Previous attempts to eliminate race discrimination from the NHS have have failed. Roger Kline, Yvonne Coghill and Saba Razaq argue employers must use research evidence to shape interventions and metrics to hold managers to account

Two years ago The Snowy White Peaks of the NHS held a mirror to the UK’s largest employer of black and minority ethnic staff. It summarised evidence that BME staff were treated less favourably than white staff in recruitment, board membership, career development, disciplinary processes and bullying.

In his Mid Staffordshire public inquiry report, Robert Francis wrote: “There lurks within the system an institutional instinct which, under pressure, will prefer concealment, formulaic responses and avoidance of public criticism.” For patient care, read race discrimination. Many NHS employers were not collecting data, failing to analyse data, listen to staff or act on the evidence all around them

Race discrimination undermines the effectiveness of the care and safety of all patients

This was despite extensive evidence that race discrimination not only damages BME staff but undermines the effectiveness of healthcare providers and the care and safety of all patients, not just BME patients.

It risks patients not getting the best staff. It risks higher turnover, absenteeism and lower discretionary effort, as well as grievances, disciplinaries and tribunals. It makes NHS staff ill. It leads to higher levels of bullying of BME staff increasing the risk that staff may not admit mistakes or raise concerns and work in less effective teams. Unrepresentative boards and monocultural leaderships are likely to be less innovative and ill-tuned to local health needs.

Research on NHS staff engagement points to powerful correlative evidence linking the treatment of BME staff in particular to patient experience and care. It found that the staff survey item that was most consistently strongly linked to patient survey scores was discrimination, in particular discrimination on the basis of ethnic background”.

Progress is impeded by the reluctance of many NHS employers to address race discrimination, while BME staff hesitate to raise concerns about race because they rightly believe it might damage their career. 

Failed standard

The workforce race equality standard 2015 followed the 2004 NHS race equality action plan, launched after the McPherson inquiry. Focused on improving policies, procedures and training, it the action plan emphasised coaching, mentoring, and support for BME staff. But despite good intentions, the lack of measurable outcomes, incentives or sanctions, benchmarking and research underpinning meant it failed.

In creating the NHS workforce race equality standard we considered the research evidence on effective change in workforce equality and culture. We found Kalev’s research on US affirmative action particularly persuasive which found “attempts to reduce managerial bias through diversity training and diversity evaluations were the least effective methods of increasing the proportion of women in management”.

Our own conclusions were similar to those of an ACAS review of workplace bullying. They led us to go beyond the dominant NHS HR paradigm of reliance on policy, procedure and training. The standard’s mix of narrative, data, and metric driven accountability drew on lessons from US affirmative action and on the success of chief medical officer Dame Sally Davies’ policy of refusing funding applications to her research budget unless applicant institutions had achieved the Athena SWAN silver award, aimed at promoting women in science.

The lack of measurable outcomes, incentives or sanctions, benchmarking and research underpinning meant the action plan failed

The workforce race equality standard mixes challenge and support. The NHS standard contract requires providers to provide evidence of year on year progress; it is included within the CQC’s “well led domain”; and the data will be published and benchmarked. The intention is to prompt root cause analysis to understand how to close the gap between White and BME staff treatment.

NHS providers (including the private sector) must publish data against nine metrics summarising the gap between the treatment and experience of white and BME staff in the NHS – and then demonstrate year on year improvements in grade composition, appointments, disciplinary action, access to career development, bullying, and board composition.

Our first baseline report on the first set of annual WRES reports shows how far we have to go. The next report will include workforce data which we expect will corroborate BME staff survey responses.

Evidence based equality

Trust boards and national bodies often say they are not sure what to do. Research shows it is not enough to simply put policy, procedures and training in place and then support individual members of staff who use this framework to develop their career or challenge unfairness.

Too many organisations still think the key to fair recruitment is improving policies and introducing unconscious bias training. It is not. Successful organisations have leaderships who are determined change will happen, who model the behaviour they expect of others, who use metrics to hold managers to account and use research evidence to make specific interventions.

Such leaders understand their organisations must be proactive and intervene to challenge race discrimination, not primarily leaving it to individuals to raise concerns. Organisation that want to challenge specific aspects of discrimination first scrutinise the data, identify appropriate metrics, and then use innovative approaches to address the challenges of recruitment, discipline, bullying and boards in ways that have wider benefits.

Fairer appointment panels benefit all staff and erode the “club culture” so dominant in the NHS. Fairer disciplinary practice helps erode the “blame culture” all organisations profess to want to end. Such approaches overlap with measures needed to improve cultures of poor staff engagement, bullying and discrimination more generally.

Workforce race equality in the NHS has often been an evidence-free zone. It is time we did better, and we will.

Roger Kline, Yvonne Coghill and Saba Razaq are members of the NHS Workforce race equality standard implementation team.