Published: 30/09/2004, Volume II4, No. 5925 Page 30 31 32 33 34 35 36

The 'snow-capped' NHS employs many people from black and minority ethnic communities - but it doesn't often promote them. Rebecca Coombes reports on plans to create more BME senior managers

Health Secretary John Reid described the NHS as 'snow-capped' in a Fabian Society pamphlet in July.

He meant that white people still make up the top of the service, while tens of thousands of black and minority ethnic staff struggle to make their way up to the highest peaks.

A combination of factors - new laws, political pressure and a realisation that a racially mixed workforce makes good sense for a service treating an increasingly multi-ethnic population - has seen many NHS organisations make significant progress in the last 12 months.

But no NHS trust can yet claim to have a workforce that truly reflects the diversity of the community it serves.

Neither is that accolade likely to be given any year soon. Even goahead areas, such as South Yorkshire, which has tried to attract BME students to preregistration training, do not expect rapid change.

Although thousands of BME people work in the NHS, their numbers are still concentrated in the lower grades.

Staff complain that their colour still acts as a bar to promotion.

BME managers, including those interviewed by HSJ, say they feel they have to work twice as hard and have twice as many qualifications to succeed.

While representation in the non-medical workforce hovers around 11 per cent, only 6.7 per cent of managers are from a BME background. There are only five BME chief executives in the NHS, all in primary care trusts.

Meanwhile, use of NHS and social care services from BME communities is rising. The recent inquiry into the death of black mental health patient David 'Rocky' Bennett was an unpleasant wake-up call to anyone complacent about the importance of race awareness in the NHS.

There are no easy answers and it is impossible to know how far discrimination is responsible for holding BME staff back. But critics warn that too many employers do no more than observe the letter of the law.

The requirement to develop a diverse workforce has been included in Department of Health policy for at least a decade. Ambitious staffing targets in the NHS plan gave the issue new urgency. But the Race Relations (Amendment) Act 2000 has been the real driver of change in many areas.

It means that as well as eliminating unlawful discrimination, organisations must now promote equal opportunities and good race relations. All authorities must publish a race equality scheme, demonstrating what action they are taking.

In theory, NHS organisations must take account of racial equality in the day-to-day work of policy making, service delivery, employment practice and other functions.

Anecdotal evidence suggests that some race equality schemes are far more advanced than others. One recruitment agency compiling information on trust equality and diversity leads recently found that 30 per cent either didn't have one or didn't know who it was.

As well as abiding by the law, NHS bodies have also been working towards DoH targets for BME representation at board level. The target - to increase representation in executive posts at board level to 7 per cent - was to be reached by the end of March this year. The DoH said it had no results yet, but believed organisations were 'fairly on track', with representation rising to 6.7 per cent last summer.

There is no prospect of any further quotas being imposed on employers and critics are divided over their usefulness.

The Improving Working Lives standard, notably practice-plus status, also demands that NHS organisations demonstrate real progress towards achieving a diverse workforce.

Practical support is available for NHS organisations. In June, for example, the Commission for Racial Equality published its Strategic Health Authority Race Equality Guide in response to specific requests for assistance.

The guide recommends that employers set their own local BME recruitment and retention targets.And it says trusts should not only monitor the ethnicity of staff in post, but all applicants for employment, training and promotion.

But most notable is the DoH's Positively Diverse equality programme.

The programme has enjoyed a phenomenal growth rate since it was piloted in 30 trusts and health authorities two years ago.

However, its coverage is still limited to 200 organisations.

Employers like Positively Diverse because it provides a strategic framework for tackling equality and diversity, an area they find difficult to approach in an organised, methodical way.

It provides six stages for employers to work through, from 'mapping' - where the organisation is currently - to monitoring progress.

Programme leader Maroline Lasebikan says it is most definitely not about 'doing an audit'.

'Positively Diverse is not about making you do something. It is giving you the tools. It is not the only way of achieving diversity, but it is a whole-systems approach. At the very least, trusts should be recognising this diversity as an important agenda item - it is not just about meeting legislation.'

She explains: 'You need a helicopter view of an organisation otherwise you are going to be hard-pushed to make it flow through. Trusts have such a lot on with Agenda for Change, for example. You need to take a strategic view and make diversity part of everyone's job. If you separate it, it is just too big to handle. It is not easy and it requires a lot of commitment.

