What can be done about race inequality in the NHS workforce? How can we ensure representative leadership happens? Helen McKenna talks with Yvonne Coghill, Director at NHS England Workforce Race Equality Standard (WRES); Dionne Daniel, Project Lead, Nursing Workforce Remodelling Research Project; and Ben Morrin, Director of Workforce at University College London Hospitals.
- Diversity should be a strategic priority
- Leadership in today's NHS: delivering the impossible
- Closing the gap on BME representation
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- HM: Helen McKenna
- YC: Yvonne Coghill
- DD: Dionne Daniel
- BM: Ben Morrin
HM: Hello and welcome to the King’s Fund Podcast where we talk about the big issues and ideas in health and care. I’m Helen McKenna, I’m a senior fellow here at the King’s Fund and I’m going to be your host.
Today we’re going to be talking about the NHS workforce in terms of race equality and representative leadership and the aim of the discussion is to look at where the NHS currently is at on these issues, how things have changed over time, how health compares to other sectors and then what is being done right now to improve things, and today I’m joined by some fantastic guests from a range of settings, but rather than me introduce you all, I’m going to ask you to introduce yourselves. So let’s start with you Yvonne Coghill and as well as telling us a bit about who you are and what you do, as we’re talking about workforce issues today, can you also tell us about the most unusual or awful job that you’ve ever had?
YC: Okay, so my name’s Yvonne Coghill and I am the director of the workforce race equality standard in the NHS, NHS England. Soon to be NHSI and NHSE and the acronym is usually called the RES, so probably for the rest of this discussion I will be mentioning the RES.
So what’s the most unusual job that I had, I started to work because I’m probably older than all of you put together in this room, many, many, many years ago at age 14 when I started to work in a Wimpy bar and I remember one Saturday morning, we all were standing outside having a laugh and a joke and messing around as you do at 14 years old, and the gateaux that were piled high served to guests all went over, smack. I remember this because the guy’s name was Pete who was our manager and he could have only been about 24 but we thought he was really old, because he was at that time and he came and he just looked at it. He looked at it and he said not a word, nothing. He didn’t say a thing, just clear it up. And we all worked all day and of course at the end of the day you go for your pay. None of us got a penny, not a penny. Today, the work that you’ve done will pay for those cakes. So we was, I’ve never forgotten it, it was fascinating but it was probably one of the worst but also one of the best jobs that I’ve ever had because it was such a laugh.
HM: Wow, a whole day of work without knowing that you weren’t getting any money for it.
YC: Yeah, clever.
DD: My name is Dionne Daniel, I’m a senior nurse in the NHS. In terms of the most unusual job I’ve ever had is probably this one. So my full title is Project Lead, Workforce Remodelling Research Project and basically I’m doing an action research project looking at new rules and how that sort of fits into the NHS. I guess it’s unusual because people mainly focus on operational rules within the NHS and sometimes when you’ve got an academic slant, it’s seen as should only be in the university and I’m excited because we always talk about how do you bring research into practice and actually the best way to do that is to research in practice. So I’m really excited about the role. It’s the longest title in the universe, but I love it so far.
HM: And Ben?
BM: Hi I’m Ben Morrin, the workforce director at University College London Hospitals, long title, and my most unusual job was probably about 1995 when I had a summer in America working on a camp looking after children and my job was to wake them all up in the morning by playing the trumpet at the top of the hill, over the lake which was a really lovely setting but I soon met some fellow counsellors who decided to do things like: take the valves out of my trumpet,put rice krispies in my trumpet, all the things that got me in lots of trouble. So I look back with fond memories of what they did and we’re still in contact and they’re still sending me videos and things of all the things they did to me. That was probably my unusual job.
HM: And can I just check Ben, can you actually play the trumpet or was it just blow this instrument?
BM: It’s harder if you have things stuck inside it.
HM: So I thought it would be worth at the outset, just starting with some broad questions to understand a little bit about the fact about where we are now, what does the data say Yvonne?
