The Mann Review on antisemitism and other forms of racism: some initial thoughts

RogerKline
2 days ago
18 min read

Warning. This is a very long blog for which I apologise, but the proposals in the Mann Review deserve serious and critical attention. This is an initial response and does not consider the role of education institutions or regulators but is focussed on some of the proposals impacting employment relations practices.

Introduction

Racism is a dangerous and serious onslaught on NHS staff, on patient care, and on the effectiveness of the NHS. The Mann Review helpfully notes:

One of the most significant reviews of systemic and institutional racism is the Macpherson report (1999) into the racism that led to “failures, mistakes, mis-judgements, and a lack of direction and control” that plagued the investigation into the murder of Stephen Lawrence. Macpherson defined institutional racism in the police as “the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture, or ethnic origin”. He found this in processes, attitudes and behaviour “…which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantage minority ethnic people.

Methodology of the report

The Review rightly references the extensive evidence of racism in the NHS. Unfortunately, its title, in referring to “antisemitism and other forms of racism” contributes to its confusion over what responses best tackle racism including antisemitism.

Firstly, antisemitism is a dangerous and deadly ideology. Those who claim it does not exist in the NHS are looking the other way. But Islamophobia which is just as dangerous and which is espoused by leading politicians and media outlets, got just 15 words in the original announcement of this Review and is again only mentioned in passing in the Review itself giving an impress of a hierarchy of discrimination. The primary focus on antisemitism downplays the importance of Islamophobia and leads to an heavy focus on overt racism and antisemitism and fails to address covert racism effectively.

Secondly, racism is not an example of antisemitism but, rather, antisemitism is a specific form of racism and religious discrimination expressed as hatred towards Jews. The Review title is back to front as NHS England recognised when first announcing the Review in 2025. https://www.england.nhs.uk/long-read/request-for-action-on-racism-including-antisemitism/

Most racism in the NHS is primarily covert. It is rarely admitted. It may not be deliberate. It is likely to result from precisely the “processes, attitudes and behaviour…which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantage minority ethnic people” that the Macpherson report describes and which the Mann Review approvingly quotes. Of course, overt racism exists both from colleagues, from patients and others and certainly impacts staff, but it is less common than the covert racism embedded in many NHS workforce practices. Much of the antisemitism (and potentially Islamophobia) identified by the Mann Review seems more likely to be overt whereas covert racism requires (at least in part) a rather different approach and may only be identifiable through inferences from the wider evidence as explained by the high profiler Michelle Cox case:

Despite the claimant’s grievance about (her line manager’s) conduct, the Tribunal considered that the respondent’s grievance outcome and appeal outcome avoided addressing the reasons for (her) behaviour towards the claimant. They did not draw inferences from the evidence gathered despite, as the Tribunal found there, were many aspects from which inferences could be drawn. In addition, by setting a high bar of needing to see ‘deliberate’ discrimination, the respondent failed to consider the possibility of subconscious discrimination at all. (para 117)

Much (not all) of the sustained discrimination, for example, in career progression or in bullying, harassment and other forms of discrimination is hard to prove in individual cases, even where it is in plain sight in the data and lived experience of staff. But the Mann Review proposals barely touch on how these forms of discrimination should be tackled.

Thirdly, when the Review does address racism (including antisemitism) in general, it emphasises exhortation, training and regulation but does not address how such institutional racism is embedded and why, despite exhortation, a raft of policies, procedures and training, progress in tackling racism has been painfully slow. Without an clear understanding of the causes of NHS institutional racism, the Review struggles to set out a coherent response beyond regulation and exhortation. and its remedies are only partial and indeed in part flawed despite some helpful proposals.

Fourth, throughout the Review any research underpinning of its recommendations is not mentioned. In other aspect of NHS strategy, what is proposed relies on research. After all, if we don’t know why what is proposed has a reasonable likelihood of working, why are we doing it? The Review rightly demands Action Plans with Board and national regulatory scrutiny, but that supposedly happens now, yet as the Review notes it is possible for a Trust to be rated as “good” by the CQC though its WRES data is shocking. Moreover, I cannot recall a single example where NHS England as regulator ever sanctioned a Trust Board where racism was present in plain sight. I doubt many staff have confidence in NHS England or the DH regulating racism in Trusts when their Boards cannot put their own house in order.