To make it work, Ms Lasebikan says, 'You have to listen to staff and be able to interpret what they say into strategic planning.

But how do you reduce health inequalities if you do not have the right staff in the right place with the right skills? How do you retain staff if morale is not high?'

NHS chief executive Sir Nigel Crisp has also taken a personal interest in the BME agenda. In March he launched a new BME training programme for both mentors and mentees. Four hundred and seventy-seven mentees have gone through the training programme and have now been matched with mentors.

Mentoring is not a new concept, but a DoH spokesperson comments: 'When Sir Nigel announced the scheme he did so with the knowledge he was kickstarting a greater commitment to mentoring at the most senior levels within the NHS.'

This type of leadership is what has been traditionally lacking, says Hounslow PCT's John James, one of only five BME chief executives in the NHS.

'If I were marking the NHS's record on racial diversity as a school report I would say: 'Could do better, '' he jokes.

'I think it is fair to say that Sir Nigel's work is welcome and in parts overdue, but it requires real leadership. There have always been various initiatives around race but that is all they are - not a sustained programme of development, ' he says.

'You need a real commitment and not just saying the right thing when it is politically correct to do so.

'I think [former BBC director general] Greg Dyke showed that diversity was important, although that was not always reflected in programming. The real acid test is whether you make a lasting difference.'

Mr James says metropolitan areas with a diverse community can't just use the Race Relations Act as the only driver of change.

'There is something wrong there. To take it seriously it must be about service priorities. You have to be thinking about strategies for improvement.

There is a good business argument for doing it.

'What will make a difference is people working in the health service who see their career progress and do not ask why, despite being skilled and able, they are still at the same level, ' he argues.

Ms Lasebikan agrees the business argument for diversifying the NHS's workforce has strengthened. 'It is not just a moral argument any more. Trusts are competing with the private sector that has already realised that minority communities are one of the few growth areas.

Youngsters have got certain expectations of employers, ' she says.

Acknowledging that BME staff are still an untapped resource, the DoH has also launched the Breaking Through programme, designed to fast-track participants into senior leadership roles.

Run by the NHS Leadership Centre, it has been enthusiastically received by aspiring BME managers. The programme, which will run annually for three years, has 320 people in the first cohort.

Christina Pond, a programme director at the centre, says breaking through had deliberately shied away from the 'sheep dip' approach, where everyone gets a dose of the same solution.

'People are at various stages in their management career, and are placed on the modules that best suit their needs and aspirations.

Everyone gets a personal development, ' she explains. 'We hope people come with the support of their organisation. It is no good developing people and then putting them back in to an unreceptive environment.'

The leadership centre already runs leadership programmes, so what is different about the content of Breaking Through?

'There are work issues that are different for BME staff than for other groups, ' says Ms Pond.

'Part of the programme is a powerful learning opportunity and personal leadership development - that is very similar to other programmes. But the context is different. It gives BME managers a safe and confidential place to talk about race discrimination and the lack of role models.

'You are bringing together a group of people with similar working experience. We introduce them to role models who can speak very personally about the obstacles and how to overcome them.'

She sees BME leadership as the key to changing the NHS.

'The problems are deeply entrenched and a huge challenge.

There are still people who will deliberately discriminate against BME people. There are also BME people who do not see themselves as being able to fulfil a senior role. Unless we can develop leaders who can embrace diversity we will never get that change in an organisation.'

Gamiel Yafai is diversity director at advertising agency Euro RSCG Riley. Around 90 per cent of his clients are from the public sector.

He celebrates the many 'fantastic' initiatives in the NHS to make organisations more racially diverse, but adds that 'very few organisations are sharing it either internally or externally'.

Mr Yafai explains: 'Communication is a big issue. I think the DoH needs to promote it more. There was a real buzz at the HR in the NHS Conference around Sir Nigel Crisp's mentoring scheme. You need to feed this enthusiasm down.'

And Mr Yafai has his own ideas about how to achieve it: 'Individual trusts need to produce outcomes of their actions, review and assess what they do and then celebrate their successes.

