You can access a full version of this WRES report in Word, including detailed data breakdown.

Foreword

The NHS is about people – the patients we care for, their families and loved ones and of course, the people who work in it.

Our NHS workforce is the foundation – we are 1.6 million strong, 350 professions and disciplines, backgrounds and different nationalities.

Every individual, irrespective of their background, enriches the NHS with distinctive skills, which support the NHS to deliver exceptional care and services for all.

This Workforce Race Equality Standard 2023 report is a snapshot of where NHS trusts and foundation trusts in England are today on addressing race inequalities.

There is continued evidence of ongoing and sustained improvement since 2016 across the indicators that measure representation, shortlisting to appointment and continuous development. It also highlights areas where there is more to be done to address existing discrimination. Inequalities in any form are at odds with our NHS values.

The overview of the regional variations in experiences presents an opportunity to consider steps that can be taken to raise all regions to similar levels of improvement. It is through shared learning and collaboration, that we envisage continued improvement in the coming years.

To ensure we retain the talents we have and continue to attract more people to join our workforce,  that is why NHS England has published the first ever equality, diversity and inclusion plan for the NHS.

The six high impact actions aim to ensure our staff work in an environment where they feel they belong, can safely raise concerns and provide the best possible care to our patients. Great patient care starts with caring for our staff.

The NHS Long Term Workforce Plan focuses on the future size, shape, mix and number of staff needed in all parts of the country to deliver high quality and productive care in the future. To meet these ambitions, we must improve the experience of our workforce, thereby improving retention and attracting new talent drawn from the widest pool to the NHS.

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

Key findings

• in March 2023, 26.4% (380,108) of the workforce across NHS trusts in England were of a black and minority ethnic (BME) background. This is an increase of 13% (43,070) from 2022
• the total number of BME staff at very senior manager (VSM) level has increased by 61.7% since 2018 from 201 to 325. The percentage representation of BME staff at VSM level has increased from 10.2% to 11.2% over the past year
• at 76% of NHS trusts, white applicants were significantly more likely than BME applicants to be appointed from shortlisting, higher than the 71% last year
• just 39.3% of staff from a black background believed their trust provides equal opportunities for career progression or promotion, with levels below those of other ethnic groups since at least 2015
• white Gypsy or Irish Traveller women (39.0%) and men (45.7%) experienced the highest levels of harassment, bullying or abuse from other staff
• in 2022, the percentage of staff experiencing harassment, bullying or abuse from other staff in the last 12 months was higher for BME staff (27.7%) than for white staff (22.0%). Although disparities between the experiences of BME and white staff persist, harassment, bullying and abuse from staff has followed a largely downward trend since 2018
• in 2022, a higher percentage of BME staff (16.6%) than white staff (6.7%) experienced discrimination from other staff; a pattern that has been evident since at least 2015
• in 2022, a lower percentage of BME staff (46.4%) than white staff (59.1%) felt that their trust provides equal opportunities for career progression or promotion

WRES indicator 1

Percentage and number of staff in NHS trusts by ethnicity

In March 2023, 26.4% of the workforce across NHS trusts came from a BME background (380,108 people).  Across all NHS trusts there were 144,750 more BME staff in 2023 compared to 2018 (equating to a 61.5% increase). Over the same period, the number of white staff increased by 53,279 (equating to a 5.7% increase).

Percentage and number of staff in NHS trusts by ethnicity; regional breakdowns

London had the highest percentage of BME staff at 52.1%, whilst the South West had the lowest percentage of BME staff at 15.0%.  About a third of all BME NHS staff (33.2%) work in the London region; whilst, just over a sixth of the overall NHS workforce in England (16.8%) is situated in London.

Percentage representation by ethnicity at each AfC pay band, for staff in NHS trusts

The largest representation of BME staff is at Agenda for Change (AfC) band 5 at 38.5%.  BME representation reduces at higher bands with the lowest representation of 11.2% at AfC band 9 and at the very senior manager (VSM) level. Overall, 4.4% of staff did not disclose their ethnicity, down from a high of 4.7% in 2019.  At VSM level, 6.0% of staff did not disclose their ethnicity.  Given that just 11.2% of staff identify as being from a BME background at VSM level, a non-disclosure rate of 6.0% adds a large margin of uncertainty regarding the actual level of BME representation in the most senior roles.

