February 25 2021

A tale of two metrics

Roger Kline, Research Fellow at our Business School, discusses the two main findings from the 2020 NHS Workforce Race Equality Standard report.

The 2020 NHS Workforce Race Equality Standard (WRES) report is out.

There has been a sustained and significant closing of the gap between the treatment of Black and Minority Ethnic (BME) staff and White staff in disciplinary action. The progress on disciplinary treatment, however, is in sharp contrast with the standstill around recruitment and career progression.

Black nurse in green scrubs, face mask and blue gloves holding a clipboard of papers

What are the key findings?

Firstly, a growing number of Trusts have adopted a simple accountability nudge which aims to interrupt bias by requiring line managers to explain to a very senior manager, prior to any disciplinary investigation being started, why a formal disciplinary investigation is the only way of addressing an alleged concern.

Secondly, the parallel moves towards a just and learning culture (rather than blame) in a growing minority of Trusts (pioneered by Mersey Care) have led to a similar accountability nudge emphasising early informal intervention.  

It is a pity that neither of these interventions were prompted by any national initiative but in combination they seem to be working as research suggested, possibly compounded by some form of “Hawthorne” effect.

There may be some managerial attempts to do “workarounds” on the accountability nudge but there is no evidence this is on a large scale. These two approaches together save a large amount of management time, benefit wider culture change, and stop much unnecessary disciplinary action.

Comparing the numbers

In the last four years, the total number of NHS staff in England entering the disciplinary process has dropped from by 28.2% from 15,711, to 11,278 in 2020.

In the same period the relative likelihood of BME staff entering the disciplinary process has substantially closed from 1.56 to 1.16.

What explains this dramatic change when the other key WRES metric on recruitment actually got worse 2016-2020?

Table: Staff entering the disciplinary process 2020

Total White staffWhite staff entering the formal disciplinary processWhite staff likely entering the formal disciplinary processTotal BME staffBME staff entering the formal disciplinary processBME staff likely entering the formal disciplinary processRelatively likely BME staff compared to White staff
969,2108,4800.87%276,2452,7991.01%1.16

A comparison of how tackling these two metrics has been undertaken is telling. Whilst there has been some limited progress in the diversity of very senior posts, the standstill over the last two years amongst middle and lower grades reflects the failure to apply research evidence to the challenge.

By contrast, in 2016, I suggested that the NHS needed to change how we approach incidents that might normally lead to formal disciplinary investigations. The suggestions was to use the almost forgotten NHS Incident Decision Tree and combine the research evidence about the reasons for the disproportionate disciplining of BME staff in the NHS to create a new approach to “incidents”. The Incident Decision Tree was a simple but sophisticated means of asking four questions about an individual involved in a patient safety incident with a view to deciding if suspension was appropriate. 

This is not a new problem

Research commissioned in 2008 by NHS Employers highlighted the disproportionate disciplinary action against BME staff and subsequent evidence showed the discriminatory patterns of discipline involving midwives in London.

In 2017, the very significant variation between NHS Trusts as to the likelihood of White and BME staff being disciplined or suspended was noted and an accountability nudge was again advocated to interrupt bias and focus on learning not blame.

The NPSA Incident tree guidance argued:

“We know from research carried out in the NHS and in other industries that system failures are often the root cause of safety incidents. Despite this, where a serious patient safety incident occurs in the NHS, the most common response is to formally suspend the staff involved from duty and then deal with them according to disciplinary procedures. This route can be unfair to employees and divert managers from identifying contributory systems failures. Suspension of key employees can also diminish trusts‘ ability to provide high-quality patient care.”

I know of no evidence that greater levels of disciplinary investigation and action in healthcare lead to improved care. No one knows how much NHS time and energy is wasted on unnecessary disciplinary investigations, suspensions, hearings, and appeals, but it is a lot.

What’s the cost?

In 2018, Duncan Lewis and I estimated a typical bullying case cost employers around £40,000 (management time, sickness leave costs, cover, early retirement, replacement costs) excluding legal costs and the cost of professional regulator referrals and it is likely that is the figure for disciplinary cases is similar.

The biggest cost of all is the impact on patient care.

Unnecessary disciplinary investigations and hearings risk creating an environment where the response to a mistake or sub-standard behaviour is not “how do we prevent it happening again” but “who is to blame.”

The steep authority gradients in much of the NHS as a whole, and within individual occupations, exacerbate the problem. An environment of blame, allied to a steep authority gradient is toxic for patient care and safety.

None of this means that there will never be a need for NHS disciplinary investigations or indeed suspensions or sanctions. But in too many organisations moving to a formal investigation had become the default position without there being proper consideration as to whether that is necessary.

In researching the causes of disproportionate disciplinary action in the NHS against BME staff, Archibong and Darr (2010) found in their report NHS Employers that:

“….line managers found it difficult to deal with issues relating to disciplinaries and there were often inconsistencies in the application of disciplinary policies. It was acknowledged that the informal stage of the disciplinary process was critical in sorting out minor issues and that some managers were hindered in this process by a lack of confidence in applying informal strategies with BME staff. It was perceived that managers were more likely to discipline BME staff over insignificant matters and that disciplinary concerns involving staff from minority ethnic backgrounds were not always considered to have been dealt with fairly and equitably by human resources managers.”    

More recently we explored some of these issues again. Once a disciplinary investigation commences, it is very distressing for the member of staff concerned even if they are cleared of any allegation; it is very time-consuming for managers and HR; it can be demoralising for colleagues if they think the processes are unfair; and can run the risk of reinforcing blame, not a learning culture.  

Investigations can easily lead to “tunnel vision”, where the determination to find fault will inevitably eventually unearth some shortcoming, as it would with any member of staff. Bias is pervasive in workplace investigations, and this is especially true when the alleged “suspect” is of BME origin.

The data is good news for staff and patients

This different approach will not prevent the need, sometimes, for disciplinary investigations and sanctions. But the benefits are clear.

It is time to pay similar attention to identifying and implementing evidence based interventions to end race discrimination in NHS recruitment and career progression. That is surely the next big challenge for the NHS.

Less rhetoric, more practical action rooted in mitigating bias through accountability. That’s what research strongly suggests will work and it is good news that the revamped WRES team are focussed on that.

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