'The main bulk of diversity training at present is about risk assessment - in other words, preventative measures. I think that is sad, but at least people are being educated about diversity and inclusion at the same time.

More focused diversity training still needs to be done but delivered by trainers who truly understand the issues relevant to the trusts. I think that when people get involved with diversity and equality it is like a bug. You want to do more.'

Yvonne Coghill is a primary care manager on secondment as private secretary to NHS chief executive Sir Nigel Crisp

Yvonne Coghill's experience in the NHS was relatively positive until she started to apply for very senior posts. Then she began to encounter what she calls 'invisible barriers'.

A qualified nurse and health visitor, Ms Coghill entered the health service more than 25 years ago as a student nurse. Her first management job came in 1989, followed by various jobs in primary care groups.

'I thought it was time to start thinking about becoming a director; I had the qualification and experience. I have a master's degree and have been on the King's Fund senior managers programme. But I applied for three director posts and failed each time.'

A break came when she was accepted to the Department of Health's new mentoring scheme - and was given NHS chief executive Sir Nigel Crisp as a mentor. 'I've learnt from Sir Nigel that you have to have qualifications and skills, but you also need softer skills such as knowing how to present yourself, making people who are potentially going to be your boss realise you have a lot to offer.'

Ms Coghill thinks black and minority ethnic networks are invaluable. 'There were networks in the 1980s but not as robust as those today.'

Antoinette Scott is service development manager, directorate of performance and commissioning, Ealing PCT.

Antoinette Scott was a clerical assistant at Hammersmith Hospitals trust when she realised she had not realised her true potential.

'I was happy as a PA but I used to watch others go into management positions and think: 'I could do that' I did an honours degree over four years in my spare time and that really opened my eyes. My line manager was very supportive from an early stage. It wasn't until then that I truly got motivated to move on. I think It is an area in which the NHS could do better. Look at the NHS's management training scheme - what efforts are made to bring it to the attention of staff from minority backgrounds?

'Mentoring has been the most encouraging thing. I am aware I am going to meet discrimination and am prepared to deal with it. You do not see many people from minority backgrounds at senior level. I always feel I have to keep proving myself doubly, that I have to strive to be A-plus to be taken seriously, ' she adds.

She wouldn't hesitate to recommend a career in the NHS to friends and family.

'My 12-year-old nephew now says he wants to be a health service manager when he grows up. I would say do it - there are not the closed doors that there used to be.'

Nasrin Khadim is assistant director of nursing, Tameside Acute Care trust.

Nasrin Khadim has been an assistant director of nursing for several years. A Pakistani woman, she is resistant to the idea of positive discrimination.

'The colour of my skin has never been an issue for me. I work across Manchester and have contact with lots of organisations, ' she says. 'I really think it depends how you present yourself. If you do not personalise issues, how can anyone else?'

Ms Khadim says she has thrown herself into networking and seeking out role models. 'I know being a black and minority ethnic employee can be isolating. But I think you have to network and make your own alliances.

'The Breaking Through programme makes you think in that way. It is an opportunity to have very effective mentorship, to have direct access to your chief executive. The programme has paid for coaching. You get an external mentor and clear guidance.

'At Breaking Through you can bring personal issues, for example, if you have been discriminated against, you can talk about it and as a group analyse it. But it is not therapy and people shouldn't treat it as such. It is very much a leadership programme.'

Ms Khadim is hopeful for the future. 'The NHS is the best place to work - it offers so much.'

Bryan Carpenter is director of human resources, Royal Bournemouth and Christchurch Hospitals trust 'I've lived through the past 25 years' worth of initiatives from the centre and very little has changed - certainly not to the degree that I would have expected, ' says Bryan Carpenter.

'It is quite wrong for any trust to say they are diverse or are equal opportunities employers, because we are at a point in the development of the country where patently we are not.

'Growing up as a black person in Devon, I know all about the attitudes prevalent in rural communities. It makes me angry when I hear [Department of Health director of workforce development] Andrew Foster say you have to start with getting places like Bradford right before you think about places like Cornwall. It is the other way round - where 'minorities' are really in the minority.'

Mr Carpenter is vehement that the motivation to increase the number of BME managers is correctly placed.

'People go on about the business case for diversity - as if they are afraid of talking about the moral case.