Percentage representation by ethnicity at each AfC pay band, amongst non-clinical staff in NHS trusts

In non-clinical roles, BME representation was at 17.3% overall.  BME representation peaked at 19.8% at AfC band 6.  BME staff were underrepresented at AfC band 8a (16.5%) and above, with BME representation falling to a low of 10.7% at the very senior manager level.

Percentage representation by ethnicity at each AfC pay band, amongst clinical staff outside of doctors, in NHS trusts

In clinical roles outside of medicine, BME representation was at 26.9% overall.  The clinical workforce can be considered in two sections.  Staff at AfC band 4 and under include health care support workers and nursing assistants.  Whilst staff at AfC band 5 and above include mainly registered nurses, alongside other staff such as physiotherapists, psychologists and pharmacists.  BME representation was highest at clinical AfC band 5 (41.6%) which is the base grade for registered nurses. BME representation above AfC band 5 falls dramatically to 23.0% at AfC band 6 and 17.8% at AfC band 7, pay bands that include charge nurses and nurse managers.

Percentage representation by ethnicity and level of seniority for doctors in NHS trusts

Within medicine, BME representation was at 46.8% overall.  BME representation peaked in non-consultant specialist grades at 61.0%, falling to 40.5% amongst consultants, and falling further to 34.7% amongst senior medical managers.

Race disparity ratios

The race disparity ratio is a summary measure of the representation of BME staff across the AfC pay bands, compared with white staff. The workforce on AfC pay bands is considered at three levels: lower, bands 5 and below; middle, bands 6 and 7; and upper, bands 8a and above. Three measures of progression are considered: from lower to middle bands, from middle to upper bands, and from lower to upper bands.  A ratio of one indicates parity of progression, and values higher than one reflect inequality, with a disadvantage for BME staff.  In non-clinical roles, the gap between BME and white representation has been decreasing each year in terms of the lower to upper levels.  However, in clinical roles (outside of medicine), the gap between BME and white progression has been widening over the past four years, particularly in terms of the lower to middle and lower to upper levels.

There were regional variations in the race disparity ratios. Race disparity ratios were higher, and inequality greater, in clinical roles where the particular issue is with progression from AfC band 5 to band 6 and above.  The highest levels of disparity were seen in the London and South West regions, respectively the regions with the largest and smallest levels of BME representation. These two regions have at least a four-fold disparity in the representation of clinical BME staff at higher bands compared to the lower bands.

WRES indicator 2

The relative likelihood of white applicants being appointed from shortlisting compared to BME applicants

At 76% of NHS trusts, white applicants were significantly more likely than BME applicants to be appointed from shortlisting, an increase from 71% last year.  Trends differ between regions, with year-on-year improvements in the North West, progressive deterioration the North East and Yorkshire region, and marked improvement in the East of England. Recruitment from interview remains the most difficult to change metric, with the national likelihood ratio remaining broadly unchanged since the inception of the WRES in 2015/16.

WRES indicator 3

The relative likelihood of BME staff entering the formal disciplinary process compared to white staff

At 46% of NHS trusts, BME staff were over 1.25 times more likely than white staff to enter the formal disciplinary process, a modest improvement from 47% last year.  The London region performed persistently worst on this indicator, although improvements have been made over the past two years.

WRES indicator 4

The relative likelihood of white staff accessing non–mandatory training and CPD compared to BME staff

For all regions the indicator fell within the non-adverse range of 0.80 to 1.25.

