NHS trust boards have failed in their duty to grow BME representation so what compelling action can now be taken to tackle the problem? Alison Moore on HSJ’s latest roundtable
Everyone who works in the NHS is aware of how important black and minority ethnic staff are to the delivery of healthcare.
But many BME staff find it hard to progress in their careers and hit an invisible glass ceiling, with few getting to senior or board level. This can be true even in organisations with substantial numbers of BME staff members, reflecting a diverse local population.
National NHS policy says that trust boards should be as representative as possible of the communities they serve and this can help both the planning and provision of services. Yet in recent years BME representation on trust boards may have diminished rather than grown: in London the proportion fell from 9.6 per cent in 2006 to 8 per cent in 2014, despite more than two fifths of NHS staff in the capital being from a BME background.
Vijaya Nath Director of leadership development, The King’s Fund – roundtable chair
Tracie Jolliff Head of inclusion and systems leadership, NHS Leadership Academy
Roger Kline Research fellow at Middlesex University and NHS England director, workforce race equality standard research and engagement
Professor Aneez Esmail Professor of general practice, Manchester University
Yemisi Oluyede Head of workforce health, diversity and equality, the Royal Free London Foundation Trust
Caroline Bernard Head of communications, NHS Providers
Wendy Irwin, Wendy Irwin, head of equality and diversity, RCN
Joy Warmington Non-executive director, Birmingham and Solihull Mental Health Trust
Beverley Powell Equality and diversity advisor, Barnsley Hospital Foundation Trust
Heather Caudle Chief nurse, Ashford and St Peter’s Hospitals Foundation Trust
Jon Restell Chief executive, Managers in Partnership and advisory board member for the NHS’s Workforce Race Equality Standard
An HSJ roundtable, sponsored by the NHS Leadership Academy, attempted to look at where we are now, examine some of the barriers to progress, and debate what can be done to overcome them. To do this, we assembled a panel of successful BME staff, academics, policymakers and representatives from professional bodies.
King’s Fund director of leadership development Vijaya Nath, chairing the debate, said there was much evidence and data around the impact of low BME representation but people were asking when does the talk end and action begin? “This debate will matter for nothing if we are not offering a way forward,” she said.
“For far too long boards have abdicated responsibility and said we have someone in the organisation with the title ‘on diversity’ and now it is happening.”
Many in the room had personal experience of trying to combat discrimination in the NHS and outside. Professor of general practice at Manchester University Aneez Esmail said: “As an ethnic minority doctor I have suffered a lot of discrimination in my career. I made it my job to research this, expose what is happening and offer a solution.”
Leading researcher Roger Kline, who was involved in the development of the NHS’s Workplace Race Equality Standard, added that he had seen time and time again people who had not got to where they should be in their careers because of ethnicity.
Yemisi Oluyede, head of workforce health, diversity and equality at the Royal Free London Foundation Trust, had seen many BME staff in distress. She said: “When I started work in the NHS a lot of nurses when they saw my name on the door would knock, come in and within two minutes they are in tears. The issues are the work and their environment.
“It is time for action. We have been talking but where is the difference we have made? There are so many people going through the system not realising their potential.”
Basis for action
She pointed to the dearth of black chief nurses as an example, but added that white allies were needed as well.
Others, too, wanted to use the discussion as a basis for action. Caroline Bernard, head of communications at NHS Providers, spoke of the need to get members to support and understand the need for diversity while Heather Caudle – chief nurse at Ashford and St Peter’s Hospitals Foundation Trust – said she saw around her people wanting and willing to get a handle on these issues. “I hope to bring back to my colleagues a sense of urgency,” she said.
NHS Leadership Academy head of inclusion and systems leadership Tracie Jolliff stressed it should not be a “them and us” situation. “It’s about time we all stood on the same side of this argument and acted to create change.”
However, non-executive director at Solihull and Birmingham Mental Health Foundation Trust Joy Warmington said: “I think we need more thought. I think action without thought leads to the situation we have at the moment where we have not gone as far as we needed.” There was a need to be more strategic, and to highlight the waste of opportunity and lives in an increasingly diverse society.
“We want to be a bit more courageous and think outside the box, and to be honest about what has not worked. Some things looked very seductive but we have been doing them for 50 years.”
Ms Nath added: “We want a compassionate culture but we can only deliver compassionate care if the totality of the workforce feels valued.” She asked the panel to identify what they saw as the main barriers to getting better representation of BME staff at board level.
In denial mode
Mr Kline said: “I think there is denial in the system about the scale of the problem, in understanding the narrative as to why the problem is important and the evidence as to its causes. The proposed solutions in most cases are simply not evidence driven, they are not led by research which says why this is happening. To challenge that we need to understand what it is not about.”
