Black History Month seems a good time to reflect on what has been achieved, and how much remains to be done, since the introduction of the NHS Workforce Race Equality Standard, say Roger Kline and Yvonne Coghill.
Two and a half years ago The Snowy White Peaks of the NHS served as a wake-up call to the NHS. Something was seriously amiss in the way the NHS treated and valued the more than one in six members of its workforce from black and minority ethnic backgrounds.
Moreover this was not just a moral affront to the principles of the NHS Constitution and damaging to those staff whose talent was ignored and treatment was unfair but there was (and is) increasing evidence that such treatment adversely impacted on the effectiveness of NHS organisations and on the experience and care of patients.
The publication of Snowy White Peaks coincided with the arrival of a new NHS England chief executive who took the issue seriously, and a chair and chief executive of the quality regulators, the Care Quality Commission, who recognised the powerful case for treating workforce race inequality as an obstacle to good care and NHS effectiveness, especially the academic evidence of the links between the treatment of BME staff and patient care.
We have highlighted the immense waste of talent that NHS data demonstrates when organisations exclude BME staff from development opportunities and recruit “people like us”
The NHS Equality and Diversity Council, which brings together all the leading NHS bodies, agreed to adopt a radical new Workforce Race Equality Standard recognising that past efforts had not reduced the patterns of discrimination that existed for many years.
The development of the standard drew on an understanding of the research evidence that challenged the previous paradigm, which largely depended on individual staff taking advantage of recruitment, bullying and grievance policies and procedures to raise concerns which managers had been trained to implement.
In place of the approach to race equality developed a decade previously by the NHS, the standard emphasises measurable outcomes, accountability, mandatory implementation, benchmarking and root cause analysis to understand and change the causes of discrimination.
A balance sheet?
Firstly there is a wide consensus that the NHS has a serious problem. The data which all organisations are now required to collect and analyse does not lie. It may not say why there are such big gaps between the treatment and opportunities of BME and white staff but denial and avoidance is much harder.
Secondly the “business case” uses evidence that was not available in 2004 when the NHS Race Equality Action Plan was developed. We have drawn on the evidence from a range of research to emphasise the strong correlations between the treatment of BME staff and patient experience, the use of resources, the innovation of teams and leadership and the safety of patient care. We have highlighted the immense waste of talent that NHS data demonstrates when organisations exclude BME staff from development opportunities and recruit “people like us”.
Thirdly we have emphasised that to understand and change the gaps in treatment and experience, NHS organisations must undertake root cause analyses. Closing the gaps on recruitment and promotion, on disciplinary action, on bullying, and on staff development requires the same approach as we would expect organisations to take with any other factor impacting adversely on patient care. Collect and understand the data, talk to staff and patients, read the research, find good practice elsewhere that works, and see if it can be adapted or adopted in one’s own organisation.
Identifying, understanding, validating and then disseminating good practice is what boards expect us to do and has been our priority in recent months. In the course of doing that we have become clear that some of the approaches the NHS has invested in were never likely to be successful.
Playing the race card
Research strongly suggests that the key ingredient in success is accountability allied to leaderships that model the behaviour they expect of others. That accountability must be demonstrated through progress in closing the gap in metrics between white and BME experience, not simply by sending more BME staff on development courses (useful though that may be).
As an NHS we don’t find race inequality easy to talk about. Yet talk we must. BME staff fear raising issues of race lest they are accused of “playing the race card” whilst white managers are often nervous about how raise issues informally with BME staff so they fester until they become formal matters.
Good leaders will make a priority of enabling such discussions to take place, starting with the board but extending to all managers, providing a safe space for such discussions whilst making clear expectations that race discrimination is absolutely unacceptable.
Culture eats policy and process for breakfast. What we are trying to do is change NHS behaviours and hopefully people’s values, change “how things are done round here”. So what have we achieved so far? Firstly, for the first time in the history of the NHS we have a simple, effective and methodical collection and analysis of workforce data on race equality, a precondition of effective change. As of last week, 99 per cent of trusts had provided data required for the standard.
Secondly, we have helped create a business case that is evidenced and compelling to boards demonstrating workforce race discrimination not only impacts terribly on the health, morale and potential contribution of BME staff but also on organisational effectiveness, patient care and safety. Race equality is now a board issue, not just a matter for equality leads.
Thirdly, by weaving a requirement to close the gap between the treatment and experience of white and BME staff into the NHS standard contract, CQC inspections of the “well led domain” and by insisting on publishing data on whether progress has been made, this issue has moved up chief executive agendas.
The steps needs to end discrimination in disciplinary processes are ones that will improve the overall quality of discussion between managers and staff and will shift organisations away from a blame culture
Fourthly we are now able to begin to point towards evidenced examples of good practice which answers the “what should we do” questions we are always asked by boards.
Fifthly we have sought to ensure that the voice of BME staff within organisations helps shape the work being done.
The biggest challenge will be how the first steps made are sustained over time. Some organisation don’t regard the agenda as important. Others do but feel overwhelmed by other issues. Key to long term sustainability will be ensuring that an understanding of equality is intrinsic in emerging leadership development in the NHS.
The steps needs to end discrimination in disciplinary processes are ones that will improve the overall quality of discussion between managers and staff and will shift organisations away from a blame culture. The steps needed to tackle the disproportionate bullying of BME staff will help tackle bullying generally.
We have much to do. Progress is too slow. But for the first time we are seeing organisations starting to take practical steps, rooted in an understanding of the research evidence, which will show that reducing and ending race equality in the NHS workforce is not only necessary but is possible. And ultimately that will benefit all patients as well as staff.
Roger Kline and Yvonne Coghill are joint directors of the NHS Workforce Race Equality Standard