The most valuable asset the NHS has is its staff. A wealth of research demonstrates that when such staff are treated fairly, with respect, in a safe environment where they can question and challenge, it leads to safer and more effective patient care, more productive teams and a healthier workforce, less likely to leave the NHS.
Prior to the General Election, Ministers such as Stephen Barclay showed no interest in such evidence. They did nothing to ensure NHS staff who raised important concerns were listed to (1), did nothing to address the scandalous levels of bullying and harassment, and actively used the “culture wars” to try to undermine equality, diversity and inclusion in the NHS. They did so in the teeth of research, and their own Messenger Report (2) which highlighted the importance of tackling discrimination, and which named disability and race as the two biggest challenges.
A changing approach?
We now have signs of a different approach from the new Secretary of State:
· “I’m deadly serious when I say NHS managers who silence whistleblowers will be out and will never work in the NHS again.” (3)
"I will not tolerate, under any circumstances, NHS or social care staff in any health or care setting being subjected to intimidation, harassment or racist abuse. We have a zero-tolerance policy in the NHS and we'll take a zero-tolerance approach in social care too. People who are abusing NHS staff can be turned away, and should be turned away, if that is the way that they are treating our staff." (4)
When General Sir Gordon Messenger was asked by Sajid Javid (remember him?) to consider leadership in the NHS he found that
“acceptance of discrimination, bullying, blame cultures and responsibility avoidance has almost become normalised in certain parts of the system, as evidenced by staff surveys and several publicised examples of poor practice. This exists at the micro-level, in individual workplaces, and across sectors, where the enduring lack of parity of esteem, conditions and status between healthcare and social care remains a blight on effective collaborative working.” (2)
The last (2023) NHS staff survey shows staff well-being, engagement and the willingness to raise safety concerns deteriorating, whilst bullying remains rife and discrimination is ubiquitous. (5) The latest WRES data shows it is still over twenty (20.5) times more likely that a White Band 5 nurse will become a Director of Nursing compared to a Band 5 BME nurse
The NHS Constitution stresses NHS workplaces and patient care should be free of discrimination. Research strongly suggests how staff are treated (including whether they face discrimination) impacts on patient care, staff well-being and organisational effectiveness. Inclusion is the extent to which staff believe they are encouraged to contribute to the effectiveness of that group and where all staff believe they are valued members of the work group, and in which they receive fair and equitable treatment.
Research evidence
Specifically, where diversity, including at senior levels, is underpinned by inclusion, it benefits staff engagement, retention, innovation, productivity and the safety and quality of care. Inclusive teams 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[i] enabling efficient, productive and safe care.(6)
There is a wealth of relevant research:
In hospital settings, managing staff with respect and compassion correlates with improved patient satisfaction, infection control and mortality rates, Care Quality Commission (CQC) ratings and financial performance. (7)
High work pressure, staff perceptions of unequal treatment, and discrimination against staff all correlate adversely with patient satisfaction. (8)
Organisations with more diverse leadership teams are likely to outperform less diverse peers with good correlations between leadership diversity and financial performance. (9)
Inclusive leaders who promote equality and diversity are good for organisations (10)
The cost of bullying and harassment of staff alone has been conservatively estimated as costing the NHS £2.3 billion per year. (11). Some workforce groups, notably LGBT+ staff, disabled staff and black and minority ethnic staff, report that they experience particularly high levels of bullying from colleagues and managers. whilst staff who are bullied are likely to be less willing to raise concerns and admit mistakes. See also Lucian L Leape , Miles F Shore, Jules L Dienstag, et al (2012) Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Acad Med. 2012 Jul;87(7):845-52. doi: 10.1097/ACM.0b013e318258338d.
At least 150,000 NHS staff choosing to solely work as bank or agency staff, many because they feel they were treated unfairly in their substantive roles – especially black and minority ethnic workers, and women seeking flexible working arrangements. (12).
There has been some progress on equality in recent years but the experience of many staff is that discrimination remains “normalised” as Messenger put it. This is especially, though not only, true in respect of race discrimination where previous Ministers pressurised NHS England to downplay any prioritisation of race discrimination.
The recent report Too Hot to Handle (13) highlighted the failure to hear, listen to and act on the concerns raised by the 26% of NHS staff who are of Black and Minority Ethnic heritage. The recent racist riots are a direct threat to the NHS since they run both the risk of deterring new international staff joining the NHS and of driving away Black and Minority Ethnic staff who have become indispensable to the NHS. But what the NHS absolutely must do is focus on the underlying embedded racism in the NHS not just the real threat from racist riots and intimidation
Where there has been some progress on these issues it has come about where specialists in equality, diversity and inclusion have worked alongside leaderships who understand and act on both the moral case and the evidence base, despite the avoidance and denial that characterised previous Ministers.
