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  • Roger Kline

If not now, why?

In a blog last week (1) I asked “After the speeches: what now for NHS staff race discrimination?” and suggested that:

“No one should be a member of any NHS Board if they cannot confidently explain to staff and managers (and interview panels) why tackling race discrimination is important for the NHS and demonstrate what they are doing personally to achieve this. It must not be an optional extra. To gain the insight required to act requires difficult face to face discussion, reading, and listening and acting on lived experience”.

Our shared humanity and our sense of social justice should be sufficient to prompt us to ensure we gain that insight.

But it might be useful to summarise additional reasons since all healthcare leaders need to be familiar with these too.

The NHS has an extraordinarily diverse workforce, but NHS staff surveys,  workforce data and the lived experience of staff show that many staff experience discrimination in their NHS working lives notably in recruitment, development, disciplinary action and through bullying, all of which are likely to adversely impact on staff health and well-being, organisational performance and on patient care and safety. We know from NHS staff survey data that staff with disabilities and LGBTQ staff are heavily bullied. We know that women are still seriously under-represented at senior levels of the NHS. And we know from a whole range of indicators that the experience of the NHS staff from Black and Minority Ethnic (BME) heritage is worse than that of White staff across many indicators.

Why does this matter?

  • It is unethical. It is contrary to NHS values as enshrined in the NHS Constitution. Everyone working in the NHS deserves respect, deserves to be valued and to be able to work to their potential. Our shared humanity towards fellow staff and , and social justice, requires this

  • It wastes talent. Across the NHS it is one and a half times (1.46 times) more likely that White staff will be appointed compared to BME candidates even after shortlisting. (2) If shortlisting, appointments and access to development are influenced by whether candidates “fit in” or “are like us” or by biases and criteria not based on their potential and talent, then that must surely risk patients not getting the best possible staff.

  • It undermines patient care. Managing staff with respect and compassion correlates with improved patient satisfaction, infection and mortality rates, Care Quality Commission (CQC) ratings and financial performance (3). We know that bullying and have a substantial cost for NHS staff, organisational performance and patient care and safety (4), The staff survey item that is most consistently strongly linked to patient survey scores was discrimination, in particular discrimination on the basis of ethnic background. (5) The percentage of staff reporting their Trust provides equal opportunities for career progression was related to CQC ratings of quality of care provided and use of resources as well as with levels of staff absenteeism. (6)

  • It may prompt blame not learning. If some groups of staff (notably BME staff) are disproportionately disciplined or referred to regulators when other staff might not in similar situations, then research suggests that may be because they may be being held to a different standard and their cases dealt with more formally than other staff, with an emphasis on blame not learning (7).

  • It impedes effective team work. Bullying and treating some staff as “outsiders” is likely to make them less likely to raise concerns, less likely to admit mistakes and less likely to work in effective teams. Inclusive and compassionate leadership helps create a psychologically safe workplace where staff are more likely to listen and support each other resulting in fewer errors, fewer staff injuries, less bullying of staff, reduced absenteeism and (in hospitals) reduced patient mortality (8). Yet BME staff in particular are more likely to not be listened to or suffer consequences raising concerns than White staff (9).

  • Discrimination impacts adversely on staff well-being. There is now a wealth of evidence that discrimination and bullying adversely impact on staff mental and physical health (10). Specific impacts associated with race discrimination include higher risk of coronary artery calcification, high blood pressure, cognitive impairment, mortality, diabetes, breast cancer incidence, uterine fibroids, delays in seeking treatment, and lower adherence to treatment regimes (11). That in turn impacts on performance, career progression, turnover, productivity and safety. NHS staff were largely infected by Covid 19 through occupational exposure and there is now a range of evidence that this was directly or indirectly as a result of discriminatory work practices (12).