YC: The NHS is a very diverse organisation. In fact, it’s probably the most diverse organisation in Europe. We are the biggest organisation in Europe. Nearly 21per cent of our workforce come from black and minority ethnic backgrounds. So, that’s thousands of staff, nearly 45 per cent of our doctors are from black and ethnic minority backgrounds. Nearly 25 per cent of our nurses and midwives are from those backgrounds and of course it varies by region and of course London being London has many more black and ethnic minority people working in it and some organisations have 40, 50, 60 per cent of black and ethnic minority people working in it. So, the NHS is one of those organisations that has embraced diversity. That shows very much in the numbers of BME people we have working with in the NHS. What it struggles with I think is inclusion.
HM: What happens in terms of leadership, say at the Trust Board level, how representative are we looking at when it comes to that.
YC: So what we know is that people are less likely to be at Board level, particularly executive board level, if they come from black and ethnic minority backgrounds and we have about 5per cent of people from black and ethnic minority backgrounds in those really senior level positions. So, it’s not brilliant, it’s not good. We have a real problem with pipeline in the NHS and people getting stuck at 5 and 6. So I think when you look at the numbers of BME people nearly pushing 20-21 percent, and at Board level it’s 5- 6 per cent then you think to yourself there is a problem, there’s something going on here.
HM: Do we know of the data on national bodies as well?
YC: We’re going to be producing another report within the next two weeks on the arm’s length bodies and this time we’re looking at 8 and the picture is much worse for arm’s length bodies than it is in the NHS as a whole. But I just might add, that this is a national, international problem. This is not just about the NHS.
HM: Absolutely. I was going to ask about that because how does the NHS compare to other sectors when it comes to diversity of its workforce and also representative leadership. You know, is the NHS actually ahead?
YC: Well the answer to that question is yes. And I say this to senior leaders because what people say to me is, “Yvonne it’s always bad news,” it’s bad news but actually, it’s good news because we’re actually looking at the problem and what I’ve said to them, actually it’s a great story because what the story is, is that we as a NHS recognise that we need to look at the problem, decide that we need to do something about it and actually we are now doing something very, very positive. Not only positive, we’re the only organisation that are doing the thing that we’re doing to my knowledge, internationally, which is to compare black and ethnic minority experience with white experience and close the gap on those experiences, so that everybody has what we call equity.
HM: And Ben, so Yvonne has kind of pointed out that the NHS has opened itself up but this is not, this problem is not exclusive to the NHS. In fact, it’s a much broader problem and is an international one. Do you think though that the NHS as an institution, if you can call it an institution, has a problem specific to itself?
BM: Yes I do. I think the quality of people within the NHS and its importance to our country in so many different ways, there is no more important starting place for thinking about workforce leadership management than thinking about equity and inequity in the way that we employ and the relationship to the way we do that and patient and public outcomes in terms of health and wellbeing. And the great value of the workforce race equality standard is the transparency of it, the way it shines light on things we need to get fundamentally better at in so many different ways. The NHS has got a long way to go and what we need to do is keep working on focussing on it, this can’t be seen as a temporary a one year, two year programme, it must be driving the action day to day of colleagues across the system. So I’m really, I feel as though I’m in two places on this. I’m embarrassed to an extent as a leader of the NHS about the position we’re in but enthused by the opportunity of really making this the starting point for the way that we think about so much more.
YC: Yeah, I agree. I think it’s really important that people like Ben say the things that he has been saying. You know, “Yvonne Coghill says it, well she would say that, wouldn’t she.” “Dionne says it, well you know,” but when white middle class people start to speak up and say, actually this isn’t right, we need to look at this through different lenses, other peoples experiences. We need to think about ways in which we can change the NHS, not just because it’s the right thing to do, but actually because it is important for patient care, patient safety and patient satisfaction that we have a fully included, engaged and motivated workforce. I think over the years, having been doing this a long time now, we now have so much more in terms of evidence that if you have an included and motivated workforce, you then have higher quality patient care, patient safety and patient satisfaction, and we have people like the wonderful Professor Michael Wes, Jeremy Dawson, who have done amazing work around all of this. So there’s nowhere to hide with this anymore, there’s no well actually, let’s give it to the band 6 E&D lead over there to deal with this issue, this is a real leadership issue, which needs to be looked at head on from the board and lead by board members like Ben.
