NHS equality, diversity, and inclusion improvement plan

A note on language

In the pursuit of equality, diversity and inclusion, language is powerful and can help to shift attitudes and behaviours. 

This plan acknowledges that some definitions and terminology in legislation do not always reflect the identities or lived experience of individuals. 

Achieving equality of health outcomes requires identification of barriers and biases, and targeted action to overcome specific inequalities, discrimination and marginalisation experienced by certain groups and individuals.

This includes, but is not limited to, those with protected characteristics under the Equality Act 2010[1].

The aim of this plan is to improve equality, diversity and inclusion, and to enhance the sense of belonging for NHS staff to improve their experience.  Therefore, while we refer to the protected characteristics as defined in the Equality Act 2010, the actions set out here are intended to positively impact groups and individuals beyond these terms and definitions. 

We have developed the high impact actions in this plan to be intersectional. This recognises that people have complex and multiple identities, and that multiple forms of inequality or disadvantage sometimes combine to create obstacles that cannot be addressed through the lens of a single characteristic in isolation[2]

Some specific points on language

When referring to ethnicity, we use the term Black and minority ethnic (BME) to be consistent with NHS Workforce Race Equality Standard terminology. 

We use the term ‘disability’ as it is defined in the Equality Act 2010 recognising that the Act’s intention is both positive and protective for disabled people. However, we recognise that ‘disability’ is a dynamic term, within which terms such as ‘neurodivergence’ and ‘neurodiversity’ are emerging and changing, including the relationship between neurodivergence and definitions of disability.

We use the acronym LGBT+ is used in this document, where the ‘plus’ includes all those identities and sexual orientations not specifically referenced. To promote the use of inclusive language, this document uses the terms ‘trans and non-binary’, ‘gender identity’ and ‘sexual orientation’.


The NHS must welcome all, with a culture of belonging and trust. ​We must understand, encourage and celebrate ​diversity in all its forms

NHS People Plan 2020
Amanda Pritchard, Chief Executive, NHS England

Amanda Pritchard, Chief Executive, NHS England

It is our privilege to introduce the NHS’s first equality, diversity and inclusion (EDI) improvement plan. The NHS workforce is more diverse today than at any point in its 75-year history, and that brings benefits for patients and taxpayers alike.

Our NHS is built on the values of everyone counts, dignity and respect, compassion, improving lives, working together for patients, and commitment to quality. These values underpin how healthcare is provided, but must also extend to our NHS workforce.

Staff are at the heart of everything the NHS does, and always will be. To support the recovery of services following the COVID-19 pandemic, we need to increase capacity by growing our workforce and find new ways of working to enhance productivity.

To build for the future, we must inspire new staff to join and encourage existing staff to stay.

Ensuring our staff work in an environment where they feel they belong, can safely raise concerns, ask questions and admit mistakes is essential for staff morale – which, in turn, leads to improved patient care and outcomes[3].

This can only be done by treating people equitably and without discrimination.

An inclusive culture improves retention, supporting us to grow our workforce, deliver the improvements to services set out in our Long Term Plan, and reduce the costs of filling staffing gaps.

Delivering that kind of working environment in an organisation of any size takes deliberate focus, listening and action.

The NHS People Plan sets out the priorities for supporting the 1.3 million people who work in the NHS in England[4], with specific actions for improving their sense of ‘belonging’ in the NHS.  This plan builds on the People Promise and the People Plan, using the latest data and evidence to identify six high impact actions organisations across the NHS can take to considerably improve equality, diversity and inclusion.

It is also right that NHS England holds itself to account to the same standards as the NHS as a whole, and we will be implementing this plan in our organisation.

We would like to acknowledge the contributions, expertise and lived experience shared with us by staff, staff networks, managers and system leaders in the development of this plan, which have provided us with invaluable insights on improving the experience of staff across the NHS.

Dr Navina Evans Chief Workforce, Education and Training Officer, NHS England

Dr Navina Evans Chief Workforce, Education and Training Officer, NHS England

We would also like to acknowledge the inputs from our strategic partners, including the Health and Care Women Leaders Network, the Race and Health Observatory, NHS Employers, NHS Providers, NHS Confederation, and many more.

On behalf of the whole NHS leadership team, we want to thank you for working with compassion, putting our patients and people at the helm and rising to the challenges we face.

We hope this plan provides the framework for making the NHS the best place to work whoever you are, where all staff feel they belong, can thrive, and – ultimately – deliver the best possible service for our patients.


This improvement plan sets out targeted actions to address the prejudice and discrimination – direct and indirect – that exists through behaviour, policies, practices and cultures against certain groups and individuals across the NHS workforce.

It has been co-produced through engagement with staff networks and senior leaders.

The plan:

  • Sets out why equality, diversity and inclusion is a key foundation for creating a caring, efficient, productive and safe NHS
  • Explains the actions required to make the changes that NHS staff and patients expect and deserve, and who is accountable and responsible for their delivery
  • Describes how NHS England will support implementation
  • Provides a framework for integrated care boards to produce their own local plans.

The findings and recommendations of the Messenger Review– Leadership for a collaborative and inclusive future (July 2022) reaffirmed the need for this plan’s actions, which forms part of our response to recommendation two of the review. Future iterations of this plan will address how we tackle EDI challenges within social care, and will be developed in collaboration with integrated care boards (ICBs) and other key stakeholders including the Department of Health and Social Care (DHSC).