Overall, a higher percentage of BME staff (30.4%) than white staff (26.8%) had been harassed, bullied, or abused by patients, family, or the general public in 2022; a pattern that has been evident since at least 2015.  In 2020, levels dropped for both BME and white staff, potentially reflecting a reduction in the amount of face-to-face contact between NHS service users and staff during the COVID-19 pandemic.  However, since then, levels of harassment, bullying, or abuse by patients have increased to pre-pandemic levels.  In all regions a higher percentage of BME staff than white staff had been harassed, bullied, or abused by patients, relatives or the general public.  It remains a concern that more than one in four staff of any ethnicity experience abuse or harassment from the public, and that there is an upward trend for this in most regions.

Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months by gender and ethnicity in detail

Women (27.9%) were more likely than men (26.3%) to have experienced harassment, bullying or abuse from patients, relatives or the public in the last 12 months.  Women from a white Gypsy or Irish Traveller background experienced the highest levels of harassment, bullying or abuse from patients, relatives or the public (43.5%). Women (37.5%) and men (35.7%) from “other” Asian backgrounds also experienced high levels of harassment, bullying or abuse from patients, relatives or the public.  Levels also tended to be high for men and women from white Irish and “other” white backgrounds and for men and women from African and mixed African backgrounds.

Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months by gender, ethnicity and profession

Overall, BME women (30.8%) were most likely to have experienced harassment, bullying or abuse from patients, their relatives or the general public in the last 12 months, a trend that has been evident since at least 2015.  However, amongst registered nurses, white men (43.0%) and BME men (42.9%) were more likely to experience harassment, bullying or abuse from patients, their relatives or the general public than their female colleagues; with a similar trend apparent amongst nursing and healthcare assistants for white men (49.8%) and BME men (43.5%).  Overall, ambulance (operational) staff (52.6%) experienced the highest level of harassment, bullying or abuse from patients, relatives or the public.

WRES indicator 5

Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months

In 2022, at 81% of NHS trusts, a higher proportion of BME staff compared to white staff experienced harassment, bullying or abuse from patients, relatives or the public in the last 12 months, representing an increase in this percentage compared to 2021 (71%).

WRES indicator 6

Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months

At 94% of trusts, a higher proportion of BME staff compared to white staff experienced harassment, bullying or abuse from staff in last 12 months in 2022. This figure was 93% in 2021.

In 2022, the percentage of staff experiencing harassment, bullying or abuse from other staff in the last 12 months was higher for BME staff (27.7%) than for white staff (22.0%). This pattern has been evident since 2015 and was repeated in all regions.  Although disparities between the experiences of BME and white staff persist, harassment, bullying and abuse from staff has followed a largely downward trend since 2018.

Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months by gender and ethnicity in detail

Women (22.6%) and men (22.3%) were similarly likely to have experienced harassment, bullying or abuse from other staff in last 12 months.  White Gypsy or Irish Traveller women (39.0%) and men (45.7%) experienced the highest levels of harassment, bullying or abuse from other staff.  Women (33.7%) and men (32.7%) from Arabic backgrounds, and women from “other” black backgrounds (33.6%) also experienced high levels of harassment, bullying or abuse from other staff.

Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months by gender, ethnicity and profession

In 2022, BME women (27.7%) were most likely to have experienced harassment, bullying or abuse from other staff in the last 12 months, a trend that has been evident since at least 2015.  This trend was especially evident for BME women in general management (30.5%), medical and dental (32.6%), and registered nursing and midwifery (30.7%).

WRES indicator 7

Percentage of staff believing that their trust provides equal opportunities for career progression or promotion

In 2022, at 98.6% of NHS trusts, a lower percentage of BME staff than white staff felt that their trust provides equal opportunities for career progression or promotion, compared to 99.5% in 2021.

In 2022, a lower percentage of BME staff (46.4%) than white staff (59.1%) felt that their trust provides equal opportunities for career progression or promotion. This pattern has been evident since at least 2017 (and at least 2015 based on the previous version of this indicator*) and is repeated in all regions.

* The way that indicator 7 is calculated has been changed for the 2021 NHS Staff Survey and historic figures have been recalculated back to 2017.  (Previously, the figure was derived by dividing the number of “yes” replies by the sum of “yes” and “no” replies; presently, the figure is derived by dividing the number of “yes” replies by the sum of “yes,” “no” and “don’t know” replies.)

