A pyramid that is white at the top and black at the bottom: Trevor Phillips' description of the NHS in 2003 remains all too familiar five years on.
When the chair of the Commission for Race Equality issued this indictment of race equality in the NHS five years ago, 6.7 per cent of non-medical managers were from ethnic minority groups. According to the most recent data available that figure now stands at 7 per cent - hardly a staggering improvement.
Yet the NHS is England's biggest employer of ethnic minorities, who comprise some 15 per cent of its workforce.
Former NHS chief executive Sir Nigel Crisp took up the issue of tackling the "snowy peaks" of NHS management by launching a leadership and race equality action plan and appointing a new national director for equality and human rights. And the Department of Health's revised race equality scheme for 2005-08 highlights the need to "draw on the talents of everyone in the country to serve the public".
Current NHS chief executive David Nicholson has latterly taken up the mantle, calling for 30 per cent black and minority ethnic representation at the top tiers of the service.
It is acknowledged there is a lot of ground to make up before such figures can be achieved, with the vast majority of NHS senior managers' ethnic background classed as white. Anecdotal evidence suggests there are just six chief executives and as few as 60 executive directors from BME backgrounds in 446 NHS trusts.
But there is a paucity of statistics on the subject. Neither the DH nor the Information Centre was able to provide HSJ with figures for the number of BME managers, either broken down by sector or Agenda for Change grade, for this article. The number of BME chairs was also unknown.
There are no figures for the number of medical managers or their ethnic background and no full ethnic breakdown available of non-medical managers. The latter are split into the broad categories of Asian, white, black, Chinese, mixed, other and unknown.
These figures reveal Asians account for the biggest ethnic minority group in non-medical NHS management. In 2006 there were 940 compared with 731 black managers, 250 mixed, 206 other, 84 Chinese, 2,242 unknown and 31,782 white.
Could high numbers of Indians from middle class backgrounds be masking under-representation by more disadvantaged groups? Given the lack of data it is difficult to tell, but Robina Shah, co-chair of the NHS Confederation's black and ethnic minority leadership forum, believes it is important to find out.
"The groups that are most under-represented are Pakistani and Bangladeshi. We need opportunities for people from these backgrounds to step up," she says.
While national statements are made on increasing the number of minority ethnic managers, the picture on the ground is less clear. A November Healthcare Commission audit found just 9 per cent of trusts were complying with race relations legislation. Jon Restell, chief executive of union Managers in Partnership, says trusts seem to have lost impetus.
"People aren't even seeing this straight any more. Compliance is so poor, trusts are so bad at it, that people say there's nothing that can be done about it," he says.
Managers in Partnership is in the dual position of both representing members from BME backgrounds alleging race discrimination and those keen to avoid race discrimination claims. Mr Restell is sympathetic to those who argue managers already face a barrage of demands and cannot prioritise everything, but believes it can be done.
He recommends boards find better ways of communicating with BME staff. One suggestion is for leaders to speak to BME forums in other organisations to gain insight that can be fed back to their own trust. This would avoid the problem of employees holding back from discussing sensitive issues in front of bosses. Organisations that have seen some success in race equality could advise struggling trusts.
"People aren't hostile to it as an issue but they're crying out for greater support in making a practical difference," says Mr Restell.
He is unequivocal about the need for locally driven change but would welcome some kind of financial disincentive for trusts that fail to address the problem.
"This is last chance saloon territory," he warns.
Of course trusts can only draw from the talent pool available to them. When you have only half a dozen BME chief executives, those coming into the sector lack role models. One move to tackle this, the NHS Institute for Innovation and Improvement's Breaking Through programme, was set up in 2003 to help BME managers build the skills and confidence to progress through to senior level. However, it is thought that so far only one or two participants have gone on to become board-level directors.
In an attempt to improve the scheme's underwhelming success rate, changes to be introduced this year will see 15 candidates placed in organisations and given 18 months' experience at director level. It is hoped on-the-job training, coaching and some formal teaching will give more BME managers the support and access needed to make the next step.
NHS Institute head of building leadership and capacity Dave Thornton says he is aware the move could provoke resentment from white colleagues.
"That's the one thing we were conscious of, because it's a brave move," he says. "Some people will have an issue with it and others will think it's exactly what we should be doing. You have to be brave to make change."
He stresses that chief executives have been "wonderfully open" to the idea. But he concedes covert racism has to have been at play in the historic under-representation of BME communities. "It's not malicious or premeditated, it's subtle. But the statistics are quite stark. There's something going on."
In which case, can a scheme that helps just 15 people a year really have the desired impact? Hopes for the future are boosted by the NHS management training scheme, also run by the NHS Institute.
With an intake of 220 graduates a year, it has increased its BME representation from 13 per cent in 2005 to 24 per cent in 2007. Although a larger number of the BME graduates on the scheme are on its finance stream, rather than in human resources or general management, this is a marked improvement.
Mr Thornton says one way the scheme did this was by stripping away behavioural observations from its assessment centres that could have led to cultural misunderstandings with candidates.
Mr Restell has learnt from personal experience that managers can unintentionally favour people who have similar traits to their own.
"I thought I'd appointed a really diverse team [at MiP] but [psychometric tests] have shown that they have personality types very similar to my own. It's possible that we're appointing in our own image even if we think we're not."
Mr Thornton says trusts should use competency-based interviewing to ensure they do not unintentionally discriminate against ethnic minorities.