The NHS Long Term Workforce Plan will define the size, shape, mix and number of staff needed to deliver high quality patient care, now and into the future. This EDI improvement plan supports the Long term workforce plan by improving the culture of our workplaces and the experiences of our workforce, to boost staff retention and attract diverse new talent to the NHS. The plan also supports the achievement of strategic EDI outcomes, which are to:

  • Address discrimination, enabling staff to use the full range of their skills and experience to deliver the best possible patient care
  • Support the levelling up agenda by improving EDI within the NHS workforce, enhancing the NHS’s reputation as a model employer and an anchor institution, and thereby continuing to attract diverse talents to our workforce
  • Make opportunities for progression equitable, facilitating social mobility in the communities we serve.

These actions should be implemented in partnership with trade unions / staffside colleagues and forums, and in collaboration with staff networks. In line with our operating framework, NHS England will provide guidance to assist trusts and ICBs in adopting an improvement approach to the implementation of this plan, supported by a repository of good practice and a dashboard to enable the measurement of progress.  We will also implement this plan internally to ensure consistency with the NHS as a whole.

The case for change

Where diversity – across the whole workforce – is underpinned by inclusion, staff engagement, retention, innovation and productivity improve. Inclusive environments create psychological safety and release the benefits of diversity – for individuals and teams, and in turn efficient, productive and safe patient care.  

Staff survey and workforce data reflecting the lived experience of NHS staff demonstrates that we have more to do before we can say inclusive workplace environments are the norm across the NHS.[5] For example, women make up 77% of the NHS workforce but are under-represented at senior level.[6]. Just over 24% of the workforce are from black and minority ethnic (BME) backgrounds but face discrimination across many aspects of their working lives The 2022 Workforce Race Equality Standard (WRES) data showed that 27.6% of Black and minority ethnic (BME) staff experienced bullying, harassment or abuse from other staff in the preceding year; The NHS Staff Survey along with the Workforce Disability Equality Standard (WDES) shows that disabled staff in the NHS are under-represented when compared to the general population. The NHS staff survey data shows that 25% of disabled staff have experienced bullying from their colleagues, compared to 16.6% of non-disabled staff. Similarly, 23.5% of our LGBT+ colleagues face bullying and harassment at work compared to 17.9% of heterosexual staff.

Organisational efficiency correlates with staff and patient experience: :

  • Staff who are bullied are less likely and less willing to raise concerns and admit mistakes[7].
  • Increased leadership diversity correlates with better financial performance.[8]
  • In hospital settings, managing staff with respect and compassion correlates with improved patient satisfaction, infection control, Care Quality Commission (CQC) ratings and financial performance.[9]
  • High work pressure, staff perceptions of unequal treatment, and discrimination against staff all correlate adversely with patient satisfaction.[10]
  • A workforce that is compassionate and inclusive for all has higher levels of engagement, motivation and wellbeing, which results in better care and reduced staff turnover.[11] 
  • Fair treatment of every individual in the workforce helps reduce movement of substantive staff into bank and agency roles to avoid discrimination at work. 
  • A diverse workforce that is representative of the communities it serves is critical to addressing the population health inequalities in those communities.[12]
  • Organisations with more diverse leadership teams are likely to outperform their less diverse peers.[13]
  • Psychologically safe work environments, where people feel they are treated with dignity and respect, achieve more effective, safer patient care.[14]

Simply put, a diverse workforce in an inclusive environment will likely improve staff engagement, lower turnover and enhance innovation.  

Elective recovery is a top priority for the NHS[15]. Key to our success is boosting capacity, by filling vacancies, reducing turnover and improving morale[16].  To achieve this stability and to lay the foundations from which to grow the workforce of the future, the NHS must improve staff experience across all protected characteristics if we are to sustainably reduce staff turnover, increase recruitment, reduce absenteeism and create more inclusive and productive teams.

High impact actions

This plan prioritises the following six high impact actions to address the widely-known intersectional impacts of discrimination and bias.

High impact action 1

High impact action 1:

Chief executives, chairs and board members must have specific and measurable EDI objectives to which they will be individually and collectively accountable.

Leaders set the tone and culture of their NHS organisation.  

Leaders who demonstrate compassion and inclusion, and focus on improvements, are key to creating cultures that value and sustain a diverse workforce. Staff will in turn feel more empowered to deliver great care and patient experience.[17] 

As highlighted in the Messenger Review, principles of EDI should be embedded as the personal responsibility of every leader and every member of staff. It is in this context that all chief executives, chairs and board members should have distinct objectives on improving inclusion in their organization and have a personal commitment to mainstream EDI as the responsibility of all, such that the provision of an inclusive and fair culture should become a key metric by which leadership at all levels is judged.

NHS organisations and ICBs must complete the following actions:

  • Every board and executive team member must have EDI objectives that are specific, measurable, achievable, relevant, and timebound (SMART) and be assessed against these as part of their annual appraisal process (by March 2024).
  • Board members should demonstrate how organisational data and lived experience have been used to improve culture (by March 2025).
  • NHS boards must review relevant data to establish EDI areas of concern and prioritise actions. Progress will be tracked and monitored via the Board Assurance Framework (by March 2024).

Success metric for high impact action 1

Annual chair and chief executive appraisals on EDI objectives.​

Board Assurance Framework

Further information and case studies can be found in the EDI repository.  

