Mandip Kaur: Making the difference - inclusion in the NHS


Mandip Kaur

Mandip Kaur shares findings from The King's Fund's report, Making the difference: diversity and inclusion in the NHS, and discusses how leaders can create cultures of inclusion within their organisations.

Mandip Kaur: Making the difference - inclusion in the NHS

This presentation was recorded at our event, Maximising the impact of the NHS in tackling health inequalities, on 12 May 2016.


Good afternoon, my name is Mandip. I work as a leadership development consultant here in the LD team at The King’s Fund. I’m going to talk a little bit around the leadership picture in relation to discrimination and inclusion and also some of the issues around workforce as well. So I just wanted to start by asking a question of the audience and my question is have you ever Googled an NHS chief executive, and specifically looked at the images? You have Amrit have you?

You have okay. So I have as well and I just wanted to share with you what that looks like. Anybody notice anything? Yeah, so I suppose what I notice is that it’s a pretty mogenous group of people. And my understanding is that is quite reflective of leadership in the NHS at the moment.

This is what Lord Nigel Crisp called the snowy white peaks of the NHS and some of you will be aware of the seminal report by Roger Kline that was published a couple of years ago and I’ll touch on some of the findings from that report as well, and for those of you that haven’t read it, I would definitely recommend it because it’s quite harrowing reading. And the phrase the snowy white peaks was referring to that picture of leadership in the NHS at the time which was 2003 being pretty un-diverse, and what those pictures show which were from maybe a week ago when I was preparing this presentation is that in 2016 the picture hasn’t necessarily changed.

I suppose what’s important to note about this as well is when Lord Nigel Crisp made that statement he pledged to a number of interventions or plans to try and address this issue and he was really committed about it. So resource went into investment to try and redress this issue but what we know now is actually that situation hasn’t changed despite resources and investment and also what the Roger Kline research shows is actually BME representation in leadership in the NHS has actually decreased over the last ten years.

So this is the report. How many of you have come across this report or read the report? Okay quite a few of you. I would recommend it, a really thorough good piece of work. And this was looking at the situation in London and basically it looked at the governance and leadership picture in London and the key finding of this report was that the BME population are largely excluded from NHS leadership. This was also the case for some of the national bodies including NHS England, Monitor and NHS Trust Development Authority as they were CQC and Health Education England.

Now what’s quite disappointing is that two years on and the opportunity of a new board forming with NHS improvement, I believe the picture speaks a thousand words and this is the picture of the new NHS improvement board. It’s disappointing to see that two years after that report and the opportunity of setting up a new organisation and a new board, this is the picture of the leadership of that organisation.

So just to back to the snowy white peaks report, these were the findings of the report. There was one BME chair out of 40 and no CEO England and NHS was from a BME background. Almost half the trusts in London at the time had all white boards, there had been a decrease in BME board members and a decrease in BME senior managers and nurse managers. So that was the picture of leadership. When you looked at the workforce or when you looked at patients and the population of London more broadly you saw that 41% of the workforce and patients were from a BME background and 45% of the population more broadly were from a BME background. So there is a clear significant gap between leadership, workforce and patient population.

I always put the so what when I’m talking about this issue, but I assume I'm speaking, preaching to the choir here, so I don’t need to be so explicit about some of these, but just to recap why this issue is important, and we’ve talked about this all day I think in many of the discussions and the sessions that we’ve had. In relation to this issue there’s a clear and explicit link between experience of BME staff and how that links to patient experience. So it’s a patient care issue essentially. How staff are cared for impacts on the care they provide. There’s a growing body of research saying that diversity improves innovation and teamwork and as we know and we touched on earlier when Ruth talked about this in her presentation, this is really on the national policy agenda now and there is, many of you will be much more familiar with me with the workforce race equality standard and how that’s shifted some of the thinking in this and it remains to be seen what impact that will have in terms of this agenda.

Another aspect is the business case and that other sectors are looking at this from very much a business case perspective in terms of the economic and competitive advantage for their organisations but also from a talent management and talent retention perspective. There’s an interesting piece of work from McKinsey which looked particularly at the financial and competitive advantage of a more diverse board and it’s also a really good report that I would recommend you to have a look at, and that looked specifically at diversity in terms of gender and ethnicity and it found that overwhelmingly the more diverse your board was the more profitable your organisation was.

And this is just the quote that I referred to from the research that Professor Michael West led a few years ago, and this is what’s most compelling for. I know there’s lots of reasons why this is an important issue but I think for people working in NHS and in care that it really is a patient care issue, a patient experience issue and that’s the most compelling reason for me really.