'There is still institutional racism but you have to root it out in a way that will work and be acceptable to people.

'I do not want to get a job just so that someone can hit their target.'

Dean Pinnock is service manager, North Essex Mental Health Partnership trust

Dean Pinnock started his career in the NHS as a nurse and became a manager about 10 years ago. He is now on secondment to the National Institute for Mental Health in England.

'I did encounter racism, right from my training in Wakefield. But I am quite resilient and you have find ways through it.

'There was one line manager who also happened to be black, ' Mr Pinnock says. 'He was the first manager to show faith in me.

Other managers had undermined my confidence.'

'I think personal qualities are important.

You need to persevere and also work a bit strategically. You need to have an idea of how you need to get from A to B, ' he says.

Now a role model himself, Mr Pinnock says black and minority ethnic managers are not the only way to encourage BME staff.

'It is useful to have role models, however I do not think BME workers need to have a black manager to feel empowered or to boost their confidence. In training [it must be made] clear that, whatever group you are from, there is a clear career path in the NHS, ' he argues.

He believes direct action to increase BME representation can work. 'I think we should monitor what percentage of BME managers there are compared to BME employees and if there is a big disparity it should be tackled locally. In different areas there are different reasons for low representation, ' he says.

Employers need to collect and use information and put in local interventions to provide equal access.'

Unfortunately, some of the barriers facing BME staff are 'very subtle', he says, and can undermine the drive and enthusiasm of BME workers.

Role model: South Yorkshire

Tipped as carrying out some of the 'hottest' racial diversity work in the country, South Yorkshire workforce development confederation has tackled issues right from the point of student recruitment.

WDC director of education and workforce expansion Shanaz Ali says it is the only logical approach. 'WDCs could do a lot more in terms of our role in both development of existing workforce and making sure we have a fit-for-purpose future workforce.

'You can do some fantastic diversity strategies, but unless there is a pool of trained people out there you are not going to get them applying for jobs. We work with universities to make sure students reflect diversity of local population.'

Ms Ali has overseen a number of targeted campaigns to attract local BME people into pre-registration training.

The region's Positive Role Model campaign identified NHS staff from different BME backgrounds in some areas that were very hard to recruit into, such as speech and language therapy and radiography.

'We used real people in real jobs and ran it as a bus campaign and used it in talks with schools and at recruitment fairs. In Sheffield and Rotherham we have seen a steady increase in applications from minority ethnic people for cadet schemes, ' says Ms Ali.

The WDC closely monitors the progress of these students, as well as those who do not get admitted, to find out what extra support could be given. Admissions tutors are also given training. Campaigns are given extra momentum by linking in with National Student Employment Week.

Ms Ali says the WDC relies heavily on data to dictate where work is most needed.

'The workforce census gives us a baseline to work from and shows what improvements need to be made. But once you take the overseas doctors out, the picture starts to look very different. The workforce doesn't reflect the community at all.'

It was hard finding anyone working in the NHS from the local Somali or Yemeni community, for example.

'It is not all rocket science, but about applying the key principle: what are our workforce gaps? We then apply the need for diversity in everything we have done, ' she says.

One of the WDC's successes is getting every NHS organisation on its patch to become a lead pilot in the Positively Diverse programme. It means the region is particularly good at diversity training: there is South Yorkshire-wide training for people in human resources, for example.

Ms Ali comments: 'It means you are not tackling diversity in a vacuum.

You have someone at board level responsible for diversity, a crossorganisational steering group.

'It is a framework - if different directives fall in your lap it means you do not run around like a headless chicken.

'We work with trusts in our patch and have set up diversity forums made up of key people across the NHS and university who lead on diversity. You only need the forums for 18 months or two years.

'After that, the agenda should be mainstreamed and become part of Improving Working Lives .'

Ms Ali is passionate about the direct impact a diverse workforce has on patient care. 'If you have a group of [just] men sat there developing X or Y services and no other input, what kind of services are you going to develop?

'If you do not have a workforce that reflects the local community, how are you ever going to have services that are appropriate and accessible?

'You can't afford to alienate school leavers from an ethnic background. Some of these BME people will not encourage their children to work for us because of their own experiences.

