Workforce race inequalities and inclusion in NHS providers

Part of Inequalities and inclusion in NHS providers

The NHS has one of the most ethnically diverse workforces in the public sector. However, year after year, ethnic minority staff1  report worse experiences in terms of their lives and careers, when compared with white staff and people from an ethnic minority background are under-represented in senior positions in the NHS.

Addressing race inequalities in the NHS workforce is critical on multiple levels. Experiences of discrimination can cast a long shadow on ethnic minority NHS staff; the impact on people can be profound (see www.kingsfund.org.uk/nhs-stories for powerful first-person accounts collected in connection with this research).

There are also wider implications for the health service: evidence shows that fair treatment of staff is linked to a better experience of care for patients. Moreover, the NHS is in the midst of a workforce crisis and improving its performance on diversity and inclusion will play an important role in the NHS becoming a better place to work and build a career.

Overview

  • Despite having one of the most ethnically diverse workforces in the public sector, there are long-standing race inequalities issues in the NHS workforce, including a lack of ethnic minority representation at senior levels, ethnic minority staff being much more likely to report they have experienced discrimination at work than white staff, and fewer ethnic minority staff reporting their trust offers equal opportunities for career progression.
  • Our research explored how three NHS provider organisations have sought to address workforce race inequalities and develop positive and inclusive working environments.
  • The three case studies were beginning to address race inequalities and inclusion by introducing interventions to make it safer to talk about race‑related issues and interventions to enable development and career progression for ethnic minority staff.
  • This type of cultural change was complex, multi-faceted and took time, but staff at each site described how the interventions and the focus on race inequalities and inclusion had started to change their working environments for the better.
  • Drawing on the experiences and reflections of those involved in addressing race inequalities and inclusion in the three case studies, we offer a few key learning points and questions to encourage others to reflect their own organisation’s approaches to working on race equality and inclusion.
  • We hope this report will help readers in NHS organisations as they design or implement their own local approaches to creating fairer workplaces.
  • We want this report to provoke conversations about the structural and personal aspects of race inequality, and to serve as the starting point for organisations’ own deeper explorations of how they are thinking about it and working on it.
  • 1The terms ‘ethnic minority’ or ‘ethnic minority groups’ refer to people belonging to ethnic groups that are in the minority in the context of the population of England.

Our research

Our research, which was carried out before the Covid-19 pandemic, looked at how three NHS case studies have sought to address workforce race inequalities and develop positive and inclusive working environments. We have focused on the personal accounts and recollections of members of staff. This helped us to understand the reality and complexity of culture change.

We selected three NHS trusts where there are promising signs of positive change in terms of race inequalities and inclusion: Bradford District Care NHS Foundation Trust, Calderdale and Huddersfield NHS Foundation Trust and East London NHS Foundation Trust. In each trust, we interviewed a range of individuals, including:

  • members of staff (a combination of those directly involved in race equality work and those not)
  • Freedom to Speak Up Guardians
  • a local trade union representative
  • an organisation development manager
  • equality, diversity and inclusion managers or leads
  • board members (typically the chief executive and director of human resources)
  • any relevant external stakeholders.

A combination of face-to-face and telephone interviews were carried out between September and November 2019. We asked participants to give their reflections on the current culture within their organisation; the specific actions that have been taken to address equality, diversity and inclusion; and what they had learnt from the experience.

Our findings

All three case studies implemented similar interventions aimed at addressing race inequalities and inclusion, including:

  • establishing staff networks
  • ensuring psychologically safe routes for raising concerns (specifically by appointing Freedom to Speak Up Guardians)
  • enabling staff development and career progression.

In combination, these interventions could support ethnic minority staff in feeling their organisations were committing to making positive changes. People told us what had changed for them personally and how they could see a shift taking place around them, with increased awareness about the challenges affecting ethnic minority staff in the workplace. More qualitative data on staff experience would offer essential indications of how change is felt.

The implementation of these interventions was largely perceived as beneficial, however we observed there was potential for some staff to react negatively to them. The interventions made it safer to talk about race, but this inevitably raised some ugly truths about behaviours between colleagues. Leaders at all levels play an important role in supporting and resourcing race equality and inclusion initiatives and addressing resistance and issues as and when they occur.

It was clear from the case study sites that everyone has a role to play in an organisation’s race equality and inclusion effort – through leadership, participation or allyship. If making workplaces more inclusive really is everyone’s responsibility, then leaders need to think about how the design and implementation of strategies or interventions model the principles of inclusion. Leadership for race equality and inclusion is an ongoing activity that creates an emotional burden. Leaders may need support, for example through peer networks or supervision.

Experiences of staff from an ethnic minority background in the NHS

This short animation explores people's experiences of racism and discrimination and may be distressing or triggering. If you've been affected by any of the issues raised, we’ve put together a list of organisations that can offer advice, information and support. 

We spoke to 12 members of staff from ethnic minority backgrounds about their experiences working in the NHS. This short animation outlines some of those experiences, from being bypassed for career development opportunities to the impact of micro-aggressions in the workplace.

Read our feature-length article to explore these stories further. 

Thank you to the people who were interviewed for this short animation and who generously shared their experiences with us.  

With thanks to Nadia Akingbule for creating the illustrations and to Jolt for animating these stories and bringing these experiences to life. 