High impact action 2

High impact action 2

Embed fair and inclusive recruitment processes and talent management strategies that target under-representation and lack of diversity.

We know diverse boards make better collective decisions for the communities they serve.[18] There has been progress in improving diversity of senior management teams; the total number of BME staff at very senior manager level has increased by 69.7% since 2018 from 201 to 341 [19] and the percentage of board members declaring a disability has increased from 2% in 2019 to 4.6% in 2022. However, in relation to the three protected characteristics for which reliable data exists (race, disability and gender); senior teams across the NHS are less representative of their organisation’s workforce. For example, WRES data (31 March 2022) shows that BME people make up 24.2% of the NHS workforce [19] but only 13.2% of board members; 85% of people with a disability do not believe that their trust provides equal opportunities for promotion [20] and women represent 77% of the NHS workforce but only 37% of very senior managers.[21]

Talent management strategies must recognise the importance of equitable recruitment and career progression for all staff. If they do not, the NHS risks losing talent because everyone does not see themselves as having the same opportunity, leading to a direct impact on patient care.

The national ‘Inclusive recruitment and promotion practices framework’[22] highlights the principles for an evidence-driven approach. It supports boards in achieving the aspirations of the Long Term Workforce Plan by addressing workforce vacancies.

NHS organisations and ICBs are to complete the following actions:

  • Create and implement a talent management plan to improve the diversity of executive and senior leadership teams (by June 2024) and evidence progress of implementation (by June 2025)
  • Implement a plan to widen recruitment opportunities within local communities, aligned to the NHS Long Term Workforce Plan. This should include the creation of career pathways into the NHS such as apprenticeship programmes and graduate management training schemes (by October 2024). Impact should be measured in terms of social mobility across the integrated care system (ICS) footprint.

Success metrics for high impact action 2

Relative likelihood of staff being appointed from shortlisting across all posts


Access to career progression, training and development opportunities​

NHS Staff Survey

Year-on-year improvement in race and disability representation leading to parity ​over the life of the plan


Year-on- year improvement in representation of senior leadership (Band 8C and above) ​over the life of the plan


HEE National Education and Training Survey (NETS) Score metric on quality of training


Diversity in shortlisted candidates

To be developed in year two

Further information and case studies can be found in the EDI repository.

High impact action 3

High impact action 3:

Develop and implement an improvement plan to eliminate pay gaps.

As an inclusive employer, the NHS should take steps to address gender, ethnicity and disability pay gaps.  

The gender pay gap in the UK has been declining slowly over time; over the last decade it has fallen by approximately a quarter among full time employees.[23] The pay gap is relatively small for the 88% of NHS staff employed on Agenda for Change (AfC) terms and conditions. However, it is 47% for the 12% of NHS staff who are not, essentially doctors and senior leaders. 

The independent review Mend the gap (2020) describes the actions that the NHS should take to address the gender pay gaps in medicine, such as promoting flexible working for all. Many of its recommendations can also be applied to non-medical senior leaders. For example, for every 80 pence earned by Black female doctors their White counterparts earn £1.[24] In younger age groups, the pay gap favours female doctors, reflecting the large numbers of women joining the NHS, but this reverses between the ages of 30 and 34 and then widens with age.[25] 

Data on organisational ethnicity and disability pay gaps will become available in the coming years.  

NHS organisations are to complete the following actions:

  • Implement the Mend the Gap review recommendations for medical staff and develop a plan to apply those recommendations to senior non-medical workforce (by March 2024).
  • Analyse data to understand pay gaps by protected characteristic and put in place an improvement plan. This will be tracked and monitored by NHS boards. Reflecting the maturity of current data sets, plans should be in place for sex and race by 2024, disability by 2025 and other protected characteristics by 2026.
  • Implement an effective flexible working policy including advertising flexible working options on organisations’ recruitment campaigns. (March 2024)

Success metric ​for high impact action 3

Year-on-year reductions in the gender, race and disability pay gaps

Pay gap reporting

Further information and case studies can be found in the EDI repository.

High impact action 4

High impact action 4:

Develop and implement an improvement plan to address health inequalities within the workforce.

In England, 1 in 19 working age adults is employed by the NHS[26], making NHS organisations one of the largest employers within local communities. 

This creates an opportunity to positively impact population health by addressing health inequalities in the workforce [27]. A proactive approach to reducing health inequalities in the workplace[28] can make a significant contribution to the levelling up agenda[29] within local communities, supporting targets set by CORE20PLUS5[30].

NHS organisations should start by delivering action in two specific areas.

Firstly, reducing bullying, increasing civility, and having a robust approach to all abuse and harassment.  This will address some common causes of ill health, absenteeism and turnover within the workforce which disproportionately impact on those with some protected characteristics, and will improve inclusive team working, staff health and wellbeing.

Secondly, as anchor institutions in local communities, NHS organisations can make a positive impact by offering routes into employment, good work[31] and career development.

Organisations are to complete the following actions:

  • Line managers and supervisors should have regular effective wellbeing conversations with their teams, using resources such as the national NHS health and wellbeing framework. (by October 2023).
  • Work in partnership with community organisations, facilitated by ICBs working with NHS organisations and arm’s length bodies, such as the NHS Race and Health Observatory. For example, local educational and voluntary sector partners can support social mobility and improve employment opportunities across healthcare (by April 2025). 