  • Diverse teams are better teams. They provide better services especially where non-routine cognitive thinking is required – which includes a large proportion of NHS roles – as long as those teams are inclusive. (13) Inclusive teams, however, are more likely to be ‘psychologically safe’ workplaces where staff feel confident in expressing their true selves, raising concerns and admitting mistakes without fear of being unfairly judged and are more likely to be innovative. (14)

  • Performance is adversely affected in teams that are not diverse and inclusive. We know that cognitive and demographic diversity overlap substantially and both improve organisational performance in productivity, innovation, creativity, and risk awareness. The evidence is convincing as long as increased diversity is underpinned by inclusion. Inclusion may be regarded as the extent to which staff believe they are a valued member of the work group, in which they receive fair and equitable treatment, and believe they are encouraged to contribute to the effectiveness of that group. We know that where the organisational leadership better represents the ethnicity of staff, there is more trust, stronger perceptions of fairness and overall better morale of staff (15).

  • Discrimination impedes service improvement. Equality and diversity are not simply matters for compliance with legal duties. A diverse workforce and inclusive leadership contribute to service improvement. Effective leaderships are diverse, inclusive and compassionate (16) whilst research tells us that diverse inclusive teams are more creative, innovative and productive.

  • Discrimination is unlawful. The statutory requirement for employers to treat staff, applicants and patients and fairly, is now complemented by regulatory compliance through the NHS Standard Contract and the CQC’s Key Lines of Inquiry, which should be a minimum that Boards and organisations aspire to. Had timely Equality Impact Assessments and health and safety risk assessments been carried out, they would almost certainly have saved NHS staff lives.

The NHS Interim People Plan makes improving the treatment of, and opportunities for, staff an essential element of better performance by NHS organisations. It specially acknowledges the under-representation of poor treatment of different groups of staff, including BME staff, staff with disabilities, women and LGBTQ staff

Yet the proportion of staff with disabilities or who are LGBTQ being bullied remains stubbornly high. Nationally, there was no improvement last year in the relative likelihood of BME staff being appointed from shortlisting compared to white staff, or in the proportion of BME staff believing there was equal opportunities for career progression and promotion.

The current pace of change is simply too slow. The reasons for change are clear. The time is now.


(2)         WRES. Data analysis report for NHS Trusts

(3)         Dixon-Woods M, et al . (2013). Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Qual Saf 2014;23:106–15. doi:10.1136/bmjqs-2013-001947

(4)         Kline, R & Lewis, D. (2018). The price of fear: Estimating the financial cost of bullying and harassment to the NHS in England

(5)         Dawson, J. (2009) Does the experience of staff working in the NHS link to the patient experience of care?

(6)         West, M and Dawson, J. (2011) NHS Staff Management and Health Service Quality.

(7)         Atewologun, D & Kline, R. (2019). Fair to refer. Reducing disproportionality in fitness to practise concerns (GMC)

(8)         Carter M, West M, Dawson J (2008). Developing team-based working in NHS trusts. (Aston University)

(11)      Williams, D. R., & Mohammed, S. A. (2009). Discrimination and Racial Disparities in Health: Evidence and Needed Research. Journal of Behavioral Medicine, 32, 20-47.

(12)      Kline (2020)The NHS response to BME staff’s Covid deaths was late and lopsided

(13)      Scott E Page, Lewis, E, Cantor, N, Phillips, K. (2017). The Diversity Bonus: How Great Teams Pay off in the Knowledge

(14)      West M, Eckert R , Collins R (2017).Caring to change. How compassionate leadership can stimulate innovation in health care. Kings Fund. g_to_change_Kings_Fund_May_2017.pdf

(15)      King E , E., Dawson, J. F., Jensen, J., & Jones, K. (2017). A socioecological approach to relational demography: How relative representation and respectful coworkers affect job attitudes. Journal of Business and Psychology, 32, 1-19.

(16) Developing People: Improving Care (2016). ; Kline R Leadership in the NHS BMJ Leader 2019;3:129-132.

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