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Race and the NHS – a chance for change

How can we make the NHS fairer for black staff? Start by having an honest conversation, said contributors to our roundtable debate.

How can we make the NHS fairer for black staff? Start by having an honest conversation, said contributors to our roundtable debate.

Anyone familiar with the NHSs attempts to improve the prospects of black and minority ethnic staff could be forgiven for being sceptical about this years big idea.

Heather Caudle puts her views across at Nursing Standards roundtable discussion at the RCNs London HQ. Picture credit: Barney Newman

The NHS Workforce Race Equality Standard (WRES), introduced by NHS England in April, is designed to encourage more leaders from BME backgrounds and improve the experience of BME staff.

It requires organisations to show their progress against indicators of equality, including BME representation at board level.

Yvonne Coghill, the nurse charged with leading the implementation of the WRES, admits that a plethora of previous initiatives have all failed or achieved only partial success.

...

How can we make the NHS fairer for black staff? Start by having an honest conversation, said contributors to our roundtable debate.

Anyone familiar with the NHS’s attempts to improve the prospects of black and minority ethnic staff could be forgiven for being sceptical about this year’s big idea.

Heather Caudle puts her views across at Nursing Standard’s roundtable discussion at the RCN’s London HQ
Heather Caudle puts her views across at Nursing Standard’s roundtable discussion at the RCN’s London HQ.
Picture credit: Barney Newman

The NHS Workforce Race Equality Standard (WRES), introduced by NHS England in April, is designed to encourage more leaders from BME backgrounds and improve the experience of BME staff.

It requires organisations to show their progress against indicators of equality, including BME representation at board level.

Yvonne Coghill, the nurse charged with leading the implementation of the WRES, admits that a plethora of previous initiatives have all failed or achieved only partial success. These failures – and the fate of WRES – matter. Because, with some notable exceptions, there is little sign that NHS employers are getting better at using the talents of BME staff.

Yvonne
Coghill

Indeed, as Ms Coghill points out, the situation is getting worse: ‘There are actually fewer senior leaders from BME backgrounds today than there were ten years ago. In London – one of the most racially diverse cities in the world – there are no BME NHS chief executives and very few BME nurses at board level.’

To paraphrase the title of a 2014 landmark study by Roger Kline, the peaks of the NHS are still, stubbornly, ‘snowy white’.

This is not only about senior nurses being denied top jobs. There is robust evidence that BME staff have a worse experience in the workplace than their white colleagues: they are not just less likely to be appointed to senior posts but more likely to experience harassment and bullying and find themselves facing disciplinary procedures.

So what is going wrong? Why is it so hard to put right? And what chance is there that the WRES will – at long last – make a difference?

It was the hope of stimulating a wider debate about these issues – and shining a light on some of the things that do work – that prompted Nursing Standard to organise a high-level roundtable discussion, chaired by our editor Graham Scott, at the RCN’s London HQ.

Ms Coghill said she came to listen, and gather ideas that could help shape the WRES. She was joined by senior figures from the Care Quality Commission and the NHS Confederation, experts in race equality, London’s deputy chief nurse, and leaders from two major NHS trusts – including one of the very few black nurse directors, Heather Caudle.

'People say things like ‘they don’t want these jobs, do they?’

Yvonne Coghill

Several of the people at the event knew each other well, and it showed. The discussion was marked by a readiness to share uncomfortable truths.

So we heard, not just that black nurses’ talents are being wasted, but also that some are so demoralised and worn down by racism that they do not provide good care. Similarly, organisations perform better when they treat their BME staff fairly, but this does not mean that everyone wins – white middle class people have to give up their position of privilege.

There will be resistance. A strong theme was that none of this is easy, or simple, or safe. But nor is it hopeless.

If the contributors to our roundtable discussion are right, then the WRES presents a genuine opportunity for change. But they also suggested that making the most of this opportunity will require from organisations and individuals an unprecedented degree of self-examination and sustained effort.

It will mean acknowledging the deep hurts caused by racism and the need for compassion. It will require leaders to listen to black colleagues and learn from their experiences. Above all, the message from our roundtable contributors is that it is time for a different kind of conversation about race and the NHS – honest, uncomfortable and necessary.