'We need to go back to them and resell ourselves as a different organisation.'

Recruitment emergency: Greater Manchester

Greater Manchester Ambulance Service trust serves a population of 2.5 million, including the second biggest BME community outside London.

Trust equality and diversity manager Des Chow says the organisation is working hard to improve representation, starting from a low baseline.

'At a conservative estimate, the BME community makes up about 9 per cent of the total population. Our staff ratio is running at about 2.5-3 per cent now, ' he says.

'We know BME communities are not getting the information about how to join the service - everyone knows about nursing and medicine, but paramedics do not have the same profile. We have gone out to job fairs and offered placements. We have been successful on the patient transport side, but we are finding it harder to fill paramedic jobs.'

The BME staff network formally meets about three times a year, but also socially.

'Sometimes It is just for a chat. Someone might say: 'Do you think that person was being racist?' only to be told: 'No, that man is aggressive to white people, too.' But we also give advice on courses and generally complement our policies, ' he says.

The work in Manchester complements a national programme led by the Ambulance Services Association. A Managing Equalities and Diversity conference held in London is being followed by a series of regional workshops to spread the findings of research carried out by Professor Joy Notter of the University of Central England, examining the perceptions of the service among those of BME backgrounds.

Professor Notter surveyed all BME staff in the ambulance services, as well as 500 representatives from BME communities in cities across the UK.

The study revealed that very few people had considered joining the services as a career. There was considerable surprise when it was pointed out that it was possible to study for a degree in paramedic studies.

One participant said: 'Asians do not regard this as a high-paid status job. They will rather encourage children to do medicine, dentistry, etc.

Parents need to be educated about this as a career.'

Professor Notter recommended that services do a thorough review of the careers information available, and of the advice given in schools, careers offices and job centres. Information should also be supplied to parents and potential applicants through community activities and venues such as mosques, churches and temples, and women's groups.

Making waves: Portsmouth

Portsmouth has a much smaller BME community than some UK cities, but that has not made it complacent.

Portsmouth Hospitals trust diversity adviser Florise Elliott says the organisation was aware of the low representation of BME staff and had used the Improving Working Lives initiative to try to address the issue. It recently attained practice-plus status.

'We had an overseas recruitment campaign about three years ago when a large group of nurses joined the trust from the Philippines. But we realised we needed to get people involved locally.'

The trust's recruitment team goes out to schools and colleges and an Equal Voice group, made up of religious leaders and members from local community groups, which meets quarterly. The largest minority ethnic groups in the city are Bengali and Chinese, but there is also a sizeable group of asylum seekers from eastern Europe. Forty-three languages are spoken in the city.

'We have a very good ethnic minority staff network, ' adds Ms Elliott.

'It is not just a talking shop but also deals with personal and organisational development. It is a chance for people to hear about the courses on offer.

'We have had staff members who have been in the same post for a long time and by coming to the network they have been encouraged to attend a course and go for promotion.'

In partnership with Portsmouth city council, the trust also runs a Positive Action Through Health programme for BME people on the New Deal scheme.

People do placements at the trust while still actively looking for a job, says Improving Working Lives co-ordinator Samantha Curry. Some have gone on to gain employment at the trust.

'We had an African woman from France come to us through New Deal.

She was highly qualified and had been a businesswoman in France but couldn't get a job in the UK. She came on a six-month placement to our complaints office and after five months successfully applied for a job, ' she says.

'We are not 100 per cent there, ' admits Ms Curry. 'One issue is that nurses from ethnic backgrounds tend to reach a glass ceiling when it comes to promotion, ' she says.

Head of corporate HR services and deputy director of HR Mark Power is honest about the challenges. 'Our aim is to have a workforce that more accurately reflects our local community, for example. I would like to think that we haven't put up barriers.

'We are good at monitoring and have action plans. Training managers are in a rolling programme to deal with harassment and bullying.

'It is easy to have targets and provide statistics but what you need to do is have an effect, to actually retain staff.'

Further information

The Best Intentions? Race, Equality and Delivering Today's NHS. John Reid and Trevor Phillips. Fabian Ideas 611.

www. fabian-society. org. uk

Strategic Health Authority Race Equality Guide 2004. www. cre. co. uk