HM: And can I just explore something that you said earlier in your answer there, which was around that it takes somebody like Ben who’s a middle class white man to make that point for people to listen, is that really how it feels?
YC: We don’t necessarily just listen to people like Ben, but it’s so unusual to have white middle class men standing up on platforms and talking about this agenda with confidence and understanding, because the complexity of the issues are very real. This is about people’s values, their beliefs. What they believe to be true about others, so it’s not just a tick box process thing, and usually people who are senior haven’t got the experience, the knowledge to be able to articulate how this thing is for lots of people in the NHS. So they, rather than say anything they say nothing. So when you hear somebody articulating the issues as clearly and as passionately as Ben, it really does work. You know people will hear it and senior leaders hear each other as well because that’s the communities we have in the NHS.
HM: And that comes back to the problem of senior leadership not being representative so you’re not hearing it from, yeah, okay, that all makes sense. So you actually just started to run through the case for doing this work. I think it’s helpful for people listening to understand what the argument is for doing stuff about this. Obviously, there’s the moral case and the fact that it’s right, but let’s run through some of the evidence and the data.
BM: Well I’ll have a go, but I’m next to some great minds on this. So, I look upon this from a starting place of the interaction with an individual member of the public or a patient who should rely upon the very best from any health service and the quality of that interaction depends upon the individual supporting them in whatever clinical, therapeutic, management, administrative role in being focussed on their interests and improving their outcomes. So I’m interested about research that Yvonne referred to earlier on that’s very clear about the fact that if you have a combination of skills and experiences and backgrounds and perspectives in that interaction, then you’re going to lead to far better outcomes for the patient, the member of the public and the member of staff, and largely research I’ve seen back up that notion pretty clearly. The other thing I’d say which is sort of evidence but it’s probably not what you’re seeking but I hope it helps, is the most powerful thing for me, the most enjoyable part of what I have a chance to do, is gaining two forms of feedback. One is from a member, a patient who might say, or a colleague or a member of their family or friends, what a difference the NHS made to their life at the hardest of times, and the other that I frankly enjoy as much and sometimes more is when a colleague says to me, “I’m really grateful for what a colleague enabled in my working life, that someone brought in evidence of inequity, disadvantage, a really bad day to me and you did something about it, not just because it was perceived to be the right thing or for a flashy moment, but because it’s changed my life and working experience.” So I see that it’s two forms of experience and that evidence that I see in my day to day working life that brings back to me the importance of which good management can achieve very quickly to improve outcome. On the other side of this, I’d say that when things go wrong, when you’re making a wrong decision about a disciplinary, an investigation, you can have a really harmful impact on someone’s life, not just for a few hours of that hearing but for the days, the weeks, months afterwards because it affects colleagues in a way which many white leaders have not experienced because they’re not living in the societal context, they haven’t had the life experience that many other colleagues have had which has affected their viewpoint, affects their ability to afford the family life they wish to. So, we need to be much more informed about the context in which people come to work and their life experience too when we’re thinking about the NHS.
HM: Thank you Ben.
DD: Something that was Yvonne was saying, to pinch your data, I regurgitated it, the thing that always strikes me actually is that the evidence and the thing is, we know that actually if your staff in the background are happy, the other staff are happy. You know there is evidence that talks about the experience staff experience and how that really helps the patient experience and sometimes you spend a lot of time trying to get the patient experience better, I mean focussing on the people who are delivering the care and I think that’s the thing that stuck, that I’ve remembered always, and I use it everywhere. Sorry.
