The NHS is the largest single employer in the UK, employing over a million people. Since its inception, it has relied on a workforce with a high proportion of black and minority ethnic staff, many of whom were actively recruited in the 1950s and 1960s to pioneer the new health service after the Second World War. This has been an asset to an NHS which over 60 years has served an increasingly diverse population: around 10 per cent of the UK population is now from a BME group.

One of the key objectives of the NHS is to have a confident, competent and diverse workforce. However, achieving this objective hinges on policy makers, managers and practitioners being able to appreciate the problems involved and having the willingness to tackle them.

The evidence on health inequalities is stark, with many minority communities reporting poorer health, poorer access to services and poorer treatment than their majority ethnic neighbours. Minority user participation and engagement in health services is relatively low and engagement is a crucial aspect of bringing about change.

The experience of black and minority ethnic staff in the NHS has generally not been positive, with institutional racism applying just as much to the NHS as to other public institutions. Evidence on recruitment and retention in the NHS indicates that minority ethnic people are less likely to be employed, less likely to advance on the career ladder at work and more likely to be under-represented in professional and managerial occupations.

Despite a plethora of initiatives, there remains a lack of black and minority ethnic representation at top levels of management in the NHS. Less than 1 per cent of all chief executives and 3 per cent of executive directors are from a minority background although 8.4 per cent of the NHS workforce is from a minority background. Similarly, of the 400 directors of nursing across the UK, only three are from a BME background.

In spite of management reassurances about the organisation’s commitment to creating an inclusive workforce, black and minority ethnic people are sceptical and frustrated at the slow pace of progress, and the ‘business as usual’ mentality in their trusts.

People in minorities are now taking the initiative in their local trusts by forming staff networks, which appear to be successful – to some extent – in achieving concrete and positive outcomes for members.
Staff networks are actually a key component of the overall diversity and equality strategy within the NHS aimed at helping the organisation retain and develop a competent and confident workforce. Equality and diversity policies also seem to be having some impact, although research evidence suggests that, for the most part, people in minorities are not reaping the benefits of these policies due to poor implementation.

The implementation problem is related to the culture inherent in respective organisations, which can be resistant to change. The role of middle management in resisting change needs to be scrutinised. In order for national policy initiatives to translate to meaningful outcomes in trusts, all managers must unequivocally embrace the equal opportunity agenda. Central to this argument is the notion of accountability. Arguably, in order to negate any perception that local trusts’ compliance with equality statutes is just a tick-box exercise, it is imperative that those with the authority and power to effect change are held accountable.

Policies aimed at facilitating the recruitment and retention of minority ethnic staff in the health service will benefit from putting resources into tackling the organisational culture because ‘it is the transformation of cultures wherein lies part of the solution to the implementation gap’.

Ethnicity, Career, Work and the Health Services highlights the tendency on the part of trusts to focus on individual initiatives (mentoring, personal development, individual training) rather than initiatives which seek to change the culture of the organisation (diversity training for managers).
Personal development initiatives are obviously beneficial, but will be hampered in an organisation where a culture of ‘racialised’ social processes is allowed to thrive.

Dr Franklin Oikelome is a lecturer at Hull University business school. Ronny Flynn is director of health and housing at the Race Equality Foundation.

This article is based on The recruitment and retention of black and minority ethnic staff in the National Health Service published by the Race Equality Foundation. For more information on the Race Equality Foundation’s conference ‘The Healthy Option: using evidence to promote race equality in the provision of health services’ on 10 March, visit