Acting with intent: Karen Bonner on diversity and belonging in the NHS

Key:
SA: Siva Anandaciva
KB: Karen Bonner

SA:        The Windrush Generation and their descendants have made significant contributions to the NHS, our social care system and wider society, but like many people from black and ethnic minority communities they have also faced a struggle for equality and inclusion in health and care where racial disparities continue to be reflected in the health outcomes of these groups and discrimination is experienced in the workforce.  So as we reflect on the 75th anniversary of the creation of the NHS, and the arrival of HMT Empire Windrush, we ask what can be done to make the health and care system fairer for black staff, patients and communities?

Hello and welcome to the King's Fund Podcast where we explore the big issues and ideas in health and care.  I am Siva Anandaciva the  chief analyst at the King's Fund and to explore this topic I am delighted to be joined by Karen Bonner, chief nurse at Buckinghamshire Healthcare NHS Trust.  Karen, welcome to the podcast.

KB:        Thank you Siva, thank you for having me.

SA:        A pleasure.  So 22 June was Windrush Day, which I am sure has complex and varied meanings for the people and communities connected to it.  How do you feel about Windrush Day?  What does it mean to you?

KB:        I think for me whilst it is complex, the Windrush Day for me provides an opportunity for me to pause and reflect upon the contribution that my parents made.  My parents came here as part of the Windrush Generation, my dad arrived in the late 50s and my mum in 1965 and therefore it is a really important legacy for me to spend the time to reflect on, and also just such a contribution that that generation and its descendants like myself and others that have come since have made to the overall society within the United Kingdom is immense.  So I see it as a positive opportunity for me to pause and reflect on that.

SA:        The word itself, I mean I would say it's a mixture of things associated with the word Windrush that are full of pride, pride of the contribution people have made who came on Windrush, but then the other thing that comes through clearly is what's happened in wider society and how Windrush has been associated with say people being deported and more negative associations.  So does some of that confliction come through, some of that complexity come through in how you feel about the day yourself?

KB:        Yes it does.  It's really important that those issues are highlighted and addressed and there are lots of people working very hard to address those and I think two things can be true at the same time.  There can be great celebration and real pride in the contribution and acknowledgement of that and then obviously the conflict there is some of the ongoing health inequalities, the inequalities that many of us still feel and that has come through I think quite starkly with the Windrush generation.

SA:        Yes, and I think you've touched upon where I wanted to go next, which is the discrimination and health inequalities that are still being experienced by black communities.  Could you share a bit more about the inequalities you see in your own work at Buckinghamshire?

KB:        Yes, I mean I think it's really interesting being in Buckinghamshire because I moved from London, working in London for a long time which is obviously clearly much more diverse, Buckinghamshire is less diverse, but it does have pockets of real deprivation and by nature of that deprivation poor housing, social problems and education, some of it leads back to race as well.  We've done some specific work to ensure that we're hearing from everybody from all our communities.  I think if I just talk more generally it is obvious and I don't think my organisation, my country and any other parts of the UK are probably any different, in that we are still seeing this disproportionate impact on people, black and brown communities.  We saw that during COVID.  I witnessed that myself during COVID, seeing more people that looked like me in our intensive care unit than probably the diversity of the population, and so we are seeing that and we all know the statistics for pregnant women, one in four likely to be impacted if you're a black woman than you are if you're not and that is really significant for this decade to still be having such disparity.

SA:        You talked about reaching communities, I'm glad that even over the course of my career I've seen phrases like hard to reach communities exit the lexicon and be replaced by seldom heard.  Could you say a little bit more about how you've tried to reach communities whose voice isn't heard enough or heard strongly enough?