YC: Yeah, I think the question is an interesting one, you know why are we doing this? And you know, when I’m giving my talks, we usually give four reasons for doing it. One of them is, it’s the right thing to do, you know we’re all human beings, we’re all here, we all have blood in our veins, we all have families, we all go to work for a reason, you know we’re all here for ourselves and we want to have decent lives, that’s everybody. So it’s the moral thing to do, it’s the right thing to do, to be able to treat everybody well and equitably. We also know that it is part of the Equality Act, we’re a public sector body and as a public sector body we have a duty. The public sector equality duty, to actually promote equality and inclusion and to make sure that we are an exemplar. The third reason is financial reason and we know that if you are from a black and ethnic minority background you’re more likely to go off and work for agencies and banks. We also know that if you are not being treated well, you’re more likely to go off sick, you’re more likely to look for another job and all of those things add up to costing the organisations much more and I think that focusses the mind of senior leaders and engagement costs nothing. It doesn’t cost you anything to be decent to your member of staff, to talk to everybody, to include everybody, to share with everybody. It costs nothing and the final point of course, is the quality case and we know that you get a better standard of care from people that are cared for and if you don’t feel that you’re cared for, potentially you won’t care as much and it also means that potentially you will not want to talk about things that have gone wrong, for fear of the sanctions against you. Ben’s already talked about the fact that as a BME person you’re, these issues if you were going through disciplinary or performance management or whatever it is, they stay with you, they sit with you. They are part of who you are for a long, long, long time. And that unhappiness and that, I don’t want to go as far as to call it depression, but sometimes it can be, really impacts people, their families and the way they perform. So the quality of care, so those reasons are the reasons why the NHS has decided that really we have to take the bull by the horns and do something about this because it will in fact impact on patient care.
HM: And I think it’s really helpful for people to have those, that evidence, those reasons in mind. So thank you for running through those. I want to move on now to the topic of staff experience and thinking about from your perspective Dionne, maybe not talking about Bart’s but other organisations that you’ve worked at, is there a problem in terms of a disconnect between the leadership and their ability to understand the issues that are affecting staff at lower levels of an organisation?
DD: Yeah, I think it is. I think you know if you’re in an organisation for example, where a lot of people in the senior roles don’t understand the context of the environment they’re in, then that’s going to impact on how things differ isn’t it? I think we also do it well, they recognise people for their skills. They’re happy with differences and they’re happy with you know, what people bring to the table. So I will quote my present manager actually, even though she’s only been my present manager for six weeks, I’ve never felt so appreciated for the other things that I bring. I love academia, I love data, I love facts and that is being used and I live on social media by the way as well, and that I’ve been able to use that so much more than in all the 20 something years I’ve been in the NHS. So I think that’s really important and I think it’s a really important point that actually the people making a difference to inclusion not necessarily having to be people from a BME background, they are people who get it. If we make this right, people will be happy.
BM: You’ve got to name your manager so we call them out.
DD: It’s going to be Debbie Jaraz, I’m just going to say it.
BM: Call out for Debbie Jaraz.
HM: I wanted to ask as well, how useful is the NHS staff survey in terms of giving us a sense of inclusivity and staff culture, I’m assuming Yvonne you have a view on that?
YC: Yeah, I do actually. It’s really, really interesting and I think that where we are with the workface race equality standard at the moment is we use, and I think people know this, some of the staff survey for some of our indicators and some of the electronic staff record, for some of the indicators as well and what we found over the last three years is that the workforce indicators, the SAR indicators are shifting in the right direction quite relatively quickly actually, but what we call the cultural indictors, which are the ones from the staff survey, looking at bullying and harassment and that kind of thing, aren’t moving as quickly. No surprise there at all because we know that culture is very, very difficult to change in organisations. So, not surprised actually that some of the indicators are moving quite quickly and doing reasonably well, but some of the staff survey indicators aren’t. So somebody said on Twitter, when the staff survey came out, “if you look at it Yvonne, you can see that black and ethnic minority people are saying they really, really enjoy working in the NHS and they love being in the NHS much more than their white colleagues.” And I say, yes that’s true, but what you’re not taking into consideration is the fact that black and ethnic minority people have higher tolerance levels than their white counterparts. So it has to be really, really, really bad for BME people before they actually start to complain because their expectation is that it’s going to bad for them anyway. So, white people will actually say, before BME people, that “this is horrible for me, I’m out of here, I’m going”, and we actually know that because we know that in London now, we have more BME nurses than we have white nurses. There’s 27,000 BME nurses and 25,000 white nurses. We also know that that picture is shown, we can see that picture across the whole of the country, 5,000 more BME nurses, 1,500 less white nurses. So people from BME backgrounds have higher levels of tolerance, so they will say, “I have a job, thank God, I’m staying, so it’s great.” So we’ll tick the box. Whereas non BME people are more likely to want other things that will make them happy. So people need to understand why the data is as it is, as opposed to saying, “oh well look all these BME people are really happy, we haven’t got a problem.”
