After the speeches: What now for NHS staff race discrimination?

Six years ago, The Snowy White Peaks of the NHS highlighted the scale of racial discrimination in the NHS, the UK’s biggest employer of Black, Asian and minority ethnic staff. COVID-19 has shown so much more needs to be done.

600 health and social care staff have died so far from COVID-19, with a disproportionate number of those from Black, Asian and minority ethnic heritage. NHS staff infection was overwhelmingly due to occupational exposure however compared to their white counterparts, it was reported these staff were disproportionately in patient-facing services, had poorer access to personal protective equipment, were more likely to feel as though they couldn’t raise any concerns, were largely more absent from decision-making and had a greater presence amongst agency staff.

The NHS response to the risk of staff infection largely failed to acknowledge the importance of the discriminatory treatment of Black, Asian and minority ethnic staff, placing them at greater risk, instead focusing on the individual health conditions which made those risks more dangerous.

The COVID-19 impact on Black, Asian and minority ethnic staff, and Black Lives Matter, have prompted promises to tackle racism more resolutely. So, what should NHS leaders do to ensure faster progress to tackle workforce race discrimination? Here are ten suggestions for boards and integrated care system leaders:

1. Equality, diversity, and inclusion must finally become core board business. No one should be a member of any NHS board if they cannot confidently explain to staff and managers (and interview panels) why tackling race discrimination is important for the NHS. This means it must also be determined who decides what constitutes a confident explanation of why tackling race discrimination is important. Board members should be able to demonstrate what they are doing personally to tackle discrimination. Gaining the insight required to act requires difficult face to face discussion, reading, and listening and acting on lived experience. This must not be an optional extra. There is a need to set fair criteria for the removal of board members who will not conform with trust policy in this respect.
2. Every leader must seek out and understand their local challenges, looking for risk, not comfort. They must be familiar with Workforce Race Equality Standard (WRES) data and other equality data such as turnover, exit interviews, and absenteeism rates disaggregated by site, occupation, and service. Those challenges include patient and community experience. The repeated refusal of individual boards (and national bodies) to be honest and open with equality data is a serious shortcoming that must end.
3. Boards should stop signing off “action plans” unless those proposing them can demonstrate why they are likely to work. A typical NHS “action plan” on racial discrimination consists of improving policies and procedures, introducing better training, and some positive action. Yet research has found that training alone is not enough to tackle this problem and 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’. Similarly, Unconscious Bias Training, may improve cognitive understanding but has limited impact on decision-making. There is a track record of action plans not being effective time and again, and there is every danger this will continue to be the case unless there are signposts to a better way of doing things.
4. Boards must be proactive and preventative. If they don’t use research and data (including lived experience) to drive interventions and insert accountability at every stage, they will fail. For example, rather than adding a Black, Asian or minority ethnic member to a disciplinary panel, , managers must not start a disciplinary investigation unless they can demonstrate it is the appropriate and fair response to an alleged offence and not discriminatory in itself.
5. Boards must embed accountability. Start by setting clear measurable time-limited goals, ensuring managers and staff understand what they and their managers will be held accountable for. There should be consequences and/or incentives when agreed diversity goals are not met.
6. Boards and teams must prioritise psychological safety so they become inclusive, welcoming the difference that Black, Asian and minority ethnic staff bring. Boards must understand that whilst improved representation is crucial, the benefits are limited without inclusive behaviours and culturally sensitive psychological support.
7. Boards and leaders must model the inclusive behaviours they expect of others, with consequences if they do not. Culture is largely shaped by what leaders do and don’t do. Good leaders put themselves in the shoes of others, listen, enable, and are honest about mistakes. They make diversity and inclusion a personal priority, not leaving it to those subjected to poor behaviours to challenge them. Demonstrable values should be a core part of appraisals.
8. Equality, diversity, and inclusion are drivers of service improvement and must stop being primarily a matter of compliance delegated to junior staff.
9. The focus of NHS work around race equality must change. Remorselessly challenging racism must go hand-in-hand with supporting those who want to eliminate discrimination, question their own privilege and be allies. Such support must tackle the absence of a properly resourced national good practice repository on diversity and inclusion.
10. Finally, it is time to step up national accountability. Good governance has accountable metrics. Trusts must be able to demonstrate serious progression on race equality to be able to receive a ‘good’ or ‘outstanding’ rating from Care Quality Commission.
    
    

Strong statements on racism are helpful. But in 2020 anything less than decisive, practical action is unforgivable.

An earlier version of this blog appeared in BMJ Leader June 2020.