KB:        Yes, I think it's important for us to reflect on some of the terminology.  I've worked very hard in the three years I've been at Bucks to ensure that we do not use that word hard to reach because it does infer that the people themselves are difficult to reach and actually it's often not a reflection of how we're trying to communicate with people.  So there's something for us in that rather than individual.  So we've specifically gone out to community groups, so we've got an Asian community within Bucks.  So we've gone out to those specific groups, to faith leaders.  We actually had (inaudible 00:05:17), part of our chaplaincy in order for us to look at how we far reach all communities both within our organisation … because when you work in some of these organisations it's easy to forget that the people working in the organisation are also part of the people that you're serving, they are part of the community.  So it's important that we reflect that.  So our diversity of our staff is much more than actually the community at large, but using our colleagues to ensure that we are reflective of the communities we serve is important and that we are specifically going out and hearing those voices and making sure that we are going in to those community groups and reflecting that and making sure we've got the right people.  So if we look around the room and we see people all look the same, we're very clear to say this is not right, this does not feel right, this does not reflect what we're doing here.  So we make a concerted effort to ensure that we have got the right voices in the room.  So we're looking around making sure we've got men, women equally from different backgrounds, age groups and so forth and that takes real intention and actually really, really important that we do that and that is something at Bucks that we've been focusing on.

SA:        As you were speaking, I was thinking of the word conscious and just when you said intention and just the sense I'm getting from you is just how much work goes into it and how it's continuous, you've got to keep doing it, you can't take your eye off the ball.  I wanted to ask you about other things you might be involved in that … where you're seeing an impact, you're seeing inequalities reduce, you're seeing something positive come out of the work you are doing locally or regionally or perhaps even in your London roles.

KB:        Yes, so in regards to the bits that I've just referred to, it does help because people are beginning ... we're getting to communities, hearing voices and therefore adapting languages, our website, so that they can translate so we can hear from people and people can obviously communicate with us.  So our translation services and all of those things that we often … it's easy to forget that actually we need to look at the way that we communicate more widely.  On a personal level as well the thing that I would like to reflect on is the work that we've done in the organisation that we continue to do and I think you're right when you talk about focus and that real relentless focus.  You can't give up, you can't just do one thing and hope it's going to just carry on, you've just got to keep focusing on the right things.  It's around our workforce and making sure that our diversity, our leadership, we've got a very diverse board, probably one of the most diverse in the country, our chief exec is committed to that.  That brings with it richness of voice, vision, difference and that is reflected now more throughout the organisation as a diversity around our senior leaderships beginning to change and therefore the richness and the innovation and the conversations and looking at things through a slightly different lens we're seeing and hearing more of.  Yes, I'm really proud of the work we're doing, not to say that we're there yet but as an organisation we're committed to that journey as well because the wellbeing of our people is central to the wellbeing of the people that we're serving.  If we're not looking after the people that are working in the organisation, all of them, from all backgrounds, we will do badly for those that are coming in to our care as well.  So those two things for me have to be done at the same time.

SA:        That's really important and I wanted to ask you about the workforce.  We've talked a little bit about patient services, but as you absolutely are right to say discrimination and exclusion can also happen in the health and care workforce and I suppose I had a question about professional groups as well as the senior leadership of an NHS organisation that you've talked about because in a previous role I used to help run networks for chief nurses and chief medical officers, I saw very few black and brown faces in those chief nurse rooms and chief medical officer rooms.   So I suppose I'd like to hear a little bit more about your story and the experiences you've had getting to where you are.