Trust responses to racism have prompted an avalanche of largely performative Action Plans, most of which have only the most tenuous link to the research evidence on what works. The reasons for this are not just a lack of courage (though that is a factor in many organisations), or a failure to understand the roots of racism (also commonplace), or that tackling racism (of all kinds) is crucial for patient care, staff wellbeing and organisational effectiveness (see here: https://www.rogerkline.co.uk/post/not-an-optional-extra-the-price-of-not-tackling-race-discrimination-in-the-nhs). The failure exists because:

much of the NHS leadership is in denial or avoids facing up to the crisis around racism
most of the NHS sees tackling racism as a matter of compliance not also improvement and
most organisations have failed to apply the research evidence of what does work and do the hard work applying that research.

There is instead an excessive reliance on (and false assurance from) having policies, procedures, and training (methodological individualism) which research makes clear will simply not, in isolation, change culture or challenge discrimination. https://bmjleader.bmj.com/content/7/4/314

Take recruitment and career progression. Despite hundreds of action Plans, the key WRES metric of the relative likelihood of White staff and Black and Minority Ethnic staff being appointed from shortlisting is worse now than it was in 2015 when it was first measured. NHS England nationally has refused to discuss why this is, and indeed this year, for the first time, stopped publishing its annual WRES data analysis report altogether. Yet the fact that, on average across the NHS, a White member of staff is 1.77 times more likely to be appointed from shortlisting than a BME member of staff means that the cumulative effect is that on average it is 54 (fifty-four) times more likely that a white Band 5 entrant will reach Band 9 than a BME Band 5 entrant. There is no mention in the Mann Review of any alternative strategy to the current failed one that most Trusts currently adopt.

Finally, the Mann Review has one other crucial methodological failing. There is absolutely no mention of the requirement in the new statutory provisions on sexual harassment and other forms of harassment, including racial harassment, that require employers to be proactive, preventative, and require them to undertake anticipatory risk assessments to prevent harassment rather than just responding as issues arise. https://www.equalityhumanrights.com/guidance/sexual-harassment-and-harassment-work-technical-guidance

What needs to happen?

Research tells us why NHS workplace discrimination happens and what to do about it but have systematically failed to act on the research which is clear, for example, on discriminatory recruitment and career progression. https://www.england.nhs.uk/east-of-england/wp-content/uploads/sites/47/2021/10/NHSE-Recruitment-Research-Document-FINAL-2.2.pdf The NHS needs to:

Name the problem
Understand the data
See this as a priority for service improvement, staff wellbeing and organisational effectiveness, not a compliance tick box
Emphasise debiasing processes not just debiasing people
Insert accountability both within employers and onto employers
Ensure the NHS has leaders who model the behaviours we expect of others, make progress on discrimination and workforce culture a personal priority, and stop leaving it to those experiencing discrimination to have the prime responsibility for tackling it.

It works. In the one aspect of staff experience where it has been applied (without any national assistance) the number of disciplinary cases in the NHS had reduced drastically and the gap between the relative likelihood of BME staff compared to White staff entering the disciplinary process has fallen in seven years from 1.54 times more likely to 1.11 times more likely, primarily as a result of the insertion of an accountability nudge (usually in the form of a triage process). This approach was originally suggested here, https://mdxminds.com/2017/12/15/rethinking-disciplinary-action-in-the-nhs/

The Mann Review does adopt some of these principles and that is an important step forward. It introduces

How staff perform on tackling racism becomes monitored within the National Oversight Framework via a new Race Standard
It proposes that race discrimination is more prominently a precondition of being a CQC well-led trust
It seeks to require all leaders to become competent and accountable for making progress on racism
It endorses national standards on how racism is investigated
It supports clarity on refusing care to patients who are racially abusive to staff
It endorses all organisations adopting anti-racism principles

However, the Review falls short of insisting that NHS employers adopt these approaches in evidenced ways. The likely outcome is that the potential for the sustained transformative improvement that is needed, and is possible, will be missed. The following sections suggest what is needed to turn the better recommendations into the prompt for that change. And I explain why some of the proposals are ill-conceived.

