Roger Kline picResearch by Roger Kline finds that black and minority ethnic (BME) staff are grossly under-represented at senior levels of the NHS and their presence has declined despite the increasing number of BME nurses and doctors. Urgent discussion and action is needed to prevent further damage to staff well being and to patient care.

The NHS is England’s largest employer of Black and Minority Ethnic (BME) staff.  There are some 190,000 BME staff (one in six). 19.7% of England’s NHS nurses and 37% of doctors are of BME origin. There is a growing body of evidence linking the treatment of BME staff and their representation within healthcare management and governance to the patient experience and outcomes. The under-representation of BME staff at senior level, and their treatment throughout the NHS are not simply employment issues. “The ‘snowy white peaks’ of the NHS” examines whether BME representation within the governance and leadership of the NHS reflects either the proportion of BME staff employed or the proportion of BME people in the wider population.

The NHS acknowledges the importance of representative governance and leadership evidence but, whilst Health Ministers’ narrative acknowledges representation is low, it argues that recent data (for example on nurse managers) shows improvement and “although these are not substantive rises, this demonstrates that we are travelling in the right direction.”

I found the opposite. BME staff are grossly under-represented at senior levels of the NHS and their presence has declined despite the increasing number of BME nurses and doctors. BME representation amongst Board non executive directors have declined proportionately in recent years too. In London for example, 45% of London’s population and 41% of its staff are of BME origin, yet amongst its 40 NHS trusts, there is just one BME chair and not a single BME chief executive. Almost half of London’s Trust Boards have no BME person at all as a voting member of the Board. Nationally, matters are no better. Amongst the five main national NHS bodies there is not a single Board level BME executive.

Despite a plethora of policies and initiatives over the last decade, matters have actually got worse. The proportion of London NHS Trust Board members from a BME background is significantly lower number than it was just eight years ago. There has been no significant change in the proportion of non executive BME Trust Board appointments in recent years, continuing the pattern of under-representation compared to both the workforce and the local population. The national proportion of senior and very senior managers who are BME has not increased since 2008, when comparable grading data was last available, and has fallen slightly in the last three years. The proportion of nurse managers who are from BME backgrounds has actually fallen even though BME nurse numbers have risen. The likelihood of white staff in London being senior or very senior managers is three times higher than it is for black and minority ethnic staff.

The failure of the NHS to develop and promote its BME talent led its departing chief executive Sir David Nicholson to say last month that “he regrets not making more progress in increasing the number of black and minority ethnic senior NHS leaders,” that senior NHS management was “too monocultural”, and that the barriers to improvement as a “systemic problem”.

Research has shown that by every indicator, BME staff in the NHS are less favourably treated, whether in grading, recruitment, promotion, discipline, or bullying.  BME staff are also substantially less likely to access training not least because nominations come via the very NHS Trusts who entrench discrimination in the first place. Just 4 per cent of recruits to the main new nursing leadership course, set up at the request of the prime minister, for example, are from a non-white background.

Despite this overwhelming evidence, even the measures put in place a decade ago to try to remedy this deep disadvantage have been dismantled. Systematic mentoring of BME staff has been abandoned. “Stretch” targets for NHS Trusts on race equality have vanished as has the promised systematic national tracking of BME staff progress. The most important national leadership development programme, Breaking Through, has been abandoned entirely, without any risk assessment of the consequences.

There appears to be deep strategic confusion at the heart of the NHS. There is no coherent strategy, and even workforce monitoring is erratic. Key indicators are not measured or analysed and what’s not measured isn’t tackled. Many employers seem repeatedly shocked or in denial when challenged locally. Even when the NHS national staff survey shows huge discrepancies between the returns from BME and white staff, these are rarely discussed. In the NHS 23% of all staff reported being bullied last year and in each of the last four years one quarter of BME staff said that they had been discriminated against in the previous 12 months. The Department of Health strategy is overwhelmingly predicated on individual local employers driving improvement yet that approach has failed in recent years. Carrying on doing the same and expecting different results seems to meet Einstein’s definition of insanity.

The link between the treatment of BME staff and their exclusion from leadership may affect healthcare for several reasons. Patients may be prevented from getting the best clinicians and support staff if candidates’ ethnicity unfairly influences recruitment and promotion, or leads to BME staff being unfairly treated in the disciplinary process or in other aspects of their working life.

If BME staff are treated unfairly then that is likely to have an impact on morale, absenteeism, productivity, and turnover. It will also lead to the loss of time and money through grievances, employment tribunals and reputational damage.

The NHS is not the only public service (or private one) large  where deep rooted discrimination appears intransigent. In health, however, there is now an established link between the treatment of BME staff and the care that patients receive. Research shows the workplace treatment of BME staff is a very good barometer of the climate of respect and care for all within NHS trusts and correlates with patient experience.

There is evidence of a link between diversity in teams (at every level including Boards) and innovation. At a time when the NHS needs to transform its care, lack of diversity may carry a cost in patient care for everyone. Leadership bodies which are significantly unrepresentative of their local communities, such as many NHS Trust Boards, may well have more difficulty ensuring that care is genuinely patient centred – with resultant failings in the provision or quality of services to specific local communities that have particular health needs, including BME communities and patients.

There is widespread acceptance that a transformational rather than transactional leadership style is needed in the NHS, and that bullying of staff is a serious NHS problem. Numerous reports from the Francis Inquiry onwards have all highlighted the shortcomings for patients of a culture that fails to value staff. This report goes further and suggests that the discrimination that black and minority ethnic staff within the NHS face is so widespread, deep-rooted, systemic and largely unchanging, that urgent discussion and action is needed to prevent further damage to staff well being and to patient care.

Note: This article gives the views of the author, and not the position of the British Politics and Policy blog, nor of the London School of Economics. Please read our comments policy before posting. Homepage image credit: comedy_nose CC BY 2.0

About the Author

Roger Kline picRoger Kline is Research Fellow at Middlesex University Business School and an Associate of Public World. He has written the report, The “snowy white peaks” of the NHS: a survey of discrimination in governance and leadership and the potential impact on patient care in London and England”.


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