Success metrics for high impact action 4

Organisation action on staff health and wellbeing.

NHS Staff Survey

HEE National Education & Training Survey (NETS) Separate Indicator Score metric on quality of training


During 2024/25, NHS England will work with ICBs and other key stakeholders to establish a mechanism for measuring improvements in workforce health inequalities

Further information and case studies can be found in the EDI repository.

High impact action 5

High impact action 5:

Implement a comprehensive induction, onboarding and development programme for internationally-recruited staff.

Since its inception in 1948, the NHS has benefitted from the expertise, compassion and commitment of internationally recruited healthcare professionals. A warm welcome and comprehensive induction and pastoral support package will make them feel valued from the start and help retain this staff group. 

NHS organisations should complete the following actions:

  • Before they join, ensure international recruits receive clear communication, guidance and support around their conditions of employment ; including clear guidance on latest Home Office immigration policy, conditions for accompanying family members, financial commitment and future career options (by March 2024).
  • Create comprehensive onboarding programmes for international recruits, drawing on best practice. The effectiveness of the welcome, pastoral support and induction can be measured rom, for example, turnover, staff survey results and cohort feedback (by March 2024).
  • Line managers and teams who welcome international recruits must maintain their own cultural awareness to create inclusive team cultures that embed psychological safety (by March 2024).
  • Give international recruits access to the same development opportunities as the wider workforce. Line managers must proactively support their teams, particularly international staff, to access training and development opportunities. They should ensure that personal development plans focus on fulfilling potential and opportunities for career progression (by March 2024). 

Success metrics ​for high impact action 5

Sense of belonging for internationally recruited staff ​

NHS Staff Survey

Reduction in instances of bullying and harassment from team/line manager experienced by (internationally recruited staff).​

NHS Staff Survey

Further information and case studies can be found in the EDI repository.

High impact action 6

High impact action 6:

Create an environment that eliminates the conditions in which bullying, discrimination, harassment and physical violence at work occur.​

Bullying and harassment at work results in increased sickness absence and employee turnover, diminished productivity, sickness presenteeism, governance and employee relations costs. Workplace bullying therefore adversely impacts patient safety.

In the 2022 NHS Staff Survey 18.7% of NHS staff reported they had experienced bullying by colleagues, 11.1% by line managers and 27.8% by patients or their relatives. These statistics are consistently higher for people with some protected characteristics, and particularly those with a disability or and in the LGBT+ community.[32] 

Staff who are bullied in the workplace are less likely to speak up and to admit mistakes, and therefore are less likely to contribute to effective team working. Bullying affects bystanders and witnesses too,[33] eroding psychological safety within the workplace culture.[34] 

Relying on local policies to prevent bullying or discrimination is not enough. A proactive, preventative approach that seeks early informal intervention wherever possible is more likely to be effective, with escalation only where that fails. 

NHS organisations are to complete the following actions:

  • Review data by protected characteristic on bullying, harassment, discrimination and violence. Reduction targets must be set (by March 2024) and plans implemented to improve staff experience year-on-year. 
  • Review disciplinary and employee relations processes. This may involve obtaining insights on themes and trends from trust solicitors. There should be assurances that all staff who enter into formal processes are treated with compassion, equity and fairness, irrespective of any protected characteristics. Where the data shows inconsistency in approach, immediate steps must be taken to improve this (by March 2024).
  • Ensure safe and effective policies and processes are in place to support staff affected by domestic abuse and sexual violence (DASV). Support should be available for those who need it, and staff should know how to access it. (By June 2024)
  • Create an environment where staff feel able to speak up and raise concerns, with steady year-on-year improvements. Boards should review this by protected characteristic and take steps to ensure parity for all staff (by March 2024).
  • Provide comprehensive psychological support for all individuals who report that they have been a victim of bullying, harassment, discrimination or violence (by March 2024).
  • Have mechanisms to ensure staff who raise concerns are protected by their organisation.

Success metrics for high impact action 6

Year-on-year reduction in incidents of bullying and harassment from line managers or teams.​

NHS Staff Survey

National Education and Training Survey (NETS) bullying and harassment score metric (NHS professional groups)

NETS survey data

Year-on-year reduction in incidents of discrimination from line managers or teams.

NHS Staff Survey

Further information and case studies can be found in the EDI repository.

Making change happen

As England’s largest employer, the NHS must lead the way in establishing equitable and inclusive workplace environments. 

The key change management principle guiding this work is that EDI is everyone’s business – our leaders set the tone and culture, but we all have a role to play. Progressing the EDI agenda requires not only a change in systems and processes, but also cultures and behaviours.  

NHS leaders, specifically chairs and chief executives, must lead by example and demonstrate that they are committed to creating an EDI environment for their workforce. Board members should collectively and individually decide what support and development they require to confidently lead this complex and challenging agenda.  

We expect NHS employing organisations to implement the six high impact actions. They should be confident in explaining to their workforce – especially leaders, HR professionals and line managers – the rationale for this work and what is expected of individuals and teams. Using the repository of good practice, organisations should identify suitable interventions for local implementation, based on local context and conditions. NHS England will support this by collating and disseminating best practice.  