Helpful

Investigations

Recommendation 5: there should be board-level oversight of all investigations related to racism through annual reporting on volume, themes, outcomes and timelines, deep-dives into hotspots or repeated patterns, and assurance that recommendations are implemented and monitored. Existing governance systems can also be strengthened.

Comment. This could be helpful, but could be much more helpful if Trust performance on this proposal is subject to support and consequences. A few Trusts already do this. The new NHS Guidance on Investigations and the current national training programme for Trusts on conducting investigations where race and sexual harassment are a factor could enable this. But the Review is silent on what happens if a Board doesn't do this since it is currently neither part of the National Oversight Framework or the CQC Well led domain and is not planned to be.

Recommendation 13: a single national set of policy frameworks should be developed and clearly signposted to support more effective handling and investigation of racial harassment and discrimination. Work should be undertaken to develop the skills and cultural capability to deal with these issues better in trusts, including how they are investigated and staff supported.

“The investigation of racist incidents must be rooted in safeguarding principles, should be in line with the Macpherson principles and must satisfy the requirements of the Equality Act 2010. NHS services often lack the capability to effectively investigate cases of race discrimination. Discrimination can occur in the form of multiple microaggressions that collectively amount to exclusion or ostracism. Investigators may not traditionally understand how to identify, investigate, hold individuals to account and report well. NHS England is currently in the process of developing a national investigatory framework to address this issue, and training has a role to play in this too.”

Comment. These are helpful recommendations but they need to be accompanied by a clear requirement that Trusts adopt the Guidance and implement it. Will this happen?

Recommendation 18: the Department of Health and Social Care, NHS England and the Care Quality Commission should work with the health and care professional regulators to develop a clear, single set of national guidance for employers (in England), clearly defining employers’ responsibilities in tackling discrimination incidents and providing guidance and examples of the types of incidents that may require a regulatory referral, to build consistency.

“Referrals to regulators. Far too often, and increasingly, cases of suspected racist conduct are being referred to regulators - including by third party organisations, rather than staff or patients directly impacted by the actions of a healthcare professional - raising concerns which would be best investigated at the local level in the first instance.”

Comment. Too often that is simply not the case as we found in Too Hot to Handle. Any guidance will require sustained internal governance and external scrutiny but that requires these regulators themselves to meet the standard set by the best Trusts and the national guidance requires local employers to adopt or work towards anti-racism practices that are evidence based.

May be helpful but with flaws (some potentially fatal)

Early intervention and resolution

Recommendation 14: trusts should take into account the relevant Advisory, Conciliation and Arbitration Service (ACAS) code in developing their processes and strongly consider routes for early intervention and resolution. The forthcoming review of the ACAS disciplinary and grievance code should support this.

Comment. Early intervention and resolution done fairly and effectively can be effective ways of minimising grievances and disciplinary processes. However, Trusts must beware assuming mediation should be a default response in cases of discrimination and it should be approached with the greatest caution in such cases as it is likely to reproduce the trauma already experienced. The EHRC Guidance on sexual harassment comes to the same conclusion: https://www.equalityhumanrights.com/guidance/sexual-harassment-and-harassment-work-technical-guidance

Emerging concerns about racism

Recommendation 16: health and care system and professional regulators should establish a taskforce to clarify and reinforce the appropriate mechanisms, including the emerging concerns protocol, for sharing information about local areas of concern, racist incidents, thematic issues related to antisemitism and other forms of racism, and best practice for employers and regulators to address them.

Comment. This should be an extension of the requirement to risk assess all forms of harassment linked to protected characteristics including racial harassment but bizarrely this statutory framework is not mentioned and nor is the EHRC Technical Guidance explaining it.