HM: So you need to get beneath the surface and not make assumptions.
YC: Yes. And understand.
HM: And in terms of the external environment, so thinking about the Government’s hostile environment around immigration policy, thinking about Brexit and the anticipation of that, do you notice those things having an impact? Are you seeing it on the ground Dionne for the cultural change or numbers shift or what are you seeing?
DD: So, the numbers shift is cultural change. As I say, I work in East London and I’m seeing too many episodes of people having their hijabs pull over their heads and being beaten up in the streets and it’s a shock to me and in London that’s supposedly the most diverse. You know, I live in Eastbourne which isn’t as diverse as London, but there’s a lot of sort of off comments as well, you know.
HM: And sorry, is that when you say about the hijabs, that’s in the NHS or just around?
DD: That’s as an area and I’ve seen effects on people who work in the NHS and the comments are in the NHS. I have colleagues, because I think people probably know not to mess with me by now, but I have colleagues who have been told things like, “don’t you feel guilty?” “Don’t you feel guilty that you’re taking jobs from British people?” You know, I still have people who were born here, two and three generations who are still asked where they’re from and that sort of thing. It’s getting worse and it’s getting bolder. I think we’ve had a lot of comments, particularly in terms of violence and abuse of staff. You see that there is a rise, so that some organisations are having to make a direct intervention to support that. I remember going to see a patient who was very unhappy and he wouldn’t open his eyes to speak to me. We did get there eventually but he said he just wanted to be in England and I sort of had to explain to him, so that this is the staff that we’ve got here today and we need to work with them so you can get better to go home, because he was banned from his local hospital because of his behaviour and came to mine, but he was very abusive towards the staff and what saddened me really, was that staff felt that it was acceptable to have that sort of abuse hit on them and that to me was extreme because it was where I live in terms of how I’d be dealt with, to where I work where the population is so much different and that is increasing. Probably spoken too much, but I also have colleagues from the EU who have had abuse, people are spitting on and whatnot and I think it’s just a shame because actually you can’t have those views, you don’t have a choice what doctor or nurse you get when you come into hospital.
HM: No it’s outrageous and Ben, at UCLH?
BM: Yeah, I think whatever people feel about Brexit, however they voted, I haven’t met anybody in the NHS who hasn’t got a very clear, and consistent view about what they don’t want to happen, and that it is that they don’t want to have any restrictions on the ability of people to come and work in the NHS other than on the basis of their capability, now or forecast. We need the very best in the NHS, the best of the NHS relies upon the best from the world. It’s ridiculous economically on every front to think about restrictions that put us back to this idea of a homegrown mentality which is something which I thought we’d left well before each of us were born, yet seems to be coming back as a supposedly plausible nation for the way we resource the NHS. It’s absolutely bonkers.
DD: I say to people when we have these arguments about immigration and whatnot, the NHS since 1948 has depended on a variety of workforce. If people like my aunt, didn’t come from Trinidad, the NHS would not exist and that’s still the case today. In some specialities, if you didn’t have a diverse workforce we would be stuffed. So, and I know this is not political, but if we think that having a health tax and not having workers from the EU is not going to have an impact on the NHS, we need to think again because it will be crushing. So if you go to all the people services, for example, most of the workforce are staff from a BME background.
HM: And I think we’re already seeing actually, in nursing, more people left from the EU last year than joined. So there’s a real, it is a real problem.
YC: 98 per cent less applications to come here to do nursing since we made the decision that we made.
HM: Okay, I want to move on from that depressing note to what can be done. So Yvonne, tell us about what the NHS is doing to tackle this stuff from your perspective, you’re working on the workforce race equality standard, tell us about that?
