Roger Kline: The long walk to equality

A decade ago Tony Blair said, “In 10 years’ time, ethnic minority groups should no longer face disproportionate barriers to accessing and realising opportunities for achievement in the labour market.” The Cabinet Office paper that his claim graced has long been forgotten.

‘BME workforce numbers have grown to 18 per cent, but the number of BME chief executives and BME nurse directors has not risen’

For NHS black and minority ethnic staff that goal has been sunk by a triple whammy of government policy, the 2008 recession and the refusal of too much of the NHS to take workplace race equality seriously.

In 2004 there were four BME NHS chief executives. BME workforce numbers have grown to 18 per cent, but the number of BME chief executives and BME nurse directors has not risen. In NHS London, where BME staff numbers are highest, the proportion of non-medical white staff on bands 8 and 9 is over twice as high as the proportion of BME staff.

• HSJ’s Pinterest board celebrates BME leaders and the contribution they have made to shaping and leading quality care throughout the NHS’s history

Research has repeatedly confirmed that BME staff face barriers in every conceivable aspect of employment. They are twice as likely as white staff to be disciplined but are almost half as likely to be appointed from a shortlist. Black nurses take 50 per cent longer to be promoted than white nurses, while BME nurse graduates find it much harder to find their first job.

BME doctors face similar hurdles as BME workers in other occupations. One senior BME manager tweeted me recently that he’d had to “work twice as long and twice as hard” to get where he was. With a raft of NHS initiatives, policies and promises behind us, it is worth asking why progress is so slow and may even have stalled altogether.

The issues

The first problem is that the Equality Act 2010 removed the public sector imperative to collect and publish detailed data on race equality − as a result, even finding out what is happening is difficult.

‘Even when legally required to, only 20 per cent of trusts kept data that would help seriously inform policy’

We do know that Bradford University research on disciplinary processes, carried out in partnership with NHS Employers in 2009, reported that, even when legally required to, only 20 per cent of trusts kept data that would help seriously inform policy. The 2012 Equality and Human Rights Commission survey found only half of English public authorities were even fulfilling the equality duty requirement to publish equality information on staff and service users.

Public World’s analysis of trust recruitment data in spring 2013, Discrimination by Appointment, suggested shortlisted BME staff were significantly less likely than white candidates to be appointed, and that virtually no trust acknowledged this as a significant problem. We also found much data difficult to find. The pattern of apparent discrimination was the same as − or arguably worse than − five years previously.

A second problem is that while national initiatives such as Breaking Through were abandoned by the coalition government, the new NHS equality flagship, the Equality Delivery System, is voluntary. I’ll hazard a bet that few employers have made workforce race equality one of their four or five required priorities.

Dragging feet

The most recent EHRC survey of the public sector equality duty in NHS trusts suggested just over half even have clear objectives on a timeframe for improvement, or clarity about who is responsible for delivery. The NHS has form on dragging its feet. In 2007 the Healthcare Commission found that nine per cent of trusts were meeting their legal duties under the Race Relations (Amendment) Act. Not only are all types of regulators overwhelmingly white at senior levels but their work does not tackle racism.

‘Not only are all types of regulators overwhelmingly white at senior levels but their work does not tackle racism’

The impact of the “transition” from primary care trusts and strategic health authorities, and the parallel recruitment into NHS England, has also created problems. BME staff were substantially less likely than white applicants to be appointed to senior and very senior manager posts at NHS England, so much so that the HR director warned the data “does not make for easy reading”.

NHS England board member Moira Gibb had previously warned of the risk of discriminatory outcomes but, apparently, went unheeded. Not a great position from which NHS England can lead on race equality. Across the country, anecdotal evidence is that senior band 8 and 9 BME managers may have lost out as primary care trusts disappeared.

“Austerity” has also had an impact. In past recessions and major restructuring, BME, women and disabled staff have not fared well. The Labour Force Survey since 2008 shows declining rates of overall employment among minority ethnic groups in Britain, with black men and women 2.5 times as likely to be unemployed as white people. Recruitment cuts will make changes in workforce profile even slower.

Galvanise the NHS

So what can be done? On patient safety, post-Francis, we all accept we must collect robust data, listen to patients and staff, acknowledge the evidence and address the problem. For race equality that is doubly difficult since we do not collect enough data and, when we do, we often ignore what it tells us. We do not listen to BME staff whose perception of discrimination is quite different to that of many white staff. When BME staff do raise well evidenced concerns the responses still include complete denial or even retaliation.

‘For race equality we don’t collect enough data and, when we do, we often ignore what it tells us’

When former Central Manchester Foundation Trust manager Elliot Browne was awarded £1m compensation for sustained career-ending race discrimination, the trust continued to deny discrimination even though their own data suggested they had a problem. When Professor Aneez Esmail recently concluded he couldn’t rule out race discrimination in a royal medical college exam, there were apparently efforts to censor publication of his results.

Things may get worse before they get better. The impact of discretionary pay and revalidation is predictable. Over a decade ago I found that discretionary increments for health visitors were discriminatory. White clinicians have been more likely to receive the top clinical excellence awards. The Department of Health’s own equality assessment warned discrimination was a risk in medical revalidation. The widespread narrative that we are still “making progress” on race equality is open to challenge.

This depressing picture is bad news for patients as well as staff. If recruitment and other processes are adversely influenced by race discrimination then patients are unlikely to get the best staff. Michael West has shown the link between how staff are treated and clinical outcomes. His colleague Jeremy Dawson has also shown a correlation between the treatment of BME staff and patient experience. Treating any staff badly is a terrible waste of talent and hardly likely to lead to better care.

So, please, we must galvanise the NHS. We need leadership nationally and locally that builds on the achievements of a minority of good trusts. We must avoid tick-box compliance and realise the business and clinical case for race equality. We need professional bodies, regulators and trade unions to make sure they have the confidence of staff from black and minority ethnic groups, and robustly challenge discrimination.

We surely need to consider making workforce race equality a chief executive performance review objective. Above all, we need to use the momentum of patient safety to help tackle NHS staff race discrimination once and for all − for the sake of both patients and staff.

Roger Kline is a research fellow at Middlesex University and associate consultant at Public World