‘The WRES was developed on the back of more and more evidence that an excluded workforce will not give the effort it should be giving,’ said NHS England director of WRES implementation Yvonne Coghill, who opened the discussion.

‘We know that black people have a more negative experience of the NHS than senior white people. What the WRES is trying to do is get organisations and people to think about why that is.

‘Across London we have no BME chief executives and very few senior nurses. People say things like “they don’t want these jobs, do they?” or “they haven’t got the experience” when actually there are issues about power and entitlement. People [white managers] have got to own that some of the problems are down to them. They have to do things differently to get a different outcome.

'I look at some of my data and feel embarrassed'

Ben Morrin

‘The fact that the WRES is mandatory is new. In the past we have had initiatives that have been discretionary – but a six-month initiative with £200,000 thrown at it, isn’t going to scratch the surface.’

Bronagh Scott, NHS England’s deputy chief nurse for London, said: ‘There’s no point in having a mandatory standard if you don’t have a culture that embraces diversity as part of that – you can’t just force people; that would go back to “ticking the box”. One of the things we are developing at NHS England is a culture of care barometer, a tool to help people start to think about the culture of their organisation and their teams.’

Leadership consultant and coach Eden Charles, executive director of People Opportunities, said the WRES on its own cannot change anything: ‘But the way it came into being is significant. It was not a top-down thing, it started with a group of us – mostly led by Yvonne – having a conversation about how we could do things differently. It is an inspiring example of not waiting for the top.’

Ms Coghill suggested that public exposure of organisations that are performing poorly on race equality, as measured by the WRES, will give it clout: ‘We are not going to take money away [as a penalty for non-compliance] but what will happen between now and December is there will be a league table that will show for the first time where people are on this agenda. It will focus their minds on what they need to do.’

Ben
Morrin

Ben Morrin, workforce director at University College London Hospitals NHS Foundation Trust, agreed that the release of data generated by the WRES will encourage managers to do better. ‘These standards will be really helpful. I look at some of my data and feel embarrassed. In my organisation you are twice as likely to be suspended or disciplined if you are from a BME background than if you are from a white background.’

Such data, he added, should not lead to individual staff members being ‘burned at the stake’ – it is a sign the organisation as a whole needs to improve.

Over the next few months Nursing Standard will report on the progress of the NHS Workforce Race Equality Standard and explain the practical steps that can help deliver race equality in the workforce. We will highlight the innovative work of trusts – beginning with Bradford Teaching Hospitals NHS Foundation Trust – that are managing to close at least some of the gap between policy and practice. Let us know what is happening in your area.

Tom Sandford, director of RCN England and the college’s race equality champion, pointed to organisations, such as North East London NHS Foundation Trust, that have ‘doggedly pursued making things different for their staff and patients’.

‘Very talented black women now run key parts of that organisation. If North East London can do it, others can do it – it is not an impossible dream. But it is hard work over a long period of time, and it means admitting things are not right in your organisation.’

Mr Sandford emphasised that making progress on race equality is never easy. ‘It’s about privilege – it’s about someone giving up something and that is hard to do.’

For an organisation to examine its own weaknesses requires discipline, he said.

‘Our discipline at the RCN was looking our case work and saying it is not right. Black members were completely under-represented in the case work we were doing. Braver black members told us, “we don’t trust you to come to you with our concerns”.

Now we have black members over-represented in case work and that is another whole area of work because it is about black members being much more vulnerable to being disciplined.’

Ursula Gallagher, the Care Quality Commission’s deputy chief inspector for primary care in London, said part of the problem was BME nurses tend to be stuck in the most vulnerable position – the front line – when things go wrong. ‘The person who will get the can is the person on the front line and if that person is BME, because that is where we have kept them, they will get the disciplinary procedure. All of us in leadership roles need to examine this in our organisations as well as in the system as a whole. We need honesty.’