The rights of staff to not be abused by patients

Recommendation 27: establish national guidance, building on and updating the guidance issued following the 2024 riots, to support organisations when staff face violence or discrimination from patients or the public. This should include clear, context-specific guidance on how, in non-life-threatening situations, trusts support staff to refuse access to services (to protect their safety and dignity

“The NHS Constitution sets out the responsibilities and rights of both patients and staff. In detailing the responsibilities of patients, it is clear in stating that to ‘treat NHS staff and other patients with respect and recognise that violence, or the causing of nuisance or disturbance on NHS premises, could result in prosecution. You should recognise that abusive and violent behaviour could result in you being refused access to NHS services.

“This is reinforced by the NHS standard contract 7.2.3, which confirms that a provider is not required to provide or continue to provide a service to a patient ‘…who displays abusive, violent or threatening behaviour unacceptable to the Provider, or behaviour which the Provider determines constitutes discrimination or harassment towards any Staff or other Service User’, with the provider “in each case acting reasonably and taking into account that Service User’s mental health and clinical presentation and any other health conditions which may influence their behaviour”

Comment. This is very helpful albeit that all Trusts should be doing this now – but some are not. However, it is very surprising and deeply disappointing that the Review does not strongly explicitly insist that Trusts should refuse to agree to a patient demanding a health professional of a specific ethnicity. Such acts of racism are unacceptable. https://blogs.bmj.com/bmj/2020/02/13/roger-kline-what-if-a-patient-wants-to-choose-the-ethnicity-of-their-doctor

Leadership

"We anticipate that the College of Leadership and Management will also play an important role here by supporting greater diversity across all levels of leadership and in supporting the development of diverse talent pipelines towards board level roles). During periods of organisational change, including restructures and redundancies, there should be a clear expectation - underpinned by robust data - that progress on diversity is maintained and not eroded.”

Comment. For that to happen there would need to be:

a sea-change in the determination of leaders to adopt such an approach which has been largely a tick box in too many organisations
an acknowledgement of the failure to ensure that Black and Minority Ethnic staff were not disproportionally impacted both nationally and in ICBs by the redundancy and restructures currently underway, by the appointments of the regional chairs (all White) and by the failure to intentionally intervene by the Boards of NHS England and DH to intervene to prevent this outcome.

NHS England and the DH would need to improve on their inability to respond to the warnings that their restructure and redundancies were likely to disproportionately impact BME staff but their Boards did too little or no nothing with predictable results. https://www.hsj.co.uk/workforce/the-icb-and-nhse-restructure-threatens-the-services-diversity/7040117.article

Evidence based accountability

Recommendation 3 states that “in considering their work to develop robust, evidence-based workforce race equality standard (WRES) action plans, with specific, measurable targets, trusts should ensure they monitor progress against WRES action, applying the ‘explain or reform’ principles for any persistent inequalities

Recommendation 3 will be supported by the introduction of a suite of staff standards to be published in 2026 which will set minimum standards of employment and raise the profile of staff experience following the commitment set out in the 10 Year Health Plan. All standards, including a specific standard on tackling racism, will be measured through a new composite score within the NHS Oversight Framework (NOF) and wider accountability and assurance processes to ensure clear consequences for a lack of action. This will help increase accountability in relation to tackling racism, along with other relevant NHS metrics.

Recommendation 4: NHS boards and leaders should be held accountable for race equality and staff experience metrics, as part of the recently added score in the NHS Oversight Framework (NOF) that will support compliance with the new NHS Staff Standards. The metrics supporting this new NOF score, and trusts’ performance on these, should be made publicly visible.

Comment. Recommendation 3 is what should have happened for the last 11 years but has largely not. The insertion of a new Race Standard within the National Oversight Framework could be significant but will be fundamentally undermined if:

it measures the wrong metrics
it is (disastrously) part of a composite score which will mean Trusts could still score highly overall thanks to progress on access to nutritious food and drink at work; reducing violence against staff; tackling sexual harassment; standards of ‘healthy work’ and occupational health support; and support for flexible working but are hopelessly poor on tackling racism. This is an obvious and likely risk
there are no significant consequences for poor performance on racism and
no serious national support provided to help Trusts improve.

Judgement should be reserved until the Standard is published, but staff will want to know how and when the Race Standard will make the change that is needed after so many years of disappointment. If it is rolled into a single Standard as Mann suggests it will be, it is likely to have minimal impact.