So moving on we published a report which was commissioned by NHS England last year and this was about looking specifically at the workforce experience. So I’ve touched a little bit about the leadership picture, this was a report that was teaching to establish the extent of discrimination amongst NHS staff and then we later did a bit of a summary of interventions that we know have worked in other sectors that we though it would be useful to share with the NHS and there will be nothing in there that you won't already be familiar with and I would encourage you to have a look at the report on the website.

What I’d like to say about this is I feel that this is a culture issue and that it’s a strategic issue and that piecemeal interventions haven’t had impact, won't have impact and frankly are a waste of resources, they’re not evaluated and measured. So what this really is about is about leadership and it’s about culture and it’s about a long term multi-faceted strategy that is measured and that is evaluated on a regular basis so we understand the impact. So that’s where I’m coming at it in terms of it’s no longer about equalities policies and all those sorts of things are important, but this is really about culture change.

So a little bit around the method there. Essentially we did some analysis on staff survey data from 2014 and we looked at the data and we looked at it from a perspective of discriminating between managers and staff, discriminating between colleagues and discrimination from patients and members of the public. So that’s broadly what we looked at and the mix of contrasts. So I’ll just run through some of the key findings.

We found that discrimination was highest in ambulance trusts, men are more likely to report experiencing discrimination than women which is an interesting one and we can perhaps talk about that a little bit. Discrimination on the basis of age is highest amongst the youngest age group. Discrimination is highest with black employees and lowest with white employees and all other non-white groups are far more likely to experience discrimination that white employees.

Disabled staff report very high levels of discrimination, in fact they were the highest. People from all religions experience discrimination on the basis of their faith but this is by far the highest amongst Muslims. Discrimination on the basis of sexual orientation is much greater for non-heterosexual staff and the highest rates of discrimination was seen in London.

And there’s also something about just having diversity doesn’t mean that diversity will work, so you have to work at that, sometimes a bit more when you’ve got this diverse workforce. Again the so what, and I think it’s always good to come back to the so what, and for me this was the so what really and this was an extract from the report.

So what’s going on here, this widespread discrimination is completely contrary to the stated values of the sector and also going beyond that, if staff with these characteristics are reporting high levels of discrimination does that mean patients with the same characteristics are experiencing the same discrimination as well?

If you have a look at the report which I’ve tweeted, so anyone who follows me can have a look at the report, the full report is also available on the NHS England website where we look at some of the strategies that you can use. What I really just wanted to focus on is the role of leadership and the role of leaders in creating a culture where some of these issues can be talked about.

So yes we need policies, we need practices, we need procedures, we need an overall long term strategy to tackle some of this, but what we really need to see is our leaders behaving in a way that confirms that they actually believe this and this isn’t just a strategy that sits at board, in every interaction at every level our leaders are demonstrating that they do believe in diversity, they do value inclusion, there is fairness in the way that decisions are made in the organisation. So what’s much much more important that what’s written in the strategy is what people see on a day to day basis in their leadership behaviours. And part of building the evidence base and building the data is then going onto the next step of creating a space where people can have conversations about some of these issues and I also believe that’s a role of the leader. This is about creating that environment where people can talk about these experiences where somebody who’s having an experience can say, “Well this is what it feels like” and where somebody else can say, “Actually that’s really awful and I’m sorry that you had that experience”

So the way that I see it is the data and the evidence, that’s the black and white of the issue and the grey of the issue is the ability and the skill to have some conversations to talk about some of these things that are really really hard to talk about and the role of the leader is to create that space for that to be talked about.

If you want to learn more, there’s more on our website and there’s a link to the publication and also to the NHS England website where the full publication is. And I suppose I just wanted to finish by saying the human costs are huge of this scale of discrimination in the NHS and there’s established evidence around the impact on patient care and if staff are experiencing this sort of discrimination we can be pretty sure that patients are as well. What I would encourage you to do is seek the truth of your organisation. So some of this will resonate with some people, some of it won't, every organisation, every service, every team is different really but what I would encourage you to do is go away and have a look at your organisation and look at the pictures that I shared with you in the beginning, does your leadership team look like that or doesn’t it look like that? And to be curious and to ask some questions and also just to remember that data and evidence and reports are really really important but underneath those are actual people and people’s lives and their experiences, so we need to look at both together and see that as a whole picture.

Thank you very much.

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