Belonging in the NHS

NHS staff have been challenged by the response to COVID-19 on a scale and at a pace not previously seen. These pressures have, on the whole, brought out the very best in our leaders – with compassionate and inclusive leadership behaviours coming to the fore. Clinical leadership and distributed leadership have also proved to be more critical than ever in recent months.

We must continue our efforts to make the culture of the NHS universally understanding, kind and inclusive, through the testing times that lie ahead.

The NHS will be open and inclusive

The NHS was established on the principles of social justice and equity. In many ways, it is the nation’s social conscience, but the treatment of our colleagues from minority groups falls short far too often. Not addressing this limits our collective potential. It prevents the NHS from achieving excellence in healthcare, from identifying and using our best talent, from closing the gap on health inequalities, and from achieving the service improvements that are needed to improve population health.

Given recent national and international events, it has never been more urgent for our leaders to take action and create an organisational culture where everyone feels they belong – in particular to improve the experience of our people from black, Asian and minority ethnic (BAME) backgrounds.

All our jobs have become more difficult and we have to take extra special care to look after our patients, ourselves and each other. It’s a difficult time but we are pulling together as a team. Everyone is pushing themselves and doing an amazing job. I couldn’t be prouder of them all.

That’s probably why, even after 15 years, I still love and would recommend my job. The NHS has a way of attracting so many different people from all walks of life – and make them all feel they belong.

Hospital porter, South west

The NHS must welcome all, with a culture of belonging and trust. We must understand, encourage and celebrate diversity in all its forms. Discrimination, violence and bullying have no place. If we do not role model this culture, then how can our patients expect to be treated equitably, and as individuals?

A time of national awakening

COVID-19 has intensified social and health inequalities. COVID-19 has intensified social and health inequalities. The pandemic has had a disproportionate impact on those from a BAME background; on older people; on men; on those with obesity; and on those with a disability or long-term condition.

The NHS is the largest employer of BAME people in the country and BAME colleagues have lost their lives in greater numbers than any other group. We must take seriously our responsibility to look after at-risk staff, prioritising physical and psychological safety.

Systemic inequalities are not unique to the NHS. Each of us needs to listen and learn – from our colleagues, and from society – and take considered, personal and sustained action to improve the working lives of our NHS people and the diverse communities we serve.

There is strong evidence that where an NHS workforce is representative of the community that it serves, patient care and the overall patient experience is more personalised and improves. Yet it is also clear that in some parts of the NHS, the way a patient or member of staff looks can determine how they are treated.

The Workforce Race Equality Standard (WRES) has led to progress across a number of areas; for example, increases in the proportion of BAME very senior managers. The Workforce Disability Equality Standard (WDES) has begun to shine a light on the difficulties that colleagues with disabilities and long-term health conditions face.

Other staff groups also face significant challenges. For example, we know that a large number of staff who identify as LGBTQ+ do not feel confident enough to report their sexual orientation or gender expression on their employment record. And we know the weathering effect that microaggressions have on our people.

NHS England and NHS Improvement, with the NHS Confederation, has now established the NHS Race and Health Observatory. This body will bring together experts from this country and internationally, to provide analysis and policy recommendations to improve health outcomes for NHS patients, communities and our people. This will be crucial for building evidence and driving progress.

To realise urgent change, we must work systematically and give these issues the same emphasis as we would any other patient safety-related concern. We must act with integrity, intelligence, empathy, openness and in the spirit of learning. To do this, we each need to first examine our personal track record on, and commitment to, equality, diversity and inclusion.

Staff should expect their employers to take action on the following areas:

Recruitment and promotion practices: By October 2020 employers, in partnership with staff representatives, should overhaul recruitment and promotion practices to make sure that their workforce reflects the diversity of their community, regional and national labour markets. This should include creating accountability for outcomes, agreeing diversity targets, and addressing bias in systems and processes. It must be supported by training and leadership about why this is a priority for our people and, by extension, patients. Divergence from these new processes should be the exception and agreed between the recruiting manager and board-level lead on equality, diversity and inclusion (in NHS trusts, usually the chief executive).

Health and wellbeing conversations: From September 2020, line managers should discuss equality, diversity and inclusion as part of the health and wellbeing conversations described in the previous chapter, to empower people to reflect on their lived experience, support them to become better informed on the issues, and determine what they and their teams can do to make further progress.

Leadership diversity: Every NHS trust, foundation trust and CCG must publish progress against the Model Employer goals to ensure that at every level, the workforce is representative of the overall BAME workforce. From September 2020, NHS England and NHS Improvement will refresh the evidence base for action, to ensure the senior leadership (very senior managers and board members) represents the diversity of the NHS, spanning all protected characteristics.

Tackling the disciplinary gap: Across the NHS we must close the ethnicity gap in entry to formal disciplinary processes. By the end of 2020, we expect 51% of organisations to have eliminated the gap in relative likelihood of entry into the disciplinary process. For NHS trusts, this means an increase from 31.1% in 2019. As set out in A Fair Experience for All, NHS England and NHS Improvement will support organisations in taking practical steps to achieving this goal, including establishing robust decision tree checklists for managers, post action audits on disciplinary decisions, and pre-formal action checks.

Governance: By December 2021, all NHS organisations should have reviewed their governance arrangements to ensure that staff networks are able to contribute to and inform decision-making processes.

Not only do staff networks provide a supportive and welcoming space for our people, they have deep expertise on matters related to equality, diversity and inclusion, which boards and executive teams need to make better use of. Staff networks should look beyond the boundaries of their organisation to work with colleagues across systems, including those working in primary care.

Information and education: From October 2020, NHS England and NHS Improvement will publish resources, guides and tools to help leaders and individuals have productive conversations about race, and to support each other to make tangible progress on equality, diversity and inclusion for all staff. The NHS equality, diversity and inclusion training will also be refreshed to make it more impactful and focused on action.

Accountability: By March 2021 NHS England and NHS Improvement will have published competency frameworks for every board-level position in NHS providers and commissioners. These frameworks reinforce that it is the explicit responsibility of the chief executive to lead on equality, diversity and inclusion, and of all senior leaders to hold each other to account for the progress they are making.

Regulation and oversight: Over 2020/21, as part of its ‘well led’ assessment of Trusts, CQC will place increasing emphasis on whether organisations have made real and measurable progress on equality, diversity and inclusion – and whether they are able to demonstrate the positive impact of this progress on staff and patients.

Building confidence to speak up: By March 2021 NHS England and NHS Improvement will launch a joint training programme for Freedom to Speak Up Guardians and WRES Experts. We are also recruiting more BAME staff to Freedom to Speak Up Guardian roles, in line with the composition of our workforce.