The shortcomings in this approach are compounded by the absence of any sense of adopting an evidence-based strategy not to mention the failure to even mention the proactive, preventative, risk analysis which the new legislation on sexual harassment and other harassment require. Staff will ask why this approach will transform the current failure to tackle covert race discrimination in the NHS.

Good practice

“Trusts exhibiting good practice in relation to EDI and anti-racism, for example the Northeast London NHS Foundation Trust, Mersey Care and Manchester NHS Trust, should be upheld as positive examples for other trusts and regulatory bodies and used to inform models for other organisations.”

Comment. The sharing of good employment relations practice is long overdue in the NHS but it is completely unclear why these three Trusts have been identified as such because their WRES data suggests that they are very average when benchmarked against comparable Trusts. That is not a reflection on work being done in those particular Trusts but it suggests the authors have simply failed to check their WRES data. Putting randomly chosen Trusts up as examples of good practice is not helpful to them or to anyone else.

Senior leaders and EDI

Recommendation 7: all NHS board members and senior leaders should have explicit, measurable equality, diversity and inclusion objectives embedded within their performance goals. Assessment against these objectives should reference the themes in the NHS Race and Health Observatory’s 7 anti-racism principles as a framework for evidencing delivery. There is work in progress to introduce statutory regulation for senior NHS leaders within this Parliament. This will help to increase accountability for NHS leaders, meaning that there is a mechanism in place to disbar those whose conduct falls short of that expected, for example leaders who silence whistleblowers. Regulation is not expected to be in place until 2028.

Comment. This accountability was supposedly the purpose of High Impact Action 1 within the NHS EDI improvement plan. No data has ever been published on this Plan or this metric and no feedback provided to Trusts. NHS England failed to implement it. Unless statutory regulation for managers explicitly makes demonstrable anti-racism a precondition for senior appointments, this risks remaining a performative recommendation.

More generally, Anti-racism Action Plans are essential but there is a serious risk they too may become a performative tick box unless they implement an evidenced strategy and are led with clarity and determination. Signing up to “principles” is easy; acting on them is more challenging.

Unhelpful

Training for all NHS staff

Recommendation 32: the NHS mandatory training module on equality, diversity and human rights - which is accessed by 1.5 million people - requires urgent updating and the specific inclusion of quality assured content on antisemitism and anti-Muslim hostility. Subject matter experts should be consulted as part of the content review and update. Staff should be required to undertake this training, once updated, without delay and not wait until the 3-year cycle renews. This training will be replaced in 2026 with another training framework which must include the aforementioned quality-assured materials. For the NHS and other healthcare services, anti-racism (and cultural competence) training should be mandatory as this will support understanding that underpins locally agreed grievance or disciplinary policies, for example.

Recommendation 34: there must be mandatory training for the approximately 400 chairs and chief executives of NHS provider trusts on antisemitism, anti-racism and building on the Macpherson principles, within the next 6 months.

“Evidence indicates that the development of a holistic approach to training, including continued sessions over time building on initial content to develop expertise, will ensure higher retention and enhanced knowledge, allowing organisations to work towards embedding understanding of racism, including antisemitism into workplace culture and practices,“ This training should support leaders to understand how they can take evidence-based actions to address discrimination and effect change in their organisations, building on NOF and the staff standards”

Recommendation 35: the leaders of the UK health and care system and professional regulators should ensure they undertake similar training, if they have not already done so.

Recommendation 36: the proposed NHS College of Leadership and Management must reinforce the importance of the training elements on antisemitism and other forms of racism and play a major role in embedding expectations and providing access to further, comprehensive training for leaders and manager.

Comment. In a lengthy blog in response to the original announcement of the proposal for mandatory online diversity training, I summarised the research which demonstrates conclusively that online mandatory diversity training as proposed by Lord Mann was ineffective and probably counterproductive. https://www.rogerkline.co.uk/post/online-mandatory-antisemitism-and-racism-training-for-the-nhs-serious-proposal-or-performative-s

Board members may get a gold plated version of such training with sustained face to face involvement but even that will require clarity of how antisemitism is defined - especially ensuring it does not conflate criticism of Israeli policy with antisemitism, However, the other 1.5 million NHS staff will apparently get a “sheep dip” of a couple of hours online mandatory training which will be an utter waste of resources and probably counter-productive. If the “training” mirrors the Mann Report content it risks being lopsided.