YC: I have to say that the people that I am working with in the NHS have been outstanding. You know Simon Stevens, Dido Harding, Nuwad Pra, Victor Alawari, Jane Cummings, these people have put themselves out there to help support the work that I’m doing because they believe actually it’s the right thing to do and we’re beginning to reap the rewards and the benefits of that, albeit in a small way. We’re seeing some changes and particularly at senior level, they’ve bought into this thing race equality or race equity. There is still lots of work to be done and we are beginning to focus now on working on culture. I think the data is one thing and people see the data but behind each number, each figure is a story and the stories that you hear from people are heart breaking and we know that we have work to do with what we call our middle managers. The chief executives that I met in London in December recognise that as well and they are going to be meeting in London once a quarter as a learning community so that they can understand what more they need to do. They’re going to contribute financially to having somebody to support this work in London. They’re going to you know, have a training and development programme designed. I’m just so excited about the work that London chief executives have agreed that they’re going to do in order to move this agenda forward and I think across the whole of the country, because London’s London, other people will be looking to do that as well. We’ve also used all of the levers that we could possibly, because NHS loves levers don’t they, to make sure that when the thing called workforce race equality standard becomes like yesterday’s news, this work is still deeply embedded within all of the systems and processes that we have in the NHS, so people will continue to do the work that it needs to do around race equality. So I think we’re in a really good place and I think it’s really exciting and I’m really looking forward to the next generation taking it forward. I’m absolutely 100 per cent sure that the NHS is going to be a beacon of best practice internationally, not just in England.
HM: Okay. I want to leave people listening to this episode with an idea of a positive intervention that they can make. So, what is the one thing you would want people to take away from this episode that they can go away and do to change the situation? Starting with Dionne.
DD: For me it’s something that I say to everyone, be curious and I think sometimes we’re in this position because people are not curious. Don’t make assumptions. If someone speaks quickly, or has an accent, understand the background for that. If someone has a different viewpoint, and I think when we start being curious we then have the opportunity to understand people and not make assumptions. Mentor different people, don’t just mentor the people who look like you and be mentored by different people. So one of the commitments I made when I did the Ready Now programme, is that I will mentor people from different backgrounds so that people understand the experience of working with people from different cultures, colours etc. and that’s the thing for me. Be curious.
HM: Thank you. Ben?
BM: I went to see Laura Mvula sing at the weekend and she was outstanding. I was lucky enough to be near the front and I could see she had some tattoos on her arm, and one of them said, “this girl never stops,” and I looked into why she had written that on her arm afterwards. I didn’t quite find out why, but I learnt about somebody who though terribly talented had been affected by appalling racism throughout her life and I think my learning from that tattoo was, we should never stop thinking about those issues that we’ve discussed on this podcast and I don’t just mean, stop for a week or a month, I think this is consideration for us hour to hour in our world as leaders and a test for any leaders we bring on or choose.
HM: Thank you, and Yvonne?
YC: For me it’s read. Education. I didn’t become what people call now a subject matter expert overnight and I think it was reading so many books and articles and amazing things that people have done in terms of research, looking into this thing call race inequality. It’s - the history to it is just fascinating you know, what as human beings we have done to each other in order to make the dollar or the shilling or pound, whatever it is and what we have done to each other and why it is we as a country are where we are today because most people don’t know. They have no concept of what other countries and cultures have done to make this country what it is today. They have no idea and when I talk to people and this is senior people as well, they don’t read about this stuff. It’s not taught in school, it’s not, so my one thing is educate people and if you can’t educate people then they need to read for themselves.
BM: Can I put late one out, which builds on the great Yvonne Coghill’s suggestion, there’s a book by Reni Eddo-Lodge, that was Why I Don’t Talk to About Race. I’m giving out free copies because I’m so impressed with it. If anybody listening to this podcast I will give you one of these books. It’s outstanding.
HM: Fantastic, well thank you so much for joining me today and thanks to everyone who’s been listening. If you enjoyed it, please subscribe, rate and review us on iTunes and if you have feedback or ideas for topics you’d like to hear covered in future episodes, then please get in touch either on Twitter @thekingsfund or my account @helenamcarena or you can leave feedback on our website at www.thekingsfund.org.uk. We hope you can join us next time.