KB:        Yes, that's a really great reflection because I agree with you, I think we've still got a long way to go and we improve and then we go backwards sometimes, there's more to be done.  So I myself I've worked in London the majority of my profession so you can often be … I think at the time when I was working through my career there were loads of people that looked like me, it was just a given, London is very diverse, the patients are diverse the people you are working with are very diverse.  The more senior I got the less people looked like me which is probably when you look at the workforce race equality data, particularly for nursing, as around the band 8A, which is the matron role, glass ceiling/sticky floor, whichever terminology you choose to use, but clearly there's a disparity once you get to that level and the data shows that.  I've done many roles in the NHS, I'm very privileged to have been in the NHS now for over 30 years and I've worked a number of different organisations, different cultures, different places, different specialties and I recall really thinking about how am I going to fit in and I less think about that now and more about the belonging than I do about the fitting in because those two things are completely opposite to each other and I think that comes from my childhood.  I was born as a Windrush descendant, very few black children in my year at school, we were the only black family on my street, it was just normal for me to act differently when I walked outside the front door.  I think many people use the term the black community code switching, where you leave the house, you speak in a certain way or you live a certain way because you recognise that you're the minority when you are out there and then when you come back in your house, your culture and all those things that you wrap around you, that sense of belonging, is something that you have created and that's your sanctuary.  I've worked very hard to try and bring those two parts of myself closer together.  How do I bring my real self to work, and that's been a journey.  I've got to certain levels, like I said, matron and then above and looked around in rooms and thought, gosh, I'm the only person of colour in this room and I often say to my white colleagues, "Do you feel that when you look around the room?  Do you ever look around and think, gosh you're the only black person in the room?" and they often look at me and say, "No I don't really think about that," and that in itself is a problem, the fact that you look around and if everybody looks like you, you should be asking yourself why is that?  Why am I working in a really diverse organisation but when I look around nobody looks like anybody else as I walk around the rest of the organisation, and I tuned into that really early on and in some ways that created and enhanced my imposter syndrome or feeling like I didn't quite belong and what am I doing here, someone is going to find me out, someone is going to tap me on the shoulder and ask me to leave, and it did hold me back a bit in places where you felt that you didn't fit in.  Lots of funny looks, "Oh you're Karen Bonner," the raised eyebrows, surprised looks.  I don't know what they were expecting but they certainly weren't expecting me to rock up in a room even though we may have spoken or emailed.  So I've had a lot of that throughout my career.  I've unfortunately experienced bullying on a number of occasions particularly one much more I think impactful for me because it really took a toll on me, quite demoralising.  I think for me I'm very fortunate in that I've got a really great family, great friends and I surround myself with really good people.  Whilst I've had people at times where they've not been as kind in my career, I've also had lots of great people say to me, "Oh my god Karen, you're great," or, "What have you thought about this?  Have you thought about this?" or, "Why don't you do this?" and I've gone through my career, I've often … sometimes it's just easier just to find your way round things if you can't quite get through them and I've done that a lot and I was proud in 2020 to secure my first chief nurse job here at Buckinghamshire Healthcare.  At the time I was still one of only 4% of nurses in the country and that is really sad.  There's a few more of us now, but it is 2023 we're at the 75th anniversary of the Windrush and yet still we're still talking about 5% of us getting to these very senior positions and if we look at nursing I think we're about 30% across nationally of diversity in nursing.  So we've still got some work to be done.

SA:        Thanks for sharing that Karen, quite a lot of personal resonance with what you were saying and I'm sure there will be people listening out there who feel the same thing and energy, navigation, support, I think if there's anyone out there thinking about … sat on that AA step thinking about the future, there's strong advice for them.

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Welcome back.  Thinking about the system more broadly, what more do you think can be done by the system, the organisation, to help people get to those upper echelons that they deserve to be in?

KB:        I've reflected this a lot because my biggest concern is at the moment we're spending a lot of time telling people to go off and be trained and we've done that a lot and that's just not working.  You can't send people from different backgrounds off to be trained and put them back into organisations and systems that don't support them, that's the first thing.  So my reflection is there are lots more for individuals in organisations to do.  So everybody needs to take an individual accountability and that comes with complexities because people need to see it's important.  Also there's something about the system.  So we already recognise we know that some of our recruitment systems will exclude people, we know that, the way that we recruit is something that we have to pay attention to around just even getting people shortlisted before we even get them in the door and that's not just ticking a black or brown person on the interview panel, that is about really checking yourselves and learning actually what am I hearing, what I am looking for, what is stopping me from appointing these individuals?  Is it the way they sound?  Is it different?  Am I … reflecting.  It takes a lot of reflection and it's going to take a lot of individual responsibility and accountability and that means sometimes looking at yourself in the mirror and saying, "Have I got a problem with the way that person sounds or the way that person looks?" and "What am I expecting?"    Actually being able to hold that mirror up to yourself and that is very uncomfortable and my personal reflection is that some people find that really difficult to do and would rather not do that and I would say that discomfort is where you get the greatest learning and I think there's much more for individuals and us as organisations and the system for which we work in that needs to change to support people.