BME and women candidates were often better qualified for jobs and wanted to do them but the organisational systems allowed bias – including unconscious bias – to be legitimised, he added. Ms Warmington added there was a mistaken belief that the NHS was a meritocracy. “There is a huge networking and club culture. Quite a lot of black people are not part of that network,” she said.
Professor Esmail added: “I think it comes down to leadership. It has never been the job of leaders in the NHS to make this part of their everyday work. It’s always the last thing they have thought about. No one is ever accountable.” Progress would follow if the leadership was made accountable for this – but it would take time.
Organisational change, however, is another factor which can inhibit progress, suggested Jon Restell, chief executive of Managers in Partnership and an advisory board member for the NHS’s Workforce Race Equality Standard, which has been devised to tackle these issues.
Reorganisation led to managers being dispersed to different bodies and continuity being disrupted, he said. It can also contribute to a club mentality as people stick to what they know. A rapid turnover of senior managers – often with periods of interim leaders – added to this.
Expecting year on year progress on diversity with this backdrop of change and rapid turnover of chief executives might be unrealistic, he added.
Royal College of Nursing lead on diversity and equality Wendy Irwin agreed that short termism was a driver for failure. “People think they can solve systematic generational problems by teatime and they then get really upset when it does not happen,” she said. She urged that these issues should not be linked to individuals but to systems, allowing longer term approaches.
So what would lead to change? Ms Caudle suggested consistently linking the case for change with quality issues around care was important rather than making it just about NHS staff. “When you make the case for change because of the relation to inequalities of health the light bulb goes on,” she said – but it then somehow became seen as just a workforce issue and not taken seriously.
’People think they can solve systematic generational problems by teatime and they then get really upset when it does not happen’
“We don’t think strategically about the inequalities in the health outcomes of those we look after and the inequalities in the workforce.”
Mr Kline suggested issues around diversity were treated differently from others affecting patient care. “When you have any other problem that adversely impacts on patient care you look at the data, you see if anyone else with the problem has a solution and you adopt it to the situation,” he said. This did not happen with issues around BME advancement.
Other panellists identified various points in the recruitment process where changes might lead to more BME board members. Ms Oluyede questioned whether headhunters, used by many trusts to source potential board members, identified promising candidates from a BME background – or whether these people were even known to them.
Professor Esmail referred to the work the NHS Appointments Centre used to do, which had aimed to find good candidates for non-executive roles and make boards more representative. “We have examples of things that we know were working – then someone said it was a quango and got rid of it,” he said. “It just seems so frustrating that we have to go back and start things again.”
However, if good BME candidates do get to the interview stage for senior posts, do they face another insurmountable hurdle? Some on the panel felt boards could sometimes recruit in their image, choosing to recruit someone who looks like them or their son or daughter: this could lead to a continuing lack of diversity.
Mentoring and support for BME candidates could be helpful, and could raise their profile through networking and becoming better known. This could help when informal soundings were being taken about candidates. “When a chief executive wants to appoint to executive level, they want to talk to another chief executive about the candidates,” said Ms Oluyede.
Beverley Powell, equality and diversity advisor at Barnsley Hospital Foundation Trust, said: “I am finding people are successful at the application stage and short listed but when they get to the panel they are not recruited.
“We have, perhaps, subtle nuances that an institution may not like and it is being aware of that.” She illustrated this by saying that when she worked for the police, she was trained to speak and stand in a certain way. When she joined the NHS she found there were also nuances in behaviour and speech: BME staff might need to adopt and develop them to their advantage. Ms Caudle said it was a commonly made joke that nurse directors always wore pearls!
Problem in the system
But there was concern that BME staff should not have to buy a narrative which said lack of advancement was in some way of their own doing or that there was something “wrong” with them. “We have to be clear about what is the nature of the problem here and what it is that we are trying to fix. The problem is the system,” said Ms Jolliff, adding that the NHS does not have a track record of inclusion. “This is about racialised organisations that have sent messages to BME staff that ‘you do not fit’ for a very long time. It is these things that need to change.”
These issues are not limited to the NHS or to one organisation within it and other sectors can show the way in overcoming them. Ms Nath said GE had found that its senior managers were not good at promoting BME or women candidates, and did not “get” globalisation. It had then mandated change, said that managers appraisals’ would include progress against this, and found change did start to happen.
Ms Powell said that the growth of black and Asian police officers’ association had been important in driving forward this agenda in police services, and enabled BME police officers to “gain a seat at the table”.
Ms Caudle drew a parallel between the healthcare and the financial sector. Both operated in an environment where the workforce came from around the globe. Many NHS staff – including her – had come from a part of the world where health services were less good, and were using that knowledge to drive a better and more efficient service here. “We are missing a trick in terms of using this wealth of experience, and motivation,” she said.