"For far too long we've used the moral argument and it hasn't made any difference. Now we need to use the business model argument. If you're putting the patient at the centre and working with the local community you have to be representative of that community." The institute also used targeted marketing of universities and media to raise its BME intake. Gursharn Mann, a final year human resources trainee at Heart of England foundation trust, says it is important to demonstrate to BME graduates that NHS management can be a viable career.
"My dad's first generation Indian and when I told him I'd got onto the NHS trainee scheme to do HR it was really difficult for him to appreciate what the role would be," she says.
"Traditionally people from Indian backgrounds have always thought of hospitals as employing doctors and nurses. We'll probably see the NHS becoming more and more representative as decades pass and more people are born and raised in this country."
Ms Mann admits she is worried there might be barriers "either implicit or explicit" to her landing a top role but feels her confidence and determination will help her realise her goals.
"It's about how you manage your career. I was conscious it might be difficult for me to get to a senior position but knew I would do whatever it took to get there. You need to be able to manage the obstacles you face."
Ms Mann sees her cultural background as a competitive advantage, particularly around recruitment and retention, and used her background to contribute to a recruitment drive aimed at increasing BME representation during a placement at Dudley PCT.
Prem Singh, the Malaysia-born chief executive of Derby City PCT, agrees there is "a degree of helping yourself" as a BME manager.
"I've had some lucky breaks but I've had to work bloody hard," he says. "I'm a firm believer that if you deliver consistently and have a reputation from that, there's nothing to stop you from getting to be a chief executive."
But he concedes there are elements of racism in the service. "You'd be in denial if you said it didn't exist in some parts of the NHS," he says. How else do you explain the inequalities experienced by BME people with mental health problems, the former nurse asks.
"Of course I have experienced prejudice; we [BME staff] all did. It was covert and to do with people not having cultural competence."
Mr Singh believes cultural differences can also help explain the low representation from BME groups. For example, young Asian women may be self-effacing in interviews or not make eye contact. He adds that interviewers may have to ask more probing questions of those who feel uncomfortable boasting about their achievements.
"I had people saying 'we don't see you as being different'. But I don't mind being different, I want that to be celebrated," he says.
Mr Singh adds that BME representation is just as important among senior clinical leaders as it is for non-medical managers, pointing to the success of medics such as former Royal College of GPs chair Mayur Lakhani. Yet the figures for clinical staff do not make comfortable reading either. DH numbers for 2005 show people from BME backgrounds comprise 18 per cent of consultants but 57 per cent of staff grade doctors.
And although almost 14 per cent of nurses come from a BME background, only three out of 400 nursing directors are black, according to a report published last June by Race for Health, which works to increase diversity in PCTs.
Despite this bleak picture, DH equality and human rights director Surinder Sharma denies the NHS is institutionally racist. "We're reflective of society at large," he says.
Mr Sharma insists the NHS is "doing well" and that "the private sector is just as bad if not worse". Becoming exasperated, he asks HSJ: "What's BME representation like in your office?"
Mr Sharma seems unconcerned by a Commission for Race Equality report published in September that showed NHS trusts were lagging behind local government and police on race equality. And he calls the Healthcare Commission audit flawed, because it tracked whether trusts displayed their race equality scheme on the internet rather than whether they had a scheme in place. The DH is providing clear leadership on race equality; regulators need to give it priority too, he says.
Healthcare Commission equality, diversity and human rights head Trish Pashley takes issue with this: "It's quite reasonable to expect publicly available information to be put on the web. We phoned the trusts that hadn't published their scheme on the internet to ask for a copy. Lots said it was 'still in production'," she says.
Ms Pashley's biggest bugbear is the lack of numerical data on ethnicity in the NHS.
"You can't ask a regulator to work in a risk-based way if there's no data."
Positives and negatives
Meanwhile, Robina Shah warns against positive discrimination, where people are placed in jobs purely because of their ethnicity.
"You don't want a token black person. We want people who are recognised and valued in their role for the contribution they make."
She brushes off a suggestion by Jon Restell that the NHS lacks a vocal BME lobby. Members of BME forums in each strategic health authority are linking up to share best practice and work with SHA leadership teams, she says. But the fact that Ms Shah had not heard of a BME network set up last June to cover the entire NHS South East Coast region suggests grassroots campaigners are not yet as well connected as they could be.
So are the snowy peaks about to thaw? Trusts may not have much choice but to tackle the issue. The Healthcare Commission has announced that any trust not publishing the information required under race equality law may be judged to have failed a government core standard. This could affect its 2008 annual health check rating.
Ms Pashley thinks the self-declarations for 2008 will show worse compliance rates than last year, but puts this down to greater honesty - now trusts know the commission is on top of the issue - rather than worse performance.
And Ms Shah believes foundation trusts have to be particularly aware of the need to have a board that reflects their local populations.
"It's partly a community engagement issue and partly about public accountability," she says. "These are key at the moment in how we look to provide an inclusive service. It appears some people haven't made that connection." Governors and the foundation trusts' regulator Monitor could insist on it, she adds.
A planned Information Centre study is set to assess the workforce impact of structural changes as part of Commissioning a Patient-led NHS. Many suspect the policy reduced the number of BME managers by merging PCTs that were disproportionately headed by people from ethnic minority backgrounds.
The Equality and Human Rights Commission declined to contribute to this article, saying it is still working on its policies.
Finally, while the DH is certainly talking the talk, it also needs to put its own house in order. Almost half - 46 per cent - of the DH's most junior staff are BME, compared with just 6 per cent of its senior civil servants.