'BME nurses are not given the opportunity to perform to their best'

Heather Caudle

A black nurse who has made it to the top,Heather Caudle, chief nurse at Ashford and St Peter’s Hospitals NHS Foundation Trust in Surrey, suggested it is easier to be successful outside the big urban centres with their large BME populations. ‘For some reason in areas like Surrey, they don’t see me coming. They have the confidence to absorb diversity. There is a timidity in London that leads to a stronger and more unconscious effort to keep the status quo.’

The timidity or nervousness of white managers might also be a factor in the disproportionate number of BME nurses who end up in serious trouble because of poor performance.

Heather Caudle
Heather
Caudle

Ms Caudle gave this example of a black nurse ‘playing the race card’: ‘One of my matrons phoned me in tears because she had been accused of being a racist by a nurse she was trying to performance manage who was arriving to work late, phoning in sick or cancelling clinics… the amount of things this matron tried to do to help and support her. When she, rightly, escalated this, the nurse accused her of being racist. I said, “you waited rather long – your escalation happened too late”.’

A reluctance to escalate can ‘relegate a person to poor performance’, she added. ‘The key is to do it with love and a desire to get that person to where they need to be’ – a point strongly endorsed by Mr Charles.

‘By and large white managers delay the process of managing until it is too late. Taking action at an early stage with love and care is developmental,’ he said. The alternative is, ‘you leave them for a long time – and then you kick them. A critical issue is line managers not doing their jobs properly.’

Ms Coghill said: ‘You have to look at the experiences that some BME nurses have – your children being picked up by the police, being followed around a shop because it is assumed you are going to steal something. The everyday experience of being black in a white society causes something called “weathering” and that affects your performance.’

Ms Caudle added: ‘When you have routine experiences of discrimination your ability to be compassionate to yourself is impaired and that has an impact on your ability to give compassionate care.’

Ms Scott said NHS England has done work on the ability to show compassion to staff: ‘But as soon as you use the word compassion and put it next to leadership, people don’t want to hear it. They see it as fluffy.’

For the RCN’s lead on equalities and inclusion, Wendy Irwin, the most conspicuous omission from the conversation on race in the NHS is empathy. ‘We talk about compassion and self-care and caring for patients, but I don’t hear senior leaders talking about empathy or how we make constructive use of difference. We have to equip leaders to have these conversations. This is a business issue – to systematically waste the skills and talents of BME people doesn’t seem sustainable or fair.’

Eden Charles: ‘WRES is an inspiring example of not waiting
for the top...There is a deep level of change that needs
to take place in the system’

The organisations making real headway on race equality have leaders with a sense of purpose who make effective use of all their staff, said Mr Charles. ‘It is not about race in a sense. They are seeking to create outstanding organisations, so they set about creating conditions where people can flourish – and pay particular attention to those groups that need something different in order to succeed.’

Such leaders work with staff to plan and implement change – they do not impose a ready-made template, he said. ‘I get upset when I hear conversations about “doing things for BME people” – those are failing organisations.’

What often goes unrecognised, he added, is just how hostile the NHS is to BME people – and to women. This means when black female nurses do make it to senior positions the odds are stacked against them succeeding.

‘You need to change the organisation,’ said Mr Charles. ‘You can’t bring someone into a hostile organisation and expect them to thrive. There are loads of unspoken hurts. There is a deep level of change that needs to take place in the system.’Ms Gallagher said the challenge was to use the WRES to ‘change the paradigm of the conversation’ about race equality, rather than simply as a box to be ticked. She gave the example of struggling inner city GPs who endure institutional racism, ‘and we think that is their problem and not ours’.

Ms Caudle said BME nurses are often not included in the top flight of practice. ‘They are not given the opportunity to perform to their best.’

Real change requires a conversation about race equality that will take all of us, white and black, out of our comfort zones.

'We need to get better at using people’s lived experience to create change'

Joan Saddler

‘When you talk about race people get uncomfortable and run for the hills or break into tears,’ said NHS confederation associate director Joan Saddler. ‘Rather than getting offended or emotional, we need to get better at using people’s lived experience to create change.’

Joan Saddler
Joan
Saddler

Ms Saddler said there was a need to move away from the ‘deficit model’ that says BME people are a problem to be solved. It is this model that leads