Accountability is important for setting clear expectations, coupled with a focus on learning and improvement. NHS England, ICB and provider accountabilities and responsibilities for delivery of the NHS EDI improvement plan follow the principles set out in the NHS Operating Framework and are outlined in the table below. NHS England will provide regulatory accountability and oversight through existing mechanisms, such as the NHS Oversight Framework, and the CQC through the well-led domain of the single assessment framework, which is being refreshed to include a review and assessment of EDI in organisations. 

Measurement of progress is critical to guide targeted action. Progress should be measured at organisation and system level to inform delivery, and will be monitored by NHS England to inform the support we provide. 

Delivery of high impact actions and interventions by protected characteristic at trust level. ​ Measure progress against success metrics consistently within the organisation.

Engagement with staff and system partners to ensure that actions are embedded within the organisation. ​

Effective system working and delivery to ICS strategies and plans​

Compliance with provider licence, Care Quality Commissions standards and professional regulator standards.
Effective system leadership overseeing NHS delivery of EDI improvement plan, ensuring progress toward achievement of high impact actions and Long-Term Plan priorities.​

Ensuring delivery of ICB statutory functions of arranging health services for its populations and compliance with statutory duties.

Measure progress against success metrics consistently and coordinate a system view.

Compliance with Care Quality Commissions assessment frameworks.


Primary interaction between national and systems​

Translate national policy to fit local circumstances, ensuring local health and workforce inequalities are addressed​

Agree ‘local strategic priorities’ with individual ICSs and provide oversight and support.

Measure progress against success metrics consistently and coordinate a regional view.
Set expectations for equality and inclusion through the NHS EDI improvement plan ​

With regions, facilitate supportive interventions to implement the high impact actions, improve EDI performance and outcomes​

Measure progress against success metrics consistently and coordinate a national view. ​

Support from NHS England

We will work alongside systems and organisations to support the delivery of the NHS EDI improvement plan.  

A national EDI repository

We will create a repository of good practice on the FutureNHS platform to share examples of what is working in the NHS and in other public and private sector organisations. This will help prevent duplication of effort and promote learning. The repository will be continually updated and include: 

  • case studies from organisations
  • practical toolkits and resources 
  • the latest research and evidence.

A national EDI dashboard 

A national dashboard of key EDI metrics is being developed and will be available in the coming weeks by region, within ICBs and within similarly benchmarked trusts. This will enable local organisations and NHS England to monitor progress, identify challenges and assist peer-to-peer learning alongside the EDI repository. It will incorporate relevant education and training metrics, created by Health Education England.  

There is currently a range of EDI information datasets and we intend the dashboard to provide one source of information that both organisations and regulators, such as the CQC, can use to track the impact and outcomes of the NHS EDI improvement plan. 

In developing the dashboard, we are conscious that there are limitations on the availability of datasets for certain protected characteristics, such as for transgender colleagues. . Furthermore, the declaration rates on the Electronic Staff Record (ESR) for certain characteristics are not a true reflection because the available options, for example, do not reflect that Judaism is a religion and Jewish an ethnic identity. We will continue to work with DHSC and other external stakeholders to harmonise and expand the quality and extent of datasets as we engage with DHSC’s Unified Information Standard on Protected Characteristics (UISPC) programme.  

We are committed to updating the dashboard with new and refreshed datasets as they become available. 


Reliable, consistent and timely data is crucial to effective progress. There are significant differences in the range and quality of data held for the protected characteristics. This is reflected in the sections for each protected characteristic. In 2023/24, NHS England will seek to improve the range and quality of data, working with DHSC and other partners. So, for example, with the addition of a question to the NHS Staff Survey, data is now available on whether staff are internationally trained. In addition, NHS England will seek to develop a new mandated workforce standard on gender identity (gender/sex) and sexual orientation.         

Review and evaluation

Sustained improvement is central to this NHS EDI improvement plan. Trusts and ICBs will want to adopt implementation approaches that include learning. NHS England will evaluate progress, particularly on the high impact actions, in years 2 and 5 of the plan, to understand the plan’s impact in transforming culture to engender a sense of belonging in the NHS across the workforce, and what does and does not work to inform changes to our approach. 

Interventions by protected characteristic

The interventions in the table below address the negative experiences of staff with individual protected characteristics, as defined in the Equality Act 2010. They supplement the intersectional high impact actions and suggest how organisations can go further in specific areas. To inform implementation and prioritisation of their actions, organisations should use robust datasets for each protected characteristic. It is important to note that no person is only one protected characteristic, and so organisations should consider the impact of intersectionality, when implementing these interventions. 

The 9 protected characteristics as defined in the Equality Act 2010 are:

  1. Age
  2. Disability
  3. Race
  4. Religion or belief
  5. Sex
  6. Pregnancy and maternity
  7. Sexual orientation
  8. Gender reassignment
  9. Marriage and civil partnership

Engagement with staff networks informed the decision to combine some protected characteristics who face similar challenges in the workforce. To this end, gender reassignment and sexual orientation are covered together. Similarly, pregnancy and maternity are incorporated into the sex protected characteristic. The following section does not include specific interventions on the protected characteristic of marriage and civil partnership because the available evidence does not currently suggest that there is a need for a national focus on this protected characteristic from a workforce perspective, however this will be kept under review.