Percentage of staff believing that their trust provides equal opportunities for career progression or promotion by gender and ethnicity in detail

Overall, men (53.8%) were less likely than women (58.1%) to believe that their trusts provide equal opportunities for career progression or promotion.  For staff from a black background, only 39.3% believed their trust provides equal opportunities for career progression or promotion. This is below the levels of other ethnic groups since at least 2015, irrespective of gender.  Men from a white Gypsy or Irish Traveller background also had a low likelihood of believing that their trusts provide equal opportunities for career progression or promotion (41.0%).

Percentage of staff believing that their trust provides equal opportunities for career progression or promotion by gender, ethnicity and profession

As a profession, ambulance staff (operational) were least likely to believe that their trust acts fairly with regards to career progression and promotion (44.5%); with especially low levels of belief amongst BME women (42.6%), BME men (38.5%), and white men (41.3%) in this profession.  BME women (43.2%) and BME men (46.5%) in the wider healthcare team also expressed especially low levels of belief, as did BME women (44.9%) and BME men (46.9%) in general management. The difference between BME and white staff was greatest in the general management staff group.

WRES indicator 8

Percentage of staff experiencing discrimination at work from other staff in the last 12 months

At all trusts, a higher percentage of BME staff than white staff experienced discrimination from a manager/team leader or other colleagues in the last 12 months (an identical picture to that seen in 2021).

In 2022, a higher percentage of BME staff (16.6%) than white staff (6.7%) experienced discrimination from other staff; a pattern that has been evident since at least 2015, and which was repeated in all regions. The percentage of BME staff who experienced discrimination from other staff increased markedly between 2019 and 2020 and has remained at an elevated level since then.

Percentage of staff experiencing discrimination at work from other staff in the last 12 months by gender and ethnicity in detail

Men (9.3%) were more likely than women (8.3%) to have experienced discrimination from a manager/team leader or other colleagues in last 12 months.  Men from a white Gypsy or Irish Traveller (25.5%) background were most likely to have experienced discrimination from other colleagues, although levels were also high for women from this background (22.1%).  Meanwhile, women from a black background (18.9% across all black backgrounds), women from a mixed white and black African background (16.9%) and women from an Arabic background (18.1%), also experienced high levels of discrimination from a manager/team leader or other colleagues.

Percentage of staff experiencing discrimination at work from other staff in the last 12 months by gender, ethnicity and profession

BME women (16.6%) were most likely to have experienced discrimination from other staff in the last 12 months, a trend that has been evident since at least 2015.  However, rates were also high for BME men (14.1%). Rates of discrimination from other staff were especially high for BME women in general management (19.8%) and for BME women in registered nursing and midwifery (19.3%).

WRES indicator 9

The representation of BME people amongst board members

Nationally, 15.6% of board members recorded their ethnicity as BME, compared to 26.4% of staff in NHS trusts.  In every region, there was a lower percentage of BME board members compared to the overall percentage of BME staff in the workforce. London, where around half of staff in the overall workforce come from a BME background, shows the largest disparity in board membership.

The percentage of board members recording their ethnicity as BME has increased year-on-year at a national level.  However, the rate of increase in the percentage of board members recording their ethnicity as BME has not kept up with the rate of increase in the percentage of BME staff in the NHS workforce overall.  Consequently, the gap between BME representation on boards and BME representation in the workforce has increased from 9.7% in 2021 to 10.9% in 2023.  The gap amongst executive board members, at 15.7%, was especially large in 2023, having increased from 13.5% in 2021.

The representation of BME people amongst all board members compared to the workforce overall

The trend in all regions was for the percentage of BME board members to increase year-on-year, thus following the national trend.  However, in five regions (London, Midlands, North East and Yorkshire, North West, and South West) the gap in BME representation between board and workforce increased because the increases in BME representation on boards were not as large as increases in BME representation in the wider workforce.  The pattern varies for non-executive and executive directors, with an increasingly large gap for executive directors in particular.

