How the NHS works

What if NHS leaders were more representative of their patients?

The NHS comes into contact with more than one million patients every 36 hours. Over the years since the NHS was created, this patient population has grown in diversity in the fullest sense of the word. However, despite the positive way in which the NHS is seen, some sections of the patient population – perhaps because of their age, gender or ethnicity – have a less positive experience, with inequalities in access, variation in health outcomes and care that is not tailored to their individual needs. And although the NHS is often held up as one of the most multi-cultural employers in England, the lack of diversity in its formal leadership structures is a barrier to the service achieving its full potential.

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Vijaya Nath

Vijaya Nath is Director of Leadership Development at the Leadership Foundation for Higher Education.

The current leadership of the NHS neither reflects nor represents the diversity of its patient population or its workforce, in terms of gender, ethnicity and age, and is often criticised for being elitist and formed from the monoculture. For example, in London the proportion of NHS board members from a BAME (Black, Asian and minority ethnic) background was lower in 2014 than in 2006; the number of chief executives and chairs from a BAME background was also lower at only 2.5 per cent in 2014. Women remain significantly under-represented at senior leadership level, which continues to baffle as women make up more than 78 per cent of the NHS workforce. Post-Brexit, this lack of diversity represents a risk to the United Kingdom and for the NHS in that it limits new ideas and approaches.

In London the proportion of NHS board members from a BAME (Black, Asian and minority ethnic) background was lower in 2014 than in 2006.

The late American publisher and entrepreneur Malcolm Forbes succinctly captured one of the most powerful benefits of a diverse workforce and leadership when he described diversity as ‘the art of thinking independently together’. Imagine the potential of a greater range of ideas generated by a greater range of diversity.

Just imagine how the priorities, culture and ways of working in the NHS would be different if its leadership was more representative of the characteristics and values of the diverse patient population and workforce. Benefits would include, among other things, a greater understanding of users’ needs and perspectives, as well as a greater diversity of staff perspectives – for example, through clinical and non-clinical opinions, greater innovation and more creativity in problem-solving. There could also be a concerted drive to improve and widen the pool of people who would be attracted to work in NHS leadership positions.

So far, efforts to achieve a leadership mix that reflects the NHS’s diversity have proved unsuccessful. There are no quick fixes. Individual organisations need to work to alter pre-existing attitudes that still act as barriers to inclusive leadership. Investing in organisational development – including internal appreciative inquiry initiatives, which focus on identifying the positive strengths in individuals and what is working well in the organisation and how these strengths can be incorporated into the culture – can enable organisations to understand the breadth and range of diverse views and talent that already exist at individual and team level. This exploration would also enable leaders to look at ‘what’s missing’ and to use this information to inform future recruitment strategies, as well as individual development portfolios and organisational talent strategies. This is one way of achieving more diversity in leadership – growing your own talent. And let’s not think about diversity just in terms of gender and ethnicity. Respect for the diversity of thought that both youth and maturity bring is already changing many industries. For the NHS to keep up with the demands of the future, including an ageing patient population, accessing talent at both ends of the workforce will require new ways of working.

This is one way of achieving more diversity in leadership – growing your own talent.

A growing body of evidence from sectors outside health (to which health continues to look to improve on clinical innovation and quality improvement) tells us that having a diverse leadership helps companies to perform better. For example, McKinsey’s Diversity matters report found that companies with a gender-diverse board were 15 per cent more likely to outperform their peers financially and those with an ethnically diverse board were 35 per cent more likely to turn in a better financial performance. Harvard Business School has repeatedly stated that multicultural networks promote creativity. This type of evidence moves us beyond the moral argument around fairness and equity into the area of drawing on cultures of inclusion to improve performance and maximise effectiveness.

In the future there will be enormous changes to how the NHS operates both locally and globally. As well as a multi-generational workforce, innovations in technology will transform health care services; we may even see robots delivering health care. Technological innovation will also help bring a shift in power from health care professionals to patients, who will take far more control in determining their care. These and other changes mean that the workforce and leadership teams of the NHS in 2048 will bear no resemblance to the team that was in charge when the first NHS patient was treated in 1948.

A growing body of evidence from sectors outside health tells us that having a diverse leadership helps companies to perform better.

So what if, in 2026, the NHS had a community-led board that was informed by the wisdom of both a council of elders and a local youth forum? Where the ‘director of creative engagement’ is a patient leader, who now sits on the council of elders, and where the position of chair of the board rotates quarterly between clinical, non-clinical and community professionals. Where the board and the leadership team visibly represent the patient population they serve in terms of gender, ethnicity and age ranges. And where, perhaps, artificial intelligence plays a role in decision-making. How would this impact on the quality of care, equity and the provision of truly patient-centred care that better meets the needs of the local population?

This means we will need to establish more inclusive, tolerant cultures within the NHS.

In the future, human empathy could become the most important employing factor in health care. People with long-term health and care needs, for instance, are just as likely to need support in making social connections, maintaining stable employment, and finding ways to manage their own health, as they are to need direct clinical support. This means we will need to establish more inclusive, tolerant cultures within the NHS. In the current composition of the NHS’s workforce, where individual egos loom large, it would be interesting to fast forward 10 or 15 years and look at how those making decisions would fare if they needed to take into account the opinion being spurted out by a robotic team member, or one that emanates from the virtual and augmented reality of the ‘ward’ or ‘examination room’, in tandem with the views of the patient leader who is a voting board member.

The current leadership models and composition of leadership in the NHS will not propel her to achieve the successes which the future demands; we need to make a commitment to change.

The views expressed in this article are those of the author and are not presented as those of The King’s Fund. We have commissioned external authors to write for ‘The NHS if’ series as a way of presenting different perspectives on the future of health and care. We welcome a diversity of views on this issue and encourage you to leave your comments below.

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About

‘The NHS if’ is a collection of essays published by The King’s Fund that explores hypothetical scenarios and their impact on the future of health and care.

We are asking a small number of experts – some of them members of staff at The King’s Fund and others external experts in their fields – to write short essays that consider ‘what if’ questions about health and care in England. We’ll be publishing these essays on this website throughout 2016.

Our aim is to encourage new thinking and debate about possible future scenarios that could fundamentally change health and care. The essays cover three themes: the NHS and society; medicine, data and technology; and how the NHS works.

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