality and culture. It drew especially on Kalev’s research on US affirmative action which concluded that “attempts to reduce managerial bias through diversity training and diversity evaluations were the least effective methods of increasing the proportion of women in management”.
Our own findings carried out with Harvard colleagues were in line with those of the ACAS review of workplace bullying. We argued that the dominant NHS HR model of reliance on policy, procedure and training was necessary but not sufficient. More important was a more powerful narrative and the use of metric driven accountability. We were encouraged by the success of the Chief Medical Officer’s policy of refusing research funding applications from institutions unless they had achieved the Athena Swan silver award aimed at promoting women in science.
The Workforce Race Equality Standard is mandatory. It requires providers to publish data on nine metrics showing the gap between the treatment and experience of White and BME staff in the NHS – in grade composition, appointments, disciplinary action, access to career development, bullying, and Board composition – to demonstrate year on year progress. It is inspected against the CQC in its “well led domain”. Progress or otherwise is published and benchmarked. The Standard encourages root cause analysis to help close the gap between White and BME staff treatment.
Organisations who wish to change culture must be proactive and intervene to challenge race discrimination, not primarily leaving it to individuals to raise concerns.
NHS organisations have tended to put policy, procedures and training (including unconscious bias training) in place and then hope individual members of staff will use this framework to develop their career or challenge unfairness. Successful organisations have leaders determined change will happen, and who model the behaviour they expect of others. They use metrics to hold managers and themselves to account. They read and apply the evidence on effective interventions.
Above all, organisations who wish to change culture must be proactive and intervene to challenge race discrimination, not primarily leaving it to individuals to raise concerns. The benefits do not simply assist BME staff. Fairer appointment panels, for example, benefit all staff and erode the “club culture” so dominant in the NHS. Fairer disciplinary practice helps erode the “blame culture” all organisations profess to want to end. Such interventions are part of wider interventions that understand the crucial impact of the treatment of staff on patient care.
It is too soon to see if the mix of challenge and evidence-based intervention will work. Research suggests it has a much better chance than the previous attempts to do so. This first Baseline Assessment is another step towards doing so.