The United Nations has taken positive action to address a lack of representation from some groups, with the general secretary saying that some recruitment boards would not go ahead if there was not a BME candidate on them, Ms Nath said. Several panellists felt this could make a real difference if adopted in the NHS with Professor Esmail suggesting that there should be two women and two BME candidates on all short lists before interviews were allowed to go ahead.
Mr Restell said that using statistics to show underrepresentation on company boards had been very effective with other groups such as woman and he hoped the WRES could have the same effect.
But there were also good examples within the NHS where leaders had grasped these issues. Ms Oluyede said that the chair of the Royal Free had told people that he felt “embarrassed and guilty” when he looked at the figures in his own organisation and had then had meetings with staff. They had come up with some pragmatic solutions such as better quality feedback when they did not get a job, internal “masterclasses” and so forth. Feedback from BME staff who left could also be useful – and understanding how staff could be retained would deliver financial savings on agency staff for the trust – as would talking to recruits after six months in the job to see how they were doing.
The NHS Leadership Academy has also taken action to “change the conversation” in order to create much needed change, said Ms Jolliff, and had been looking at the content of its courses. “You cannot pass our assessed programmes without demonstrating that you have progressed in your understanding of what leadership for inclusion is and that you have put your knowledge into practice. On leadership we have and are embracing the difficult conversations that we need to have.”
She added the NHS Leadership Academy had learned much in relation to inclusion and was acting on it by ensuring that the content of all of its offers was inclusive and facilitated with skill.
It was investing its people to ensure they understood how to create the conditions for leadership learning on inclusion, and was pioneering both practice and knowledge in this area using the experience of programme participants to continually improve.
Raising BME representation involved leadership, accountability, transparency and making it the responsibility of the organisation and its leaders, not the individual, added Mr Kline. “There are organisations in the NHS which have done this and have changed their boards,” he said. Bradford Teaching Hospitals had managed to do this – and was scrutinising recruitment panels.
’There need to be some real consequences for leaders who are not embracing and delivering on inclusion in a very real, tangible and felt way’
There had also been examples where change had been demanded – for example, the chair of one trust had rejected a short list of candidates from an executive search agency because they were all white and said he would do his own, he added
The message needed to be: “This is good for patient care. If it is good for patient care, do it. If you don’t you will be held to account for it,” he said.
This issue of accountability was seen as key by many – but there was concern that delivering a more representative board should not be seen as a “bolt on.” “If it is not the day job of the chief executive and corporate executives whose job is it?” asked Ms Jolliff.
“There need to be some real consequences for leaders who are not embracing and delivering on inclusion in a very real, tangible and felt way.”
But she cited an example of a white male colleague championing BME inclusion as an example of effective leadership. “To be white, middle aged and middle class does not mean that you are automatically an obstacle to progress.”
However, some felt problems did persist with some boards. Ms Warmington said: “The board is a very exclusive place. It has values, attitudes and behaviours that it does not recognise it holds.” Some found the agenda around equality and diversity agenda uncomfortable and wanted to duck it, she said.
Driver for Change
The main driver for change is likely to be the WRES, included in the 2015-16 standard contract and requiring organisations to demonstrate progress on workforce equality, including levels of BME representation on boards.
Panellists felt this was a significant step forward – although it was pointed out that high level appointments around NHS chief executive Simon Stevens were still overwhelmingly white. Professor Esmail said: “What is different about the WRES is mandation. Every chair, every chief executive will be judged by this and it came from the head of the NHS. It is not something which is going to be dabbled in. This is going to be driven from the top.
’A lot of BME people will be placed on boards for the numbers but they will be set up. It may not be the right environment for them’
“Why did we say mandate it? Because that is what the evidence shows. It is not some touchy feely stuff, it is not more training.…it is mandating it.”
The introduction of the standard led to an increase in the number of female BME board members, according to NHS Trust Development Agency monitoring – but numbers had then fallen back, said Mr Kline.
This raised the question of how to ensure any change was sustainable and not tokenistic: putting BME people on boards would not be the solution if they were not supported and equipped to take on and succeed in these difficult roles. “A lot of BME people will be placed on boards for the numbers but they will be set up,” warned Ms Caudle. “It may not be the right environment for them.”
Ms Nath said there was a need to look at people who are very close to board level to ensure sustainability and also reduce attrition.
But overall panellists felt the WRES offered the prospect of progress: but NHS organisations will need to rise to the challenge and bring about real change on the ground. Only then will NHS leadership start to look like its staff and the society it serves.
Roundtable: It's time for action, not words, on BME career progression
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Roundtable: It's time for action, not words, on BME career progression