SA:        Yes.  There's almost a risk, isn't there, that by talking about a system you make it a very processed based technocratic if we just do shortlisting or we do this then it's the problem solved.  What you've been talking about has a heavy dose of personal responsibility and going into that discomfort, that's part of taking it seriously.

KB:        Yes, but it does take energy and it means sometimes you're going to trip up, you're going to make a mistake, you're going to say something wrong and somebody will call you out on it and that's okay too, you learn, you move on and you do better next time.   Black and brown people don't have a choice in the way they navigate their life.  They don't have that choice to duck out and say, "I don't want to do this today, it feels a bit too hard."  We as people and me as a black woman I don't have that choice.  So there is something about that individual commitment and I really would urge anybody listening to this to really take that very seriously.  It's a very serious thing for us to consider.  We can't just keep saying it's everybody else's fault or somebody else will fix it.  You have to do the work.

SA:        Yes.  I think the word brave is used a lot by some of the allies I've met and spoken to.  They didn't necessarily feel brave but when they were trying to put their head above the parapet and do something they were going to try and change how their organisation recruited, or change something deep, they said it was interesting how many people, how many colleagues would come up and say, "You're being very brave, are you sure you want to do this?"

KB:        And that's not taking away from those individuals because I know a lot of … I've got a lot of white allies that are absolutely … I wouldn't be here without them, that's the truth, but bravery comes in many forms.  As black and brown people often have to navigate, as soon as they go out their front door, walking to the streets, to the shop, everything takes energy and effort and sometimes if you compare that with that effort that you will make is it real bravery?  I'd question that, but I think it is important that people that are willing to step outside that comfort zone and hold the mirror up and do the work, that they are celebrated and supported as much as anybody else because, as I say, there are a number of white allies that I would name right now that I would not be in this role, I would not be talking to you if it wasn't for them also.  So I think it's important to reference them.  In fact they are the people often in power and they are often the people that really can make the biggest difference.

SA:        If you've never ever been followed around a department store it's a bit hard to get your head into that space, but it is incredibly draining and it's intense and doing this … even doing the day job of a chief nurse alone must be incredibly intense.  How does it feel to be involved in this type of work?  What do you do to ensure you look after your own wellbeing?  You've mentioned your family and friends and the support you get from there, but basically how do you take care of yourself when you're taking on this sort of agenda?

KB:        Sometimes it's incredibly draining.  Some days I just think, can I do this today?  I just want to get up and do my job and not be the black chief nurse or the person that everyone wants to look to, or demands that I  help them because they can't see what else they need to do around diversity and I had that conversation just a couple of weeks ago with a colleague who very much, "I know I need you to guide me now," and I'm like, "No, you need to do the work."  It's very tiring, it's really draining, and I think one thing I've reflected on with my chief exec actually is that people like us in these positions carry more weight and pressure than people that don't look like us and I think there's an acknowledgement that it is much more wearing and some days I'd choose … I think, can I pick that battle today?  You know what, I'm just going to let that comment slide because I just don't have the energy today because I just want to be me today and be the chief nurse and just rock up and do my job, and then I have other days where I just think I can't let that slip, that has to be addressed or I need everybody to understand that this is really important.  What's great is, is the more you get into that and you're in a safe space with colleagues, like I have with my board colleagues, that they're often saying it now and not me, and I say that to people, "I don't want to be the person in the room calling that out or the person asking the diversity question, that's not for me, this is for you."  That's helped massively, just leaning on people and saying, "Look, I don't want to be that person today, thanks very much, on the panel asking that EDI question, why don't you ask it?"  From a wellbeing perspective, I mean I usually have a great balance.  I did it really badly during the last three years.  I think we all did.  I just worked and worked and worked and I think I can be excused for that because I don't know that there was much else to do at the time really, couldn't leave your house, but it was a very intense time, but I have a really great family, I have a great social life, I get home, I don't look at my laptop, I have rules around when I do work, I have friends and family outside of the health service, so I'm not the nurse all the time in the room because that can be exhausting.  I think people forget that these jobs extend beyond your day job.  So your neighbour next door wants to knock up and ask you about her health and wellbeing if she knows you're a nurse.  That does happen in real life.  That's exhausting.  I was coming out the car the other day, very long day, and my neighbour two doors down he's like, "I'm really sorry, I can see you're really busy but," and the only how they knew I'm a nurse because I had the NHS badge in my car during COVID and they were all kind, "Oh you're a nurse," sort of thing.  So it is exhausting and so it is important that you take time, you ringfence time for yourself.  I love music, I love culture, I love the arts, yes, I spend a lot of time having lots of joy outside of work because I think it's really, really important.