Case for change


As the largest employer in the country, all NHS organisations should create an age inclusive culture which addresses the needs of staff from pre-employment to post–retirement. Discrimination against both younger and older workers has been identified in the application and selection processes[35]. The NHS has an ageing workforce across all professions with over 41% of NHS staff now aged 45 years and over[36]. We must proactively seek to retain the skills, experience and knowledge of NHS staff close to retirement.


Successive reports of the Workforce Disability Equality Standard (WDES) and NHS Staff Survey show that more must be done to achieve parity of experience and outcomes for staff with a disability, in areas such as bullying and harassment and formal capability processes.


The 2022 WRES data report for NHS trusts provides evidence that race discrimination continues to impact every aspect of the working lives of BME staff. This discrimination has an impact on the long term physical[17] and mental health[18] of our workforce contributing to structural health inequalities[19]

Religion or belief

Religious identity is an often overlooked area in the NHS.[37] Approximately two-thirds of our 1.3 million people working in the NHS declare a religion or belief. NHS Staff Survey data shows that staff from all faiths experience discrimination based on their religion or belief, and this is highest against Muslim and Jewish colleagues.[38] Recent data highlights increasing levels of antisemitism in wider society, as well as discrimination against Sikhs and other faiths, and this is likely to be reflected among NHS staff.[39]  


77% of the NHS workforce are women, so addressing sex discrimination must be a key focus for organisations. The discrimination is multifaceted –  bias in recruitment and career progression and contributing to the gender pay gap, under-representation within senior leadership teams, sexual harassment and inflexible working practices – and may deter potential recruits or force talented women to leave the NHS.[40] 

Elimination of the gender pay gap would bring social economic benefits as would likely lower poverty rates among women and reduce the gender gap in old age pensions. Government’s Women’s Health Strategy for England reports a strong correlation between the lack of support for, and understanding of, how women’s health affects their experience in the workplace including progression, retention and productivity levels. 

Pregnancy and maternity 

There is a growing evidence that the protected characteristic of pregnancy and maternity is associated with poor employment outcomes and health inequalities, and health-related outcomes may be poorer as a result of pregnancy and maternity. Additionally, in a survey of over 6,000 women and employers, over three-quarters of mothers reported negative or possibly discriminatory practices during pregnancy, maternity and/or on their return to work.[41] 

Women also experience specific inequalities in relation to the menopause.  

It is important to acknowledge that trans, non-binary and intersex staff may also experience inequalities in relation to pregnancy and menopause and may require specific support during these times. The CQC’s Maternity Survey reported that trans respondents experienced inequalities,  including in to how they were communicated with during labour and birth, their length of hospital stay after giving birth and the information and care they received after leaving hospital.[42][43] 

The recommended interventions to address this inequity are similar for colleagues of one or both protected characteristics and have been reflected as such in this document.

Gender reassignment and sexual orientation

LGBT+ staff are more likely to face discrimination from their colleagues and patients,[44] andthis can have a detrimental impact on their health.[45] 

The ‘plus’ within the term LGBT+ acts to include those identities and sexual orientations not specifically referenced. However, we recognise that this group is diverse and their lived experience is varied.  

A significant barrier in understanding the experiences of LGBT+ staff is the absence of complete and accurate data. The DHSC Unified Information Standard for Protected Characteristics (UISPC) programme is considering the current data limitation within the ESR with respect to LGBT+ staff declarations. NHS England is working with DHSC and other key stakeholders to expand the workforce data currently available on ESR to make it accurate and representative.  

Protected characteristic: Age

InterventionsCorresponding high impact actions
Line managers should have meaningful conversations with their teams, to align personal aspirations with job roles and requirements. This should include the option of phasing retirement and exploring alternative work patterns.


Organisations should encourage flexible working as part of local attraction, recruitment, retention and return plans. The plan should embed the NHS Pension Scheme and highlight its value across the career journey, with special focus on flexible retirement for staff in late stage careers.


NHS organisations should work in partnership with local educational institutions and voluntary sector partners to support social mobility by improving recruitment from local communities, and by considering alternative entry routes to the NHS, such as apprenticeships and volunteering.

2, 4

Protected characteristic: Disability

InterventionsCorresponding high impact actions
Demonstrate year-on-year improvement in disability declaration rates so that ESR data is accurate about people with a disability, as measured by the WDES.all
Promote the visibility of leaders with a disability through effective campaigns alongside providing leadership and career development opportunities tailored to disabled staff, such as the Calibre Leadership programme[46] or Disability Rights UK[47] development programmes. Progress can be measured by tracking the number of disabled staff in leadership roles. 2
Implement recommendations from the inclusive recruitment and promotion practices programme, and ensure each stage of the recruitment pathway is accessible, does not discriminate and encourages people with disabilities to apply for roles in the NHS. This can be tracked via the WDES, using Trac data. 2
Commissioners and providers of talent management and career development programmes must ensure that these are fully accessible and inclusive. Progress can be measured by tracking the number of Disabled people in leadership roles.2
NHS organisations should take steps to address the disproportionate levels of bullying and harassment experienced by disabled staff. Progress can be measured from NHS Staff Survey results. 6
NHS organisations should ensure that their reasonable adjustments policy is effectively and efficiently implemented and achieves year-on-year improvement in NHS Staff Survey metrics relating to reasonable adjustments at work.  2,4

Protected characteristic: Race

InterventionsCorresponding high impact actions
Boards should be able to demonstrate their understanding of and progress towards race equality, an essential criterion in job descriptions for board members and all very senior manager (VSM) grades. Appraisals of senior executives will include a focus on EDI, as recommended by the Messenger Review.
Board will use the EDI dashboard to establish internal data driven accountability and scrutinise progress at an organisational, divisional, departmental, occupation, and site level to address under-representation and pay gaps.
To tackle race discrimination effectively boards must give due consideration to national policies and recommendations from other arms length bodies such as the Equality and Human Rights Commission inquiry[48] and General Medical Council[49]. In addition, boards must proactively raise awareness of their commitment with patients and public. 
Boards should ensure concerns raised about race discrimination are dealt with in a proactive, preventative, thorough and timely manner, including encouraging diversity in Freedom to Speak Up Guardians[50].

