The Mann Review will not help NHS leaders tackle racism

This is a version of an article that first appeared in the Health Service Journal. To read the full article, click here.

Lord Mann’s review into antisemitism and racism in the NHS aims to strengthen accountability and tackle discrimination, but questions remain over whether its recommendations address the deeper cultural issues that continue to affect staff experiences and patient care

NHS leaders have received a “Review into antisemitism and other forms of racism in the NHS” from Lord Mann, commissioned by Wes Streeting. It makes 36 recommendations, some for the Department of Health and Social Care, some for regulators, and some for boards.

Trust chairs, chief executives, and chief people officers I have spoken to have suggested that, at best, this might be an opportunity to push tackling racism up board agendas or at worst, it is a lost opportunity and distraction from what needs to be done.

There are several striking aspects to the review. Not least, it is unclear whether a single chief people officer was consulted.

The review is heavily focused on antisemitism but, without explanation, hardly mentions Islamophobia.

It emphasises overt forms of racism, such as abuse and ostracism, with little attention to the covert forms of racism which are so prevalent in the NHS. As a result, its recommendations are primarily on regulation (one-third of the review) and training, but regulation and training, as proposed, will have little impact on culture.

The review spends many words seeking to define antisemitism, but does not define Islamophobia or racism. Surprisingly, it makes no reference to the new statutory provisions around harassment, which should frame how racism (including antisemitism and Islamophobia) is addressed in the NHS. Moreover, the definition of antisemitism used may well leave leaders (and others) unclear when and if criticism of Israel could be regarded as antisemitic.

Fourth, though the review considers how discrimination may affect patients, it makes almost no mention of how covert (not just overt) discrimination undermines the planning, safety, and care of patients.

The NHS is built on research, but not a single recommendation comes with any evidence base or research explanation of the causes of the problems identified or why what is proposed is likely to make the difference it is intended to.

A shopping list of recommendations

Recommendation one urges the NHS to adopt antiracism principles. However, unless these are an integral part of an evidence-based strategy underpinned by accountability and support, and intentionally led by boards, adoption of such principles easily becomes a tick box.

Recommendation eight states: “Some political identifiers can and do cause distress to patients, and employers should develop local policies to be clear about what is acceptable.” This is likely to consume precious board and management time, be open to legal challenge, and be pointless or worse, given its vagueness.

For example, since a lesbian, gay, bisexual and transgender lanyard might offend some patients or staff, might they be banned? Why would wearing a Palestine or Ukraine badge reasonably cause offence?

Some recommendations, such as board-level oversight of investigations related to racism (recommendation five), should already be underway, as should recommendation seven that “all NHS board members and senior leaders should have explicit, measurable equality, diversity and inclusion objectives embedded within their performance goals”, since this was in the 2023 NHS Equality, Diversity and Inclusion Improvement Plan.

The review spends many words seeking to define antisemitism, but does not define Islamophobia or racism

Recommendation 14 suggests more emphasis on early intervention and resolution, but this should also already be underway, though it crucially fails to mention the real risks of using mediation to tackle issues of racism.

Recommendation 27 says further guidance should be issued to boards on “how, in non-life threatening situations, trusts support staff to refuse access to services (to protect their safety and dignity)”, but it fails to ensure boards address the serious issue of how to respond to patients demanding to choose the ethnicity of their clinician.

Recommendations 32, 34, 35 and 36 set out a requirement for mandatory diversity training, in person for boards and online for 1.5 million NHS staff. The former may have an impact if done seriously, but the latter proposal will be precisely the sort of “sheep dip” which research is so critical of.

Recommendations three and four are the only ones that directly address the covert racism that is so prevalent in the NHS. The review exhorts trusts to use evidence-based action plans, but the only assistance offered is a forthcoming race standard which will be just one-sixth of a composite workforce standard scored within the NHS Oversight Framework and, possibly, improvements to the Care Quality Comission “well led” domain.

This could have been important, but it is unclear what will be scored, what consequences for not making progress might be, and what difference (if any) this will therefore make.

Boards challenges

What elements of the review recommendations will actually become mandatory for boards?

Where boards are not currently engaged in sustained work to tackle racism (including antisemitism and Islamophobia), how can the review prompt them to do so, since the necessity for such work is clear, even though the consequences for performative approaches are so vague?

Board leaders are repeatedly told by national leaders to focus on what has impact, but board leaders serious about tackling racism are likely to “tick the box” on most of the suggestions and instead build on what better trusts are already trying to do.

What national leaders should surely be doing, if this is really a national priority, is systematically sharing best practices and providing a national resource to enable that to happen. Moreover, as one trust chair told me, “national leaders could start by putting their own house in order”.

At best, the review might prompt more board attention to racism of all kinds. At worst, it will be seen as a diversion. The NHS desperately needs to improve its track record on racism, undermining both staff and patient care, but most boards will be sceptical that this review meets this challenge.