Improvements and shortcomings in equality, diversity and inclusion: A conversation with Navina Evans and Richard Mitchell

How would you describe the current state of race equality in the NHS? Has there been progress over the past five-10 years?  

Navina

If I look back on the last five years and I look back to my own experience and my own journey, I think there has been progress. But I think that we've already got to the low hanging fruit. We've done the easy stuff, and now we're getting into some of the more complex issues. There's still a lot of variation. And there's still the need for this issue to be prioritised in our systems, not just because it's the right thing to do, or the moral thing to do, but because it delivers better outcomes for us.

Richard

It is evident race inequality still exists both from an employee perspective and from a patient perspective. The Workforce Race Equality Standard (WRES) data, staff surveys, patient experience and population health data confirms this and COVID has further exposed the inequality. I joined the NHS in 2004 and I do not remember conversations such as the one we are having today. I hope that over the last five years there has been progress but it has been insufficient. From an employment perspective, colleagues from minority communities have worked in the NHS since its inception, yet clearly there still are inequalities as evidenced by the number of colleagues in our most senior roles. I think they are eight chief executives out of circa 200 from minority communities, which is embarrassing for all of us. This is the tip of the iceberg and the reason why there are only eight is because there is insufficient diversity around the board table, in senior leadership teams and throughout all levels of leadership in our organisations. This does not represent sufficient progress in terms of equality. 

What is the one aspect of racism or racial inequality in the NHS that shocks, or angers you the most?

Richard

From the beginning of my time (now three and a half years) at Sherwood Forest, having a truly inclusive culture where people felt listened to and valued was my number one priority and the number one priority for the board I work with. I like to think we have made a lot of progress with this and we take culture very seriously. However, earlier this year we had a conversation with a wide group about racism in the organisation and I was saddened to hear some of the experiences of colleagues here. Some people said, "it's not a racist place to work, but I do experience microaggressions at work", some said "every day we experience racism from patients" and others said "every day I experience racism in my personal life". I am embarrassed that colleagues experience racism and to an extent they feel it is tolerated. We have made improvements from a wider cultural perspective but not through all of the lenses of inclusion. We have lots more to do to ensure racism is not tolerated at Sherwood or in any other organisation.

Navina

I'm not sure if it angers me, and it doesn’t shock me, but it saddens me. Those of us from minority communities; what we accept and feel we have to put up with, or what we have to change about ourselves in order to get on, or to not have unpleasant things happen to us. We have to compromise, yes, everyone has to compromise, but we give up something of ourselves in order to fit in. I didn't really think about until recently, when we started having open conversations about this, I didn’t think about how much of that I've done myself in the name of being accepted and assimilation. And that's really quite sad, that you've got to cover up your true self.

What do you see as the key successes and failures that you've experienced, personally, as a leader in seeking to tackle racism and racial inequalities?

Navina

It's been in my objectives as my chief executive every year since I started, my first year coincided with the first year of WRES. We had the metrics, we used to measure progress, and we didn't do so well, I found that really quite difficult. I think there was an assumption that because I'm a BAME leader myself and because our chair was also from a Black, Asian and minority ethnic background, and we had some senior people in the organisation from Black, Asian and minority ethnic communities, that somehow improvement would be more achievable. I think that was naive. One of my failures was not anticipating how hard it would be.

One thing I think I can be proud of is that we made (East London NHS Foundation Trust) a safe enough place for people to have difficult conversations. And that's the most important thing, that whatever your point of view, even if you didn't agree that this was something important to tackle, it was a safe place to be able to have those discussions.

Richard

Before I started in this role, I spoke to nine people who had been in chief executive or senior leadership roles to get their advice. One of the thoughts many of them shared is about choosing where you want to focus and being really clear about why you are doing that. What you say and what you do gets noticed, and the things you are not saying or equally not doing will get even more attention. I am proud I have been clear from the beginning that inclusion is really important to me. We were celebrating Black History Month in Nottinghamshire a couple of weeks ago, and we had Lord Adebowale say a few words virtually. He said that as a leader you have to lead all of the people, all of the time. One of the things I am aware of is the huge privilege that comes from being a chief executive. I've got far more control of my time than anybody else in the organisation, I can make the time to prioritise this and show that it is important.

I feel my failure is I have insufficiently viewed inclusion, until recently, directly through the lens of racism. I wish I had done more when I joined Sherwood to understand some of the complexities at play and therefore from an informed position, begin to influence some of the changes required. I write a weekly blog for colleagues at Sherwood and the majority of the pieces focus on inclusion and culture, but it was not until blog 91 in March 2019 that I directly referenced race.

It sounds like from your previous answers that you've both been thinking about this for quite a long time. Has your recent work given you a good idea of what does work, and what doesn't work?