SA:        I think that's a really full and nourishing answer, though you've made me incredibly guilty that the first thing you had to do when you got home today was open your laptop to record this podcast, but -

KB:        (Laughter)

SA:        - that's it, that's an anomaly.   So Karen, in your current Trust and in other organisations you've worked in, I'm sure you would have had to provide care for lots of differing communities and people coming from lots of different cultures, what are your thoughts on delivering culturally appropriate care?  What does that look like?  What does that feel like and do you have any examples of doing it from your work?

KB:        So culturally appropriate care is really important and I think there is more work for us to do and I always remember when I was a junior nurse being taught things like last offices for people from Muslim communities, how you manage in those situations and I think there is more to be done in that space.  So it's important for us to think about things like if you look at mental health we know that we see disproportionate impact on men and black men in particular and how they can be perceived as aggressive in those situations and therefore it's important to be culturally appropriate in the way that you're handling those individuals, not drawing assumptions, being mindful of those stereotypes that are in your head, and therefore how you look after those individuals.  It takes a lot of energy and education and time and that is why I think having a diverse workforce really helps with that because it really makes a difference when people understand what it's like.  Basic things like creaming of people's skin.  I can't get up in the morning and not have a shower and not cream my skin because it gets really dry.  It's important that we think about what's important for that individual as  people are getting more and more … we're seeing more dementia outside of the British white population, memory boxes that relate to the memories of a person from Asia or from India or somebody who understands from different backgrounds and cultures.  I think there are lots for us to think about in that space.  So giving care that's appropriate for that individual because, as you know, women from certain communities will not have men look after them.  It's understanding what's appropriate for those individuals and again it goes back to that personalised care, but actually looking at it much more through the cultural lens and I think there is more for us to do in that space.

SA:        We started talking about the 75th anniversary of Windrush and the NHS and I guess the moment we find ourselves in is a bit of a strange one where we're having yet again another … if you look at the figures one in six people who work in the health service overall were trained overseas, we're having another boom in overseas recruitment.  Like I say, I had two questions to finish, one was how do we make sure that when we recruit staff from overseas we're doing it ethically, we're not denuding other countries who equally need nurses and doctors of the staff they need for their own health service, and then secondly, for staff who do choose to come and work in this country, how can we do things better?  How can we make them feel more welcome and feel that sense of belonging when they arrive?