Moreover, the content of the training on antisemitism risks being controversial if it follows the approach taken towards those NHS staff who already find themselves accused of antisemitism if they join protests, for example, about Israeli “ethnic cleansing” https://edition.cnn.com/2024/12/02/middleeast/israel-idf-gaza-moshe-yaalon-palestinians-ethnic-cleansing-intland and genocide https://www.ohchr.org/en/press-releases/2025/09/israel-has-committed-genocide-gaza-strip-un-commission-finds in Gaza, or who post support for such protests on social media, or who advertise such events.

Large numbers of British Jews are deeply uncomfortable about Israeli Government actions in Gaza. I am one of them. Any training that directly or indirectly conflates criticism of Israel with antisemitism will be counterproductive and dishonest. Those who blame all Jews for Israeli government crimes are indeed antisemitic. But those who criticise the Israeli government for such crimes are not antisemitic however strongly some of those who are offended by criticism of Israel’s action in Gaza, for example, claim it is.

Expressing support for causes linked to antisemitism or racism

Recommendation 8: some political identifiers can and do cause distress to patients, and employers should develop local policies to be clear about what is acceptable. In order to create an inclusive NHS, upholding the aim of everyone feeling safe to seek and receive care, NHS England should update national uniform guidance, in line with reviewing broader guidelines for those in the NHS using its name, logo or branding, including in relation to social media accounts.

Comment. Section 149 of the Equality Act (2010), means the NHS, as an employer and service provider, has a legal duty to not discriminate against a person on the basis of their protected characteristics. But Recommendation 8 seems impossible to police fairly and runs the serious risk of restricting what NHS staff can say or do even when that may be entirely legal and cannot reasonably be seen as being discriminatory.

For example, would this Recommendation mean that someone whose social media account indicates they work in the NHS not be permitted to use that to criticise genocide or ethnic cleansing in Gaza when it is clear that is happening – or indeed to criticise the murderous attack by Hamas on 7 October 2023? Should someone who supports LGBT rights not be able to wear an LGBT lanyard because it may offend some patients? Would NHS staff taking part in, and sharing pictures of legal and peaceful anti-racist protests be banned since they might upset some racist patients (or indeed staff)? More widely, unless staff are breaching the NHS Constitution why should they not be able to engage in activity that might be deemed “political.” Finally, if NHS staff who volunteer to work in Gaza or other war-torn countries be unable to talk about their experience even if it might clearly be critical of who they hold responsible?

Conclusion

There are some helpful suggestions in this Review which if implemented in an evidence-based way might be a significant step forward, However, the absence of any underpinning research, the way in which potentially helpful proposals (such as using the National Oversight Framework) are greatly weakened by the specifics of what is proposed and the imbalance between proposals on antisemitism, Islamophobia and racism generally, will inevitably lead NHS staff to wonder whether these proposals can really make a transformative improvement that is needed. That concern will be strengthened by the proposals on mandatory online training and “political identifiers” which are seriously problematic as drafted.

The report should be paused to enable a serious discussion to take place rather than stumble into what looks like a shopping list of actions, some of which may be helpful, some of which need radical improvement to become helpful, and some of which are downright unhelpful. Unfortunately, I am already being told by very senior people that they have real reservations but have no intention of raising them with national leaders for fear of the consequences.

Footnote.

This is not the first time Lord Mann and I have disagreed on how to tackle antisemitism. We did so in a landmark Employment Tribunal case on antisemitism in 2012 in which John Mann MP and myself were on opposing sides. The claimants that Lord Mann was a witness for lost all nine elements of their claim, a result which was not appealed and during which the Judge made some closing remarks you might see as relevant to this blog. https://www.rogerkline.co.uk/post/lord-mann-and-antisemitism-from-the-archives

Thank you for reading to the end.