Key learnings to consider

Although each organisation’s approach to addressing race inequalities and inclusion will be defined and designed locally depending on the circumstances, the case studies offer some key learning points for the rest of the sector to consider.

There are no magic solutions to an age-old issue. The experiences in the three NHS organisations reflects the reality of working towards race equality: to date, it has not been easy, quick or straightforward.

  • Approaches to race equality and inclusion are not ‘one size fits all’. There is a lack of proven interventions and it is down to individuals and organisations making a concerted effort at a local level to iterate the approach that ‘works’ for them.
  • Addressing inequalities and inclusion needs to be an ongoing, ‘moment-by-moment’ activity that engages with and responds to people’s lived experiences.

Further work

Comments

Shainy Paul

Position
RGN,
Comment date
18 June 2022

Am a nurse qualified over 23 years, joined NHS 2011. I was very motivated and dedicated person, wanted to have progress in my career, but never get anywhere. In fact I made complaint, but the person who I made a complaint came to investigate the complaint. I have lot of bad experiences to list down from my trust.
Finally I applied for a specialist nurse, as usual I never be a suitable candidate. But at the interview they offered me a Bank post as band 6 in the specialist nurse position. So I agreed with that. I have to chase up more than 3 months to sort this out. Finally they informed me that, I have to finish the competencies to become a band 6.
As I have no choice Infront of me I agreed with this. Eventually my competencies completed, but now they can not offer me as band 6 as I am band 5 permanent in ward.

Derek Jones

Position
Volunteer,
Organisation
NHS England
Comment date
19 October 2020

Hi,
Briefly: i am a retired NHS Mental Health Clinical skills tutor. I am currently supporting a colleague that has a lead role in Diversity and Inclusion. I would be grateful if you would let me have access to your work, as i was interested in your comments.
As senior managers (Over the years) we have both seen how easy it is to produce masses of data and glossy reports-which produces no positive action!! This time we are determined to make a difference-so anything you feel you can offer in terms of advice or research etc would be most welcome.
Regards,
Derek Jones

Anonymous

Position
Senior Radiographet,
Organisation
Kings College London
Comment date
01 September 2020

I have experienced many forms of discrimination throughout my career. I have applied for many promotions but never seem to be the right candidate.
It progresses more deeply when it is your turn for promotion they then decide to use forms of nit picking and constant criticism to give them reason to why you can not be selected. This in order to give the promotions and praise to the staff members they like and want to have status and diversity within there job role.
I have been verbally abused and had to go through a traumatic grievance procedure but the system put in place seems to try and protect the senior managers that are bullying. The trust champions have little powers and the union reps are reluctant to actually deal with the problem as it would mean them potential ally loosing there job.
Policies and accountability needs to be the way to stop the systemic discrimination within the nhs system. Also having more BAME members in positions to actually make changes.

annonymous

Position
staff nurse,
Comment date
16 July 2020

As a mature staff nurse I feel discriminated against. I have 21 years of experience but yet am not able to be accepted when I went for band 6 interview several times. The younger newly qualified nurse get it faster. I belief there should be way to support experience mature nurses. you feel humiliated see all the people you mentor and supported getting it and you are not able to get it.
I love working with ELFT because of the opportunity they give staff but as a mature and experience nurse I didn't think their is much support in area of progressing your carrier I feel stuck. But I have seen other mature people from different race moving up the ladder

Shilpa

Position
Senior Researcher,
Organisation
The King's Fund
Comment date
13 July 2020

Hi Celia - thanks for your comment. This sounds like a really interesting intervention. If you're willing to, please email me via website@kingsfund.org.uk as it'd be good to hear more about how this approach worked at your trust. Shilpa

Celia Oke

Position
[former] Workforce Diversity and Inclusion Manager,
Organisation
St George's University Hospitals NHS Foundation Trust
Comment date
12 July 2020

One essential ED&I intervention that is absent from your review is the elimination of systematic discriminatory practices and policies through the evaluation and analysis of practices. This is done through equality impact assessment, benchmarking and full review of people/HR processes.
This is a process fundamental in establishing strong ED&I foundations and usually shunned by Trusts as the it isn't a visible, high profile intervention. Ironically without this work, Trusts will continue to experience racism because establishing staff groups, and speaking groups without a proper foundation to support them means they have a short shelf life.

Gillian King

Position
Community Live Donor Facilitator,
Organisation
Royal Free London
Comment date
09 July 2020

I co-wrote a paper which was published in the AMTCP book series in June 2018. I outline all the issues of inequality in the NHS and suggest health literacy as a solution. Now is the time for action, not more report writing, I did all my research for the paper at King's, the information on inequalities for staff and patients has been around for a long time. But nobody seems to want to do anything about, it, other than write more reports! I do apologise for my tone, I'm just frustrated that no one is paying attention to the blinding obvious! Feel free to contact me about my work, if anyone is interested in more details.

Anonymous

Comment date
08 July 2020

I would have loved to contribute to your work; as I am a senior member of nursing staff from the Ethnic minority who has suffered and continues to suffer within my team.

I agree we have the support to speak to our Line Manager and HR staff. Despite all this, I would like to say if the bully is someone at a higher level than you, like a Consultant Surgeon, your voice is never heard. The Trust does their best to keep the situation calm but will not address it firmly to the Consultant Surgeon. I am happy to talk if you are looking for more reports.

Thanks,
Prefer to remain anonymous for my security, as I am not sure if my comments will be made public.

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