Research is resoundingly clear that progress depends on inclusive leaderships explicitly paying attention to EDI:
Support from top management is key in determining the success of diversity programmes. (14)
Where diversity interventions lack the involvement of top managers and fail to address overall work processes, their long-term effectiveness in transforming organizational culture is likely to be limited (15).
Being prepared to become uncomfortable when talking about racism, sexual harassment, the disproportionate bullying of LGBT+ staff and staff with disabilities is an essential precondition of effective interventions
Seeing compassionate behaviours as a key source of staff well being and good patient care (16)
Such leaders model the behaviours they expect of others, understand the importance of inclusion and psychological safety, act as allies in the fact of bullying and discrimination and know that how staff are valued and treated is the cornerstone of an effective NHS. They go problem sensing not comfort seeking on such issues, are proactive and preventative, and value staff who raise concerns. They integrate equity into every aspect of the work of the NHS prioritising difficult issues such as tackling racism. They work to become comfortable talking about discrimination especially about race.
We need Ministers and NHS leaders who understand that when that happens then patient care, staff retention and engagement, innovation, creativity and staff well-being all benefit. Such evidence-based leadership is the cornerstone of the service improvement we all seek. That is much more likely to lead to sustained improvement than performative and transient change. (17)
A sustained commitment to challenging bullying and harassment, addressing the fear staff have of speaking out and an explicit commitment to placing equity, diversity and inclusion centrepiece within service improvement rather than as a compliance add-on is now essential. That means being proactive and preventative not waiting for staff to raise concerns.
Let’s hope the new Ministers make that clear to the whole of the NHS especially regulators and senior leaders. It would put clear water between this Government and its wrecking-ball predecessors. Tackling discrimination and bullying, and protecting whistleblowers is not an alternative to improving healthcare but is a precondition of doing so.
Roger Kline OBE, FRSA, Research Fellow, Middlesex University Business School
References
(1) The National Guardian’s Office 2023 report on Speaking UP was entitled “Fear and futility” https://nationalguardian.org.uk/2023/06/08/fear-and-futility/, whilst its 2024 report found nearly 40% of cases it handles involve inappropriate behaviours. https://nationalguardian.org.uk/2024/07/24/analysis-of-the-2023-nhs-staff-survey/
(2) Health and social care review: leadership for a collaborative and inclusive future. Independent report from General Sir Gordon Messenger and Dame Linda Pollard into leadership across health and social care in England. (2022) https://www.gov.uk/government/publications/health-and-social-care-review-leadership-for-a-collaborative-and-inclusive-future/leadership-for-a-collaborative-and-inclusive-future
(5) NHS staff survey (2023) https://www.nhsstaffsurveys.com
(6) Shore LM, Cleveland JN, Sanchez D. (2018) Inclusive workplaces: A review and model Human Resource Management Review; see also Edmondson, A (2018) The Fearless Organisation: Creating Psychological Safety in the Workplace for Learning, Innovation and Growth. Harvard Business School: Whiley
(7) Dixon-Woods M, Baker R, Charles K, 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 See also M West (2021) (West M (2021) Compassionate Leadership: Sustaining Wisdom, Humanity and Presence in Health and Social Care.
(8) J Dawson (2018) Links between NHS staff experience and patient satisfaction: Analysis of surveys from 2014 and 2015. NHS England
(9) L E Gomez1, Patrick Bernet (2019) Diversity improves performance and outcomes[1] J Natl Med Asso . 2019 Aug;111(4):383-392. See also Lorenzo and Reeves (2018) How and Where Diversity Drives Financial Performance. Harvard Business Review. January 2018.
(10) Juliet Bourke , Andrea Titus (2019). Why Inclusive Leaders Are Good for Organizations, and How to Become One Harvard Business review (March 2019).
(11) Roger Kline, Duncan Lewis (2019) The price of fear: Estimating the financial cost of bullying and harassment to the NHS in England. Public Money and Management Volume 39 2019 Issue 3
(12) Mark Gill James Humphreys Robert Price (2021) Behavioural Insight Research in Temporary Staffing NHS England and Improvement. See also Record revenue for staff agencies supplying NHS (BBC March 24 2023) https://www.bbc.co.uk/news/health-65042658.amp
(13) Kline R, Warmington J. (2024) Too Hot to Handle: why concerns about racism are not heard or acted upon. Brap. https://27aa994b-a128-4a85-b7e6-634fb830ed15.usrfiles.com/ugd/27aa99_9a9468c5e4da43288da375a17092d685.pdf
(14) Rynes, S, Rosen, B. (1995). A field survey of factors affecting the adoption and perceived success of diversity training. Personnel Psychology, 48(2), 247–270.
(15) Michael West. (2015) Leadership and Leadership Development in Health Care: The Evidence Base. The Kings Fund 2015.
(16) See https://www.compassionomics.com/
(17) Kline R (2023) Paradigm lost? Reflections on the effectiveness of NHS approaches to improving employment relations Roger Kline https://bmjleader.bmj.com/content/leader/early/2023/05/17/leader-2022-000729.full.pdf
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