The representation of BME people amongst non-executive board members compared to the workforce overall

In March 2023, 20.3% of non-executive directors recorded their ethnicity as BME, an increase on the 18.4% seen in 2022 and 16.2% seen in 2021.  However, the gap between BME representation in the workforce and amongst non-executive board members has remained steady over this period at around 6%, reflecting increases in BME non-executive directors and increases in BME staff joining the NHS year-on-year.

The representation of BME people amongst executive board members compared to the workforce overall

In March 2023, 10.8%, of executive directors recorded their ethnicity as BME (lower than the 20.3% for non-executive directors), an increase on the 9.7% seen in 2022 and 8.9% seen in 2021.  However, the gap between BME representation in the workforce and amongst executive directors has increased from 13.5% to 15.7% over this period, reflecting larger increases in BME representation in the workforce (from 22.4% to 26.4%) than amongst executive directors.

Internationally recruited nurses, midwives, and nursing assistants

Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months

A question asking NHS staff survey participants whether or not they were recruited from outside of the UK first appeared in the November 2021 NHS staff survey.  Internationally recruited nurses from white backgrounds experienced the highest levels of harassment, bullying or abuse from patients, relatives or the public.  The same challenges were identified for internationally recruited nursing assistants from white backgrounds in 2022.

Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months

Domestic and internationally recruited nurses and nursing assistants from BME backgrounds, alongside internationally recruited nurses and nursing assistants from white backgrounds, experienced high levels of harassment, bullying or abuse from other staff.

Percentage of staff believing that their trust provides equal opportunities for career progression or promotion

Domestic and internationally recruited nurses and nursing assistants from BME backgrounds were least likely to feel that their organisation provides equal opportunities for career progression or promotion.

Percentage of staff experiencing discrimination at work from other staff in the last 12 months

Domestic and internationally recruited nurses and nursing assistants from BME backgrounds were most likely to suffer discrimination from other staff.

In summary, domestic and internationally recruited nurses and nursing assistants from BME backgrounds and white nurses and nursing assistants recruited internationally, tend to have poorer experiences of working in the NHS.

Nurses, midwives, and nursing assistants, ethnicity in detail

Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months

Nurses, midwives, and nursing assistants from “other” white backgrounds experienced the highest levels of harassment, bullying or abuse from patients, relatives or the public.  Levels were also high for nurses, midwives, and nursing assistants from mixed, black British, and “other” backgrounds.

Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months

Nurses, midwives, and nursing assistants from all BME backgrounds and from “other” white backgrounds experienced high levels of harassment, bullying or abuse from staff.

Percentage of staff believing that their trust provides equal opportunities for career progression or promotion

Black British nurses, midwives, and nursing assistants were least likely to feel that their organisation provides equal opportunities for career progression or promotion. Levels were also low for nurses, midwives, and nursing assistants from all BME backgrounds and from “other” white backgrounds.

Percentage of staff experiencing discrimination at work from other staff in the last 12 months

Black British nurses, midwives, and nursing assistants and those from “other” backgrounds were most likely to suffer discrimination from staff.  Levels were also high for nurses, midwives, and nursing assistants from all BME backgrounds and from “other” white backgrounds.

In summary, amongst nurses, midwives, and nursing assistants, the largest part of the NHS workforce, BME staff and staff from “other” white backgrounds have poorer experiences of working for the NHS than their white British colleagues.  This inequality is most marked for black staff who feel the least equality of opportunity and are most likely to be victims of discrimination.

Conclusion and next steps

This year’s report is an opportunity to take stock of some of the progress made, existing and persistent challenges and an opportunity to take lessons for improvement. It also presents a snapshot of where we are and where we need to be against key ambitions in the NHS Long Term Workforce Plan and the NHS EDI improvement plan.

The data and insights are not just a reflection of the past and present but, more importantly, a pathway to developing sustained actions that builds a future where equality, diversity, and inclusion are integral to the NHS.

