December 15 2017

Equality in the NHS: a work in progress

Roger Kline is Research Fellow at Middlesex University Business School and was joint director of the NHS Workforce Race Equality Standard Implementation Team from its formation until September 2017. Roger is also the author of The Snowy White Peaks of the NHS (2014) that prompted the creation of the Standard.

The NHS Workforce Race Equality Standard (WRES) Data Analysis for 2016-17 records progress made in the world’s largest single current intervention intended to tackle workforce race equality.

Its publication comes weeks after the Civil Service adopted an approach to workforce race equality which draws on similar principles.

Both interventions are significantly different to most previous public sector interventions. There are some early signs that in the NHS the approach may be starting to work, albeit with much to do.

Portrait Of Female Nurse Wearing Scrubs In Hospital

First, the good news

For the third year running since the WRES was agreed in 2014, there was a significant increase in the number of black and minority ethnic (BME) nurses and midwives on more senior grades (Para 6.1.9). About half of all nurses and midwives are on Band 5, the entry Band, where the proportion of BME staff has been steady. However, the number of BME nurses and midwives joining Bands 6 and 7 in 2015-17 was double that of 2014; whilst for Band 8a the number of BME nurses and midwives joining trebled in 2015-17 compared to 2014, though improvement in the most senior grades was less marked. Almost 2000 more BME nurses and midwives have been appointed to more senior grades over this three year period than would have been the case if appointments had not markedly increased since 2014-15.

While the precise reasons for this improvement need further inquiry, the only significant driver since 2014 that might have impacted on the grading of BME staff was the WRES. There were no obvious demographic reasons to explain this change.

Secondly, while it remains 1.38 times more likely that BME staff will enter disciplinary investigations compared to white staff, this is a significant improvement on last year’s data which showed it was 1.56 times more likely they would do so. (Para 6.3.2). There is much more work to be done here, but innovative work is underway to level this particular field, some of which was summarised in Para 7.2.2 of last year’s report.

Thirdly, the 2017 analysis reports an increase in the number of Very Senior Managers (VSM) – above Band 9 – from BME backgrounds of 1.2%. This is welcome but for NHS trusts nationally, across the non-medical workforce (clinical and non-clinical), the proportion of BME staff in Bands 8a-9 and VSM was still only 10.4% compared with 16.3% in the workforce as a whole.

Finally, there is also a significant increase in the number of BME board members in Trusts but this increase is primarily amongst non-executive members, not employed executive Board members (Para 6.9.2).

Big challenges remain

Firstly, for BME staff the likelihood of being appointed from shortlisting has not improved at all (Para 6.2.2). It is still the case that white staff (across all grades) who have been shortlisted are 1.6 times more likely than BME staff to be appointed even once shortlisted, whereas the likelihood of white and BME staff being appointed should be the same. The scale of this challenge – a priority for the NHS – is shown by NHS staff survey data reporting that despite an improvement, it remains twice as likely that BME staff, compared to white staff, do not believe there are equal opportunities for career development and progression (Para 6.7.2).

Secondly, there is no significant improvement in the scale of bullying of BME staff, or on whether BME staff continue to report they are discriminated against (Para 6.8.2). The gap between the percentage of white and BME staff experiencing harassment, bullying or abuse from other colleagues in the last 12 months actually increased slightly (Para 6.2.2).

Finally, there remain marked differences between regions and types of Trusts. The London region remains significantly worse in its treatment of BME staff, something that is hard to understand given the self-evident importance of BME staff within London’s NHS. The ambulance sector remains an outlier on several indicators, though this is also the case for the treatment of white as well as BME staff.

An approach which is having an impact

Notwithstanding the scale of the challenge that still remains, the WRES is already having more impact than previous NHS interventions. What distinguishes the WRES from previous interventions in the NHS is that its approach is evidenced. It draws on three strands of evidence. The first was the Audit Commission report “The Road to Race Equality (2004) which I’ve discussed previously. The second was the impact of linking the Athena Swan Charter to access to NHS research funding. The third strand was partly summarised in a review of the wider international evidence on what works in equality, which emphasised mandation.

In light of this, the WRES was designed to:

  • be mandatory not voluntary
  • be subject to inspection linked to either sanctions or incentives
  • focus on measurable outcomes not just on improved processes
  • have a credible narrative, supported by leaders, that articulates diversity as a high institutional priority
  • place accountability at the centre of the development of specific initiatives to achieve these outcomes.

Such a question meant that clarity on what type of interventions might work became essential. The “shared characteristics” of effective interventions became a substantial part of the second WRES Data Analysis report on the 2016 data (April 2017) and sought to summarise the international evidence on “what works.” Seven key characteristics were identified:

  • Acknowledge the challenge – avoid the temptation to “ascribe more weight to positive information about the service than to information capable of implying cause for concern” (Francis 2013);
  • See workforce equality as integral to service improvement not just compliance – as an integral part of providing better services and improving staff well-being, not as a separate discrete task;
  • Insist on detailed scrutiny of data from Employee Staff Records and national staff survey data to identify the specific challenges that Trusts as a whole, or individual departments or services or occupations may have on race equality against the Standard. Accept that while data can identify patterns and hotspots of good and poor practice – root cause analysis may well be needed to understand it;
  • Ensure that the narrative underpinning strategy is specific to each organisation and work to ensure it is understood not just by Boards but by managers and front line staff;
  • Learn from previous failed approaches which relied on policies, procedures and training which will not work in isolation while relying on individual members of staff to challenge discrimination. Methodological individualism, which relied on individual members of staff raising concerns, complaints or grievances was not a strategy that was ever going to be effective. Leadership meant organisations must take prime responsibility, for example, for talent management and career development and be proactive in developing staff and challenging discrimination, in a radical break with the culture of allowing panels to appoint “people like us” or those who might  “best fit in”;
  • Specific interventions must be evidence driven and able to answer the question “why do you think this will work?” since unless that question can be answered replication is hit and miss;
  • Above all, accept that accountability is crucial. Unless leaders model the behaviours expected of others and face uncomfortable truths, and insist on evidenced interventions with locally developed targets, the best intentions will not bring about change.

Research and interviews with private sector organisations undertaken in 2016 confirmed such principles had some likelihood of success.

In the foothills of the Snowy White Peaks

The NHS is England’s largest employer of black and minority ethnic staff – 37 per cent of doctors, 20 per cent of nurses and 17 per cent of all directly employed staff are from black and minority ethnic (BME) backgrounds. Research has consistently shown the NHS treats black and minority ethnic (BME) staff less favourably than white staff not only in recruitment, promotion, career progression and discipline but also in referrals to professional regulators. BME staff are also more likely to be bullied at work and treated less well when they raise concerns. NHS Boards at every level, and in both executive and non-executive positions, are disproportionately white and often unrepresentative of the local populations served by NHS Trusts. The large scale NHS national staff survey (340,000 responses) suggests the perceptions of BME staff are well grounded.

If the approach taken through the WRES in 2015-2017 is sustained there can be some confidence in further improvement. It would have been good to have had an updated version of the section in the April 2017 data analysis report which set out at length the “shared characteristics” of effective interventions, since without such work there will always be a risk that work to improve workforce race equality can drift into an emphasis on good intentions and “cultural change” rather than practical support for interventions that work.

We are still in the foothills of the “Snowy White Peaks of the NHS” but this report suggests the original WRES architecture was sound and that sustained improvement is possible, even though there is still a very long way to go.

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