Protected characteristic: Religion or belief

InterventionsCorresponding high impact actions
ESR and qualitative data should be tracked to highlight the experience of people with different faiths or no faith through all stages of the employment journey. For example, NHS organisations can track turnover data by religion to identify and address trends.  all
NHS organisations should review their policies and processes to ensure they are supportive of religious expression in the workplace. This includes access to facilities for prayer, understanding of cultural differences, including religious clothing, and flexibility around religious observances such as the Sabbath and Ramadan.  all
Boards should ensure concerns raised about religious discrimination are dealt with in a proactive, preventative, thorough and timely manner, including by encouraging diversity in Freedom to Speak Up guardians[50].6

Protected characteristic: Sex and pregnancy and maternity

InterventionsCorresponding high impact actions
NHS organisations to focus on closing the gender pay gap and improving the experiences of the lowest paid people, extending the Mend the gap review recommendations for medical workforce to the wider workforce.  2,3
NHS organisations should ensure that their flexible working policy is easily accessible and suitable for all their staff; supporting their work–life balance, management of caring responsibilities, health and wellbeing, and enabling continued professional development. 2
NHS organisations are encouraged to adapt NHS England’s policy on menopause awareness as applicable to their local workforce. They should also adopt and implement the Supporting our NHS people through menopause: guidance for line managers and colleagues. This will ensure they fully support colleagues experiencing menopause, maximising their wellbeing and allowing them to work for as long as they wish to contribute. all

Protected characteristic: Gender reassignment and sexual orientation

InterventionsCorresponding high impact actions
Where colleagues feel comfortable, actively encourage LGBT+ staff to self-declare their sexual orientation on ESR and TRAC, emphasising how this can improve the experiences of LGBT+ staff. We recognise that national changes to ESR must be made before trans and non-binary staff are able to do so. all
Review organisational data for LGBT+ staff across multiple sources such as ESR, TRAC, NHS Staff Survey and local qualitative and quantitative data from LGBT+ staff networks and communities. This will inform the key areas of concern that need to be addressed.  all
Organisations to ensure that diversity training on gender reassignment and sexual orientation is included within mandatory training.1
Executive teams within the organisations should actively talk about the benefits of allyship as well as champion, and sponsor LGBT+ staff networks. They should also build the concept of allyship into existing and new development programmes.1
Organisations to ensure that LGBT+ staff are closely involved in the development and delivery of its LGBT+ training and educational interventions and its health & wellbeing programmes so that these are fully inclusive.all


Our organisations must be more inclusive and our leadership more diverse. We have an obligation to improve the experience of staff so that they feel like they belong. This plan articulates meaningful action to transform the lived experience of our staff and realise the benefits that we know come from greater equality, diversity and inclusion.

There is a wealth of evidence that shows having a diverse workforce and making sure everyone feels part of a team delivers the best care for patients.

It is the job of NHS leaders to ensure we deliver, taking an active role in ending all forms of discrimination, role-modelling inclusive behaviours and creating an environment in which our workforce feel safe and empowered. But everybody has a role to play supporting, encouraging and promoting inclusion.


[1] Equality, diversity and inclusion in the Workplace | Factsheets | CIPD

[2] Using intersectionality understand structural inequality Scotland evidence synthesis (www.gov.scot)

[3] West M (2021) Compassionate Leadership: Sustaining Wisdom, Humanity and Presence in Health and Social Care

[4] Hemmings, N et al (2021) Attracting, supporting and retaining a diverse NHS workforce  https://www.nuffieldtrust.org.uk/files/2022-10/1636121852-nhs-workforce-diversity-web.pdf https://www.nuffieldtrust.org.uk/files/2022-10/1636121852-nhs-workforce-diversity-web.pdf

[5] Cambridge Dictionary definition for ‘lived experience’ – the things that someone has experienced themselves, especially when these give the person a knowledge or understanding that people who have only heard about such experiences do not have.

[6] NHS Confederation (2020) Action for Equality: the time is now https://www.nhsconfed.org/system/files/media/Action-for-equality-the-time-is-now_4.pdf

[7] Lucian L Leape , Miles F ShoreJules 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.

[8] Gomez LE, Bernet P (2019) Diversity improves performance and outcomes. J Natl Med Asso 111(4): 383-392. doi: 10.1016/j.jnma.2019.01.006. Epub 2019 Feb 11. https://pubmed.ncbi.nlm.nih.gov/30765101/

[9] Dixon-Woods M, Baker R, Charles K, et al (2014) 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 West M (2021) Compassionate leadership: sustaining wisdom, humanity and presence in health and social care.