Richard

Inclusion and tackling inequalities requires continuous learning, reflection and commitment.  You don’t do it and move on.  We have generations of inequality and a lot to do to move forward. We have got colleagues who for a long time have been told to keep their heads down, and we are now asking them to speak up. And that's psychologically a big difference. We are saying you've got a voice and we are trying to grow a safe environment here. There are things we can do today that impact on today and the near future and there are things we can do now that will have an impact in the longer term. So what works and what doesn’t? You have to remain committed, a one off campaign is not enough, you have to continue to create the space for change and embed it, things won’t change immediately and this can be frustrating. Patience is key, this is not one person’s job or responsibility and people have to have confidence and trust in you in terms of what you are trying to do and know that you mean it.  I recognise we have more work to do at Sherwood.

Navina

I think we take one step forward, two steps back, three steps forward, one step back, this work is continuous. This takes a social movement. I can't wake up one morning and think, I'm going to start a social movement, and just because I really care about something, and so does Richard, and so does so-and-so, therefore it’ll happen. Social movements evolve because enough people believe in something that matters. People must want to be part of something. I think that part of the success, and part of what's important is the power of listening to people's stories. We've set up several virtual forums where somebody would just tell their story. One of my senior Black colleagues told the story of how she went to the chemist and noticed that all the Black hair products had security tags on them. None of the white hair products had security tags on them. When you start to put yourself in people's positions, and realise these things are happening every single day to some of the people we work with, and they have to come to work to deliver an intervention or attend meetings.

Richard, at our annual conference you spoke really powerfully about the need to recognise your own white privilege as a trust leader. How do you think a better understanding of white privilege across the NHS, and throughout society, will help to tackle racism?

Richard

In the past, my view was, I have gone to university, I got a graduate job, I've progressed through the NHS and become an executive. That's because I'm a fairly nice person and I work hard. I recognise that that is not quite the case. The achievements and the opportunities I've had are due to a range of reasons. They certainly are because of the privileges I got because of my parents and because of the school I went to, and the people I've been able to work with and spend time with. I've never experienced exclusion from school, never been stopped in a shop, I've never been arrested by the police and I’ve never experienced racism. Is all that because I work hard? It's not. So I think white privilege means the fact that, given that I'm white, my face is almost certainly going to positively impact my life trajectory. And I didn't notice it for quite a long period of time. I think a better understanding of white privilege for me helps me realise that my experiences up until this point, and my experiences today, are probably not consistently the same as those of people from the minority communities that I work with or that we serve. Recognising that ensures we can be a better employer and that we can more effectively challenge the racism colleagues experience.

Navina, recently you said that the NHS needs to do more than simply seek to improve health outcomes for ethnic minority people. What are the wider responsibilities NHS leaders have towards people and communities of colour?  

Navina

Firstly, we have a responsibility to use our resources responsibly. We're the guardians of a finite set of resources. So if we don't get involved in looking after our populations, and just look after our hospital, our A&E, our beds, that's not being the guardians of the resources. We can only do that if we connect with our communities - with all corners of our communities - and with all aspects of vulnerability that we know has a particular impact on minority communities. In parts of the country where perhaps there isn’t a large population of Black or Asian or minority communities, leaders have got particular challenges, because ethnic minority people’s concerns could be hidden, and marginalised, so it's even harder in some ways to think about it and understand it. Secondly, in the NHS we are struggling to solve our problems, so why do we keep using the same solutions over and over again? They are just more exhausting. Why aren't we looking towards different communities for our solutions? Finally, NHS leaders have got to start by acknowledging and accepting that there is racial discrimination in our organisations. It is not a personal slur, it is not a failing, it is something that just is. And once we accept that, we then start to look at all of our systems, all of our processes, we will find things that we can change really quickly. Some things that will be harder to address, there are so many of our structures that disadvantage people.

How do we maintain focus on this work, when media and political attention becomes diverted elsewhere? How do we stop attention getting diverted and carry on this important work?

Navina

For those of us who really get it and care about it, it is our responsibility to support the leadership community to do this. We've got to be really creative to capture and keep people's interest. We've got to make it meaningful so people can see what's in it for them to put in the effort in to change. I had a really lovely piece of advice from someone last year. He said to me, it's about connections with society and social justice. Pick one thing that you can wrap your arms around to reduce human suffering.