KB:        So I think it's right to reference that we are seeing a boom and I absolutely agree with you.  So our international trained colleagues I welcome them.  The legacy from the day the Windrush landed as we know the day before it disembarked, actually it was there for a day before it disembarked, right up to today the health service has relied and is built on its international colleagues from abroad and my parents like many who came from that generation, they … my parents were part of the British Colonies so they had British passports, but yet still they didn't feel they belonged when they got here.  They weren't treated as such, because I was a little kid experiencing that myself with the racism and sometimes I think we've not come as far forward as we think we have as a nation and I think there's something for us to recognise that in response of how we look after our people when we get here, but firstly if I can just come on to the ethical bit.  So it's really important and I work very closely with my colleagues in NHS England, I work for them, as we do in making sure that we've done the recruitment through their ethical recruitment campaigns.  So we've been doing that in order for us … and that's the way we should do it making sure that we're only going to countries that are able to release those nurses, they either have a lot more trained and therefore there are people looking for work and I think that's important.  So that needs to continue.  That's the first thing, but that doesn't stop the fact that we still get people coming via different routes into the UK and we have to acknowledge that that will happen, but I think not going to places that we know are on the certain red lists and areas we know we could be depriving their countries is really, really important and I think as a health service we've come a long way in making sure that that ethical recruitment is there.  That being said, the bit about the wrapping around once people get here is really important and I know that there's been a lot of funding and support gone into all the support groups, the Caribbean Nurses Association, the Filipino Nurses Association, the BINA which is the British Indian Nurses Association, they've all been funded and they do a lot of work to support their counterparts as they're coming in from India and the Philippines and we have some local support groups at Bucks actually, we have a Filipino network called Kalinga, that's been set up by the Philippine community for the Filipino community in Buckinghamshire and that's everybody, that's not just nurses, that's whether you're a cleaner, whether you're a porter, whether you're a bus driver, they've got it across the whole county which has been running now for about four/five years and they're going from strength to strength to put that community spirit in to wrap around people as they come.  So that's really important and the same with the Indian nurses, we've got colleagues that adopt and look after our colleagues and there are great examples I'm sure all over the country, but once they land in your organisation what's really important is we talk about how great these individuals are when you go abroad and see them and say, "Gosh they're working in these great places, running these hospitals," but they come in and we put them at the lower band and we don't always respect their experience and actually there is something for all of us to really take a long and hard look at ourselves and ask ourselves, we've got somebody that's been here working in the Philippines for 20 years and comes over and we're treating them like the lowest grade of nursing that can be and not lesser reflecting some of their experience and I've got great examples when I worked at a previous Trust where a couple of the nurses overnight had to deliver a baby that was born prematurely on one of the surgical wards.  It was just the poor lady went into labour and these nurses from the Philippines were actually trained midwives and they delivered this baby safely.  They come with such a richness of experience.  So creating sense of belonging in the communities for which they come into.  Many of my friends come from the black community, we naturally congregate with people that look and sound and understand us as people.  The wider bit then is when you get into organisations, how do you help people to really bring their true self, their values, their language, their cultures, that actually are very rich and can benefit because of some of the patients coming are coming in from that background as well.  So I think that bit about celebrating people's difference.  So we have things like our intensive care unit, they have these parties where everybody brings in world food and they all make the food from the different places and they celebrate each other and celebrate the differences that they bring and the richness that they bring.  So celebration is really important.  Acknowledgment of people's experiences, allowing them to help us to see what it's really like to be from a different place that will help those individuals from the UK born here who may not be from other places to look … better serve the people they're looking after when they're coming in if they come with an Indian background or from a black or African background.  So those things are really important.  Sense of wellbeing, sense of belonging that you're valued, you're listen to, you're respected and you're heard, that doesn't take a lot of energy but it does take a lot of commitment.  We've really got to do this work with intention, we've got to make sure that we support individuals and not try and make them all out to be the same and that takes commitment, as I said earlier, from individuals and collective from the board, leadership and that's really important.  If it starts with the leadership and therefore it infiltrates the culture throughout the organisation.

SA:        Karen, that sense of belonging, celebration and respect I think that is a great point to end the episode and sums up a lot of the issues we've covered today.

KB:        Thank you.

SA:        Well folks, that's all we've got time for I'm afraid.  Thank you Karen so much for joining us today.  You can find a link to more of our work reflecting on the 75 years since the arrival of HMT Empower Windrush in the show notes.  The show notes for this episode and all our  previous episodes can be found at www.kingsfund.org.uk/kfpodcast and you can get in touch with us via Twitter, our account is @thekingsfund.  The producer for this episode was Natalie (inaudible 00:30:44) and it has been edited by Bespoken Media.  Don't forget to subscribe, share, rate and review this episode wherever you get your podcasts and of course thank you for listening.  We hope you can join us next time.