In 2004, the Audit Commission reported that the NHS had made slower progress than other public sector bodies in achieving race equality.
The public spending watchdog suggested that service reorganisation and an inability to recognise that race equality was key to meeting targets, rather than being an obstacle, were often to blame. Despite a raft of policy initiatives, guidance and legislation, the issue has not gone away.
As recently as December 2007 Surinder Sharma, the national director for equality and human rights at the Department of Health and the NHS, berated trusts for their failure to comply with basic race equality legislation. The cause of his dismay was the finding by the Healthcare Commission that just 9 per cent had published online all the legally required documentation, which includes data about the ethnic backgrounds of staff.
With around 15 per cent of its 1.3 million employees from black and minority ethnic backgrounds, the NHS is the single largest employer of BME staff in the UK. But their under-representation in senior posts shows how much of a struggle race equality continues to be.
“The NHS is 60 years old and was very much part of a non-diverse Britain,” says Joan Saddler, co-chair of the NHS BME Leadership Forum and chair of Waltham Forest primary care trust. “Now it’s suffering from ‘projectitis’ and there is no time to bed down programmes.
“Everyone faces barriers, but BME staff face more,” she continues. “The NHS could have done something much more quickly, but that takes good leadership, and that’s not been seen as a priority.”
That is set to change however, because leadership is now a major focus for the NHS: every strategic health authority has been asked to develop its own leadership programme to nurture “up-and-coming talent”, says NHS chief executive David Nicholson, writing in the Appointments Commission’s winter bulletin.
At the annual conference of Breaking Through, the scheme set up in 2003 to fast-track BME employees into director posts, its national lead Yvonne Coghill said: “Leadership is key to ensuring the reforms are understood and more importantly, sustained… and BME leadership is an integral part of that.” Ms Coghill, who started her career in the NHS as a nurse, was the first black person to have mentoring under the 2004 leadership and race equality action plan to encourage trusts to promote BME staff.
Reliable data on exactly how many BME staff make it into top posts is hard to come by. Definitions of seniority vary and the data is often patchy or based on anecdotal evidence. But despite these caveats, the figures that are available all point in the same direction.
BME applicants now make up almost a third of medical school intake. But a Race Equality Foundation briefing published last year, based on 2005 data, said only 18 per cent of consultants are from ethnic minority backgrounds, with over half of non-consultant grades held by BME doctors.
The situation in nursing is even worse, with only three out of 400 directors of nursing coming from a BME background, according to data presented last July at the launch of the South East Coast Black and Minority Network.
Joan Saddler thinks that better central monitoring is urgently needed. “We don’t know how many senior BME directors we have got,” she declares, “and such information is necessary to benchmark progress.”
Anecdotally, the number of BME trust chief executives is set to reach five this summer – out of a total of 360. It is thought there are around 60 BME executive directors.
Representation varies according to region and organisation, with 28.9 per cent of executive directors in Hackney coming from an ethnic minority background, for example, she says. But unofficial figures suggest that the proportion of BME executives across the NHS may now be as low as 1.6 per cent. Whatever the actual figures, they are unlikely to be anywhere near the 30 per cent senior-level representation David Nicholson has said he wants to see.
Breaking Through, which relaunched last October with its Top Talent programme, hopes to help the NHS towards that goal. It is the only one of the three government-backed leadership programmes to target BME candidates specifically, although the NHS graduate management training scheme and Gateway to Leadership (which brings in managers from outside the NHS) both attract BME applicants.
Almost a quarter of participants on the graduate scheme are from BME backgrounds. This is roughly double the proportion four years ago, says Dave Thornton, head of building leadership capacity at the NHS Institute for Innovation and Improvement, which oversees all three programmes. Three of the current BME trust chief executives have been on the scheme.
The Breaking Through relaunch followed criticisms about results – only two of its graduates have so far become directors – even though participants were often more qualified than their white peers, says Thornton.
“One of the problems was that Breaking Through was very popular in the BME community, but it wasn’t very well known outside,” he says. “Participants got really fired up, but then we left them to go back to cultures that weren’t that receptive.
“On the whole, NHS management tends to be filled with white, middle class men, and we like to appoint in our own image,” he says, by way of explanation for the BME talent stuck in middle management, dubbed the “Guinness effect”.