Richard

I agree with that. Whether there is media or political attention or not, I will choose to commit to this. There is a range of reasons behind my choice. Let's not forget the NHS values and its reason for being is about providing care for all regardless of wealth or class. I think there is a risk here that because of media attention, there will be a disconnect between the rhetoric and the reality of what some people say and do. I think social media can be dangerous for that reason. You see people pushing out messages because they think it is the right thing to say and maybe I have been guilty of that in the past. I would urge all of us to focus on the reality of what is happening rather than sound bites and I am far more careful about that now. Irrespective of this, the moral case and responsibility is overwhelming.  I do not think this should be led by the media, it should be led by us and I believe the case for us to continue to be involved and to make a difference is sufficiently strong for the important work to continue. I know there is huge uncertainty in the world: the EU exit, COVID, global recession, climate change – things feel pretty hostile at the moment but we need to make time for this as well, both from the perspective of being an employer in the NHS and local authority but also from the provider of care perspective.

Is there any one barrier to change that you'd most like to see removed to make sure that progress on this issue does get going?

Richard

It is difficult to identify one sadly because there are lots of barriers and they are all fairly interrelated. Listening to colleagues, I know that lots of people, whether they are junior or more senior, can struggle to understand what their path looks like when they look at people in senior roles who ultimately do not look like them, "I cannot be what I cannot see". We have to strengthen the path for them. This does not happen overnight, but we need to be able to evidence that the NHS is an increasingly inclusive organisation, where we can move beyond such a small number of colleagues from minority communities as chief executives or in senior roles. Going back to failures, I reflect on my time so far at Sherwood and I have had five opportunities to appoint executive directors here. We followed a really inclusive process and I have taken personal responsibility to find the best people for the organisation. Following a national process, I recruited five executives who happened to be white. I am confident they were the best candidates but it was a great opportunity to widen diversity in the most senior roles at Sherwood. My primary responsibility is for us to be the best employer and provider of health care that we can be however I increasingly know I have a responsibility to work with others, including regional and national partners, to really strengthen the depth in candidates across the board. So when we begin to see a change, I think that will strengthen belief for all our colleagues.

Navina

I'm a psychiatrist, so I'd say denial is a barrier. And I mean covert and overt denial, individual and collective denial, in the NHS this is a significant problem. Richard spoke earlier about sound bites and people talking the talk. I think we have to walk the talk. And anyone who thinks that's easy to do, isn't doing it. 

What do you think is the most important thing for NHS leaders and managers to think about in seeking to improve the lives of ethnic minority staff and communities?

Navina

Quite simply, talk to people, and listen to what they have to say. Ask people what will make a difference, and then do it. People are not going to ask for the impossible. 

Richard 

The links between ethnicity and deprivation are well understood. In May 2011, the Joseph Rowntree Foundation stated poverty is higher among all Black, Asian and minority ethnic groups than among the majority white population. Have we made progress since then? I don’t think so. Have we made sufficient progress, I definitely don't think so. In my organisation I hope I have made it clear for a long time that I passionately believe in the interrelationship between our working life and our personal life. If you are working and you enjoy your job and you feel that your voice is heard and you can contribute, and you are paid a decent wage and you have got a manager who cares about you, that will impact on your personal life in a positive way. If we can deliver that consistently, I believe that will contribute to a reduction in the levels of deprivation people experience. I find it incredibly sad that at Sherwood we have colleagues in full time employment who use food banks. We are taking action to help colleagues but it breaks my heart. I believe it is our moral responsibility to work together to positively change working and personal lives. Focusing on helping people to make their working lives better will benefit everybody and it will disproportionately benefit people from minority communities. This is key to the levelling up agenda.

What are your next steps, the key actions and strategies, you're now going to be putting in place within your organisations to make further improvements to equality, diversity and inclusion?

Navina

I've recently moved to Health Education England, and I'm really pleased to say that there's a huge appetite to try and understand the lack of diversity as well as a the ambition to bring this agenda into our core business, which is education and training. We could look at our work and processes for doctors, what happens in nursing, working with the General Medical Council, working with the royal colleges, working with the Nursing and Midwifery Council, working with the trusts and providers and ultimately the impact on workforce planning. Our opportunities are endless. We have the opportunity to advance the agenda of improving race equality in the NHS, so if we don't grab that, we would be doing a disservice to the people of this country. 

Richard

I can think of three things. Firstly there is much more I can do, in an anchor organisation, working in partnership with others, to ensure all people from all communities, feel they can genuinely access jobs, opportunities and have a meaningful career with us. Secondly, during COVID we have identified more effectively the work we must do to reduce health inequalities, recognising this is not going to be a quick win, as it is so deeply embedded. But again, surely it is better to take steps today, recognising you might start seeing the benefit in a year, or three years or five years. We must not sit around any longer debating population health, because the longer we talk about it, the longer it takes to deliver improvements. Finally, I will continue to support and mentor a wide group of people including colleagues in other trusts who happen to also be from minority communities. I am aware that diversity is much wider than just race and there is more I can do.