[10] Dawson J (2018) Links between NHS staff experience and patient satisfaction: Analysis of surveys from 2014 and 2015 links-between-nhs-staff-experience-and-patient-satisfaction-1.pdf (england.nhs.uk); see also West M (2021) Compassionate leadership: sustaining wisdom, humanity and presence in health and social care.

[11] West M (2021) Compassionate leadership: sustaining wisdom, humanity and presence in health and social care and King’s Fund (2022) What is compassionate leadership.

[12] Public Health England (2021) Addressing health inequalities through collaborative action. Briefing note.

[13] Gomez LE, Bernet P (2019) Diversity improves performance and outcomes[1] J Natl Med Asso 111(4): 383-392. doi: 10.1016/j.jnma.2019.01.006. Epub 2019 Feb

[14] Edmondson A (2018) The fearless organisation: creating psychological safety in the workplace for learning, innovation and growth. Harvard Business School: Whiley

[15] NHS England (September 2022) NHS delivers on elective recovery plan with progress on treatment and tests. https://www.england.nhs.uk/2022/09/nhs-delivers-on-elective-recovery-plan-with-progress-on-treatment-and-tests/

[16] National Audit Office (2022) Managing NHS backlogs and waiting times in England

[17] Ashikali T, Groeneveld S, Kuipers B (2021) The role of inclusive leadership in supporting an inclusive climate in diverse public sector teams. Review of Public Personnel Administration 41(3): 497–519. https://doi.org/10.1177/0734371X19899

[18] NHS Improvement (2018) NHS provider board membership: survey and findings. https://www.england.nhs.uk/1sthi5thew4y/wp-content/uploads/sites/54/2020/08/NHSI_board_membership_2017_survey_findings_Oct2018a_ig.pdf

[19] NHS England » NHS Workforce Race Equality Standard (WRES) 2022 data analysis report for NHS trusts

[20] Statistics » NHS Staff Survey in England

[21] Narrowing of NHS gender divide but men still the majority in senior roles – NDRS (digital.nhs.uk)

[22] NHS Employers (2021), Inclusive recruitment: Leading positive change.

[23] Appleby J, Schlepper L (2019) The gender pay gap in the English NHS. Analysis of some of the underlying causes.

[24] UK Government (2019) NHS basic pay. Ethnicity facts and figures

[25] Mend the Gap: The Independent Review into Gender Pay Gaps in Medicine in England – December 2020 (publishing.service.gov.uk)

[26] See endnote reference 1

[27] Public Health England (2015) Local action on health inequalities: Promoting good quality jobs to reduce health inequalities https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/460700/2a_Promoting_good_quality_jobs-Full.pdf

[28] Ten Ways businesses can help to reduce inequalities. Infographic. NHS England. https://www.england.nhs.uk/wp-content/uploads/2022/01/10-ways-businesses-can-reduce-health-inequalities-infographic-1.pdf

[29] UK Government levelling up the United Kingdom

[30] NHS England » Core20PLUS5 – An approach to reducing health inequalities for children and young people

[31] The CIPD (2019) describes good work as follows: Good work is fairly rewarded. Good work gives people the means to securely make a living. Good work gives opportunities to develop skills and a career and ideally gives a sense of fulfilment. Good work provides a supportive environment with constructive relationships. Accessed 05.12.22: https://www.cipd.co.uk/Images/uk-working-lives-summary-2019-v1_tcm18-58584.pdf

[32] Statistics » NHS Staff Survey in England

[33] Statistics » NHS Staff Survey in England

[34] Edmondson A (2018) The fearless organisation: creating psychological safety in the workplace for learning, innovation and growth. Harvard Business School: Whiley

[35] (2021) Good Recruitment for Older Workers: An Employers Guide. https://ageing-better.org.uk/sites/default/files/2021-10/GROW-a-guide-for-employers.pdf

[36] NHS Digital. NHS Workforce statistics March 2022:  https://digital.nhs.uk/data-and-information/publications/statistical/nhs-workforce-statistics/march-2022

[37] Héliot YF (2020). Religious identity and working in the NHS. NHS Employers

[38] King’s Fund (2015) Making a difference to diversity and inclusion in the NHS

[39] https://commonslibrary.parliament.uk/research-briefings/cbp-8537/

[40] Government Equalities Office (2019) Gender Equality at Work: Research on the Barriers to Women’s Progression

[41] Pregnancy and maternity-related discrimination and disadvantage: summary of findings (publishing.service.gov.uk)

[42] LGBT Foundation – Revealed: Improving Trans and Non-binary Experiences of Maternity Services (ITEMS) report

[43] https://www.cqc.org.uk/publication/surveys/maternity-survey-2022

[44] Statistics » NHS Staff Survey in England

[45] https://www.kingsfund.org.uk/blog/2021/04/supporting-lgbtq-nhs-staff

[46]Details on the Calibre Disabled Leadership Programme as at December 2022: https://www.ossiesway.com
[47] Details on the Disability Rights UK Leadership Programme as at December 2022  https://www.disabilityrightsuk.org/how-we-can-help/leadership

[48] Report finds evidence of inequality in treatment of ethnic minority ‘Covid heroes’ working in health and social care | Equality and Human Rights Commission (equalityhumanrights.com)

[49] Racism in the workplace – GMC (gmc-uk.org)

[50] Kline R, Somra G (2021) Difference matters: The impact of ethnicity on speaking up (National Guardian Office)