But he also blames HR managers who “come out of a tradition of administration and operations, rather than organisational development, so you get technical specialists rather than people with vision.”
Research by the Institute for Employment Studies in 2001 showed that white managers do not know how to performance-manage BME colleagues, preferring to do nothing rather than be thought of as racist, and sometimes leaving a situation to deteriorate to the point where disciplinary action is invoked.
The new Breaking Through scheme comes with a package of support and a guaranteed work experience post at senior level for 18 months. Candidates have to come from organisations demonstrably committed to equality. “The aim is to create a high-profile bank of role models to banish the culture of ‘learned helplessness’ where BME people don’t see their peers getting senior posts, so don’t bother to apply,” says Mr Thornton.
Jon Ota went on the Breaking Through programme last year and is about to become director of operations and provider services at Harlow PCT. At first, he was wary of a BME-specific programme, fearing that participants “might spend all their time talking about discrimination in the workplace, rather than what was needed to be a good leader.”
But his fears were unfounded. “The course made me realise I did have the competencies to become a director and it gave me the confidence to say ‘I’m ready’,” he recalls. “I hadn’t faced external barriers, but I had internal barriers instead.”
Other benefits included developing a network of people from a range of fields and gaining the motivation to seek out a job serving a high black and minority ethnic population, where he could make best use of his cultural insights. “Some BME people feel those who get to the top are betraying everyone else, which is more than about being left behind,” he contends. “I’m from a nursing background, and there are plenty of BME nurses. But there are not many BME directors, and they are not seen as BME people.”
“The value of this type of training lies in understanding what underpins personal and political effectiveness,” says Lubna Huq, a consultant with the Hay Group, which helped produce Breaking Through. “[Course participants] thought that doing a good job would speak for itself. But that’s not how organisations work,” she says. “You need to know how to raise your profile.”
Salma Yasmeen completed the five-week transformational leadership programme for BME staff of grade 7 and above, run by the King’s Fund just before Christmas. This focuses on behavioural and attitudinal change and developing “bicultural competence”: finding a way to preserve personal cultural values empathically and constructively, rather than confrontationally.
Salma is a focused implementation site project manager for delivering race equality in mental health at Bradford and Airedale teaching PCT.
“Working with such a highly politicised agenda in the NHS is incredibly challenging.
And there’s a real risk of burn-out doing change management. But the course has helped sustain me, and reignited my commitment,” she says. “I can see myself going right up the tree.”
Shared Leadership for Change, run by the Health Foundation, aims to increase the effectiveness of teams working to improve healthcare for BME groups and is rooted in measurable outcomes and political astuteness.
Amit Khutti is on the foundation’s leadership fellows award scheme, a two-year programme, aimed at developing future NHS leaders who can focus on health inequalities. Currently director of strategy and service planning at Chelsea and Westminster foundation trust, he is keen to become a chief executive but thinks the NHS is still not particularly attractive to BME high-flyers.
“Quite a few people in NHS management have had someone in their family do it or been involved in some way. It gets into your DNA, so I wouldn’t be surprised if BME people didn’t see it as a career move,” he says.
Research carried out by a Swedish branding company two years ago backs him up. It showed that ethnicity strongly influences career choice, with British BME graduates aiming for companies with a track record on diversity.
Appointments Commission chair Anne Watts agrees. The commission has just reviewed its own practice and concluded that it must work harder to attract BME applicants.
“Applicants do need a lot of experience, and a career in the public sector doesn’t come top of the list for most university graduates,” she says.
“It’s not just about getting the numbers through the door, it’s about ensuring there are real opportunities in the system. There is a lack of training and development, so that people who want to move on can’t do so.”
Yvonne Coghill remains optimistic about the creation of a truly diverse NHS at all levels, but she has no illusions about the barriers to this goal. “BME people are often seen as too risky by senior managers who come from backgrounds that have not mixed with diverse cultures,” she says.
Acknowledging that racism exists is also important, she says. “The NHS is part of society, which includes people who are racist and sexist. There’s always more to be done, but I think we’re on the right track.”
Dave Thornton does not think that bullying people into taking race equality on board is the answer either. “The moral argument hasn’t worked, and the NHS has not been good at making the business case… You need the stick, but you also need the carrot.”