We have seen progress, yet we remain aware of the work that lies ahead. The evolving landscape of healthcare and workforce drivers presents both opportunities and challenges. We embrace this dynamic environment, confident that together, our adaptability, resilience, and collective efforts will continue to foster an NHS where every individual is able to contribute fully, enriching our staff experience, service delivery and patient care.

Looking ahead, our vision for the future of race equality in the NHS is to clear – support the six high impact actions of the NHS EDI Improvement Plan; to help improve workforce equality across the Equality Act’s nine protected characteristics plus social mobility and intersectionality.

NHS England remains committed to transforming this vision of equality into reality. We will continue working with stakeholders, partners and systems at national and regional levels to coordinate work across several areas to improve the experience of our colleagues. 

Every voice within the NHS is instrumental in this transformative journey. We are not passive recipients of change but active architects of a more inclusive and fair future.

Appendix A – Methodology

The WRES requires NHS trusts to self-assess against 9 indicators of workplace experience and opportunity. 4 indicators relate specifically to workforce data, 4 are based on data from the national NHS staff survey questions, and 1 considers BME representation on boards.

The detailed definition for each indicator can be found in the WRES technical guidance. The technical guidance also includes the definitions of “white” and “black and minority ethnic”, as used throughout this report and within the narrative for the WRES indicators. This report presents data for all NHS trusts in England, against all 9 WRES indicators, and where possible, makes comparisons to previous WRES data.

Data sources

WRES data for 2022/23 was collected through individual NHS trust submissions via the Data Collection Framework (DCF). A return rate of 100% for trusts was achieved.

Data analyses

For the purpose of data analyses and presentation, organisations have been grouped by the 7 NHS geographical regions – East of England, London, Midlands, North East and Yorkshire, North West, South East and South West.

For indicators 2, 3 and 4, statistical analyses included the “four-fifths” rule. The “four-fifths” (“4/5ths” or “80 percent”) rule is used to highlight whether practices have an adverse impact on an identified group, such as a subgroup of gender or ethnicity. For example, if the relative likelihood of an outcome for one sub-group compared to another is less than 0.80 or higher than 1.25, then the process would be identified as having an adverse impact.

Data caveats

• this report only contains data for NHS trusts
• indicator 1 data comes from 2 different data sources: 1) 2016 and 2017 data are from the NHS workforce statistics website; 2) 2018 to 2022 data are from the Strategic Data Collection Service (SDCS) / Data Collection Framework (DCF)
• indicator 3 (staff entering the formal disciplinary process): the calculation has been changed from using a 2-year rolling average to using the year end figure. Both the numerator and denominator have changed for this calculation; so, current figures remain comparable to historical figures
• 4 of the WRES indicators (5 to 8) are drawn from questions in the national NHS staff survey. The reliability of the data drawn from those indicators is dependent upon the overall size of samples surveyed, the response rates to the survey questions, and whether the numbers of BME staff are large enough to not undermine confidence in the data
• for the national level staff survey based WRES indicators that compare white and BME respondents, a weighting is applied to each trust’s contribution to the national score. This weighting ensures that each trust’s results have an impact according to the number of staff employed, rather than according to the number of survey respondents. However, for the regional breakdowns, and for breakdowns looking at ethnicity in more detail or those considering ethnicity and gender, unweighted data are used, and respondents are pooled across trusts without adjusting for differing trust sizes
• a number of trusts have revised their past workforce data, which has resulted in the indicators for previous years being recalculated. Also, some NHS trusts may have revised their WRES data returns since their submission via DCF. The results in this report are based on the latest figures returned to NHS England via DCF and will not necessarily incorporate any updates a trust has made to WRES related publications on organisations’ websites
• the way that indicator 7 is calculated has been changed for the national NHS staff survey conducted in November and December 2021 and reported in 2022 onwards. Historic figures have been recalculated back to 2017. (Previously, the figure was derived by dividing the number of “yes” replies by the sum of “yes” and “no” replies; presently, the figure is derived by dividing the number of “yes” replies by the sum of “yes,” “no” and “don’t know” replies)

Report produced by the WRES team

Publication reference: PRN00928