Diversity and inclusion are not optional extras if the NHS wishes to improve

Health Minister Stephen Barclay wants “the NHS to ensure its leadership is as diverse as the rest of the workforce within the next 10 years.” NHS Improvement chair Dido Harding wants a step change by board leaders to improve equality and diversity. But the NHS already has statutory obligations to promote equality and the embedded equality commitments of the NHS Constitution, so what is missing?

We know good intentions are not enough. If they were, we wouldn’t need the recent mandated interventions around race, disability and gender equality.

Research tells us that data driven accountability is crucial to effective change on diversity. It is also crucial that equality and diversity are seen as a ccrucial element in improvement strategies, not just a matter of compliance. Yet there is surprisingly little awareness of the growing evidence that diversity and inclusion are excellent ingredients in improvement strategies.

Discrimination wastes talent

We can no longer afford to ignore the wealth of evidence that where staff are treated with respect, discrimination is challenged and difference is welcomed, that staff talent blossoms, turnover declines and patient care and safety improve.

In hospital settings managing staff with respect and compassion correlates with improved patient satisfaction, infection and mortality rates, CQC ratings and financial performance as well as turnover and absenteeism

It wastes talent. Discrimination is likely to prevent organisations recruiting and promoting the best possible staff. The most detailed data we have is on race discrimination. In the NHS, we know that even when Black and Minority Ethnic staff are shortlisted, it is currently 1.60 times more likely that white staff will be appointed from being shortlisted than BME staff will be. (Equality and Diversity Council, 2017).

The MacGregor Smith Review (2017) set out the extent of the waste of BME talent at every level, including the most senior ones, and drew on research suggesting UK Gross Domestic Product could increase by up to 1.3 per cent a year if workers from BME backgrounds progressed at the same rate as their white colleagues. Women make up almost three quarters of the NHS workforce but are a minority of board members and very senior managers.

Women, staff with disabilities, BME staff have fewer opportunities to access the “stretch” opportunities that are crucial to allow staff to showcase their ability and develop their potential – such as acting up, secondments, and being involved in new projects.

It impacts on patient care and safety. Analysis of Care Quality Commission ratings and NHS staff survey results also show “a clear pattern between the quality of care and staff experience of discrimination in the NHS, with staff in trusts with lower ratings more likely to say they have experienced discrimination.“ (CQC (2017).

The staff survey item that was most consistently strongly linked to patient survey scores was discrimination, in particular discrimination on the basis of ethnic background. (Dawson, J. 2009). We know that in hospital settings that managing staff with respect and compassion correlates with improved patient satisfaction, infection and mortality rates, CQC ratings and financial performance (Dixon-Woods, M et al 2015) as well as turnover and absenteeism.

Impact of bullying

Bullying of any staff impacts adversely on their health, on good team working, on the willingness to admit mistakes and the willingness to report concerns. The NHS national staff survey shows BME staff are consistently more likely to be bullied by their managers or colleagues than white staff are.

Inclusion is the degree to which an employee perceives that he or she is an esteemed member of the work group through experiencing treatment that satisfies his or her needs for belongingness and uniqueness

The bullying of staff with disabilities or LGBT staff is even higher – with inevitable consequences for how staff and teams work. The Francis Speaking Up report demonstrated that BME staff were less favourably treated when raising concerns at work than white staff with inevitable risks for safety.

It affects how services are commissioned. Unrepresentative boards may be less likely to commission patient focussed care. Salway et al (2013) suggested a diverse workforce has greater potential to tackle ethnic inequalities in access, experiences and outcomes.

However, improving the recruitment, development, and promotion of staff from underrepresented groups is not sufficient to ensure their abilities are fully recognised and used, nor does it ensure that the cognitive diversity (and resultant benefits) they potentially bring are embedded in organisations and teams.

For that to happen, leaders have not only to avoid bias and discrimination but also act as a role models for inclusion. Leaders are judged as being inclusive not only by how each individual employee believes they are treated, but by their perceptions of how all group members are treated. Increasing the diversity of an organisation and teams is important but it is inclusion which brings the really big benefits.

Inclusion is the degree to which an employee perceives that he or she is an esteemed member of the work group through experiencing treatment that satisfies his or her needs for belongingness and uniqueness. (Bourke et al, 2018) found that “research reveals that high performing teams are both cognitively and demographically diverse.

Demographic diversity, for its part, helps teams tap into knowledge and networks specific to a particular demographic group. More broadly, it can help elicit cognitive diversity through its indirect effect on personal behaviours and group dynamics. For example, racial diversity stimulates curiosity, and gender balance facilitates conversational turn-taking”

There is a growing body of research suggesting that when that happens:

• Innovation is more likely (Lorenzo and Reeves, 2018; Hewlett et al 2013; Nathan and Lee,2013) and team creativity improves (Yu & Frenkel, 2013);
• It triggers more careful information processing than is absent in homogeneous groups (Bourke,2016);
• Women in leadership moderate extreme behaviour and improve risk awareness (Grant Thornton,2017) and are more questioning (Liswood, L., 2015);
• Inclusive workplaces are likely to be more productive (Harter, 2003);
• Companies with the most ethnically diverse executive teams are 33 percent more likely to outperform their peers on profitability (Hunt et al.2018, Catalyst, 2004);
• Companies with inclusive talent practices in hiring, promotion, development, leadership, and team management generate up to 30 percent higher revenue per employee and greater profitability than their competitors (Stacia Sherman Garr et al, 2015);
• Turnover intentions decline (Olkkonen & Lipponen, 2006);
• Where the organisational leadership better represents the ethnicity of staff, there is more trust, stronger perceptions of fairness and overall better morale of staff and higher levels of engagement (King et al., 2017). In the NHS higher levels of staff engagement are associated with low rates of staff sickness, absence, and therefore, lower spending on bank and agency staff. The size of the effect is large (Dawson, 2018).

New people stimulate the thinking of the established team members because “the mere presence of socially distinct newcomers and the social concerns their presence stimulates among old timers motivates behaviour that can convert affective pains into cognitive gains” (Phillips, KW et al (2009)).

Homogeneous groups don’t come to better solutions, but are convinced that they, have whereas heterogeneous groups, do come to better solutions – but tend to think that they haven’t (Bourke and Dillon, 2018).

This evidence is embedded in Developing People: Improving Care, the NHS leadership development strategy. But the argument is not as well understood as it should be, is acted upon too infrequently by senior leaders, and has not yet decisively changed recruitment, development and team building practices. It is time it did if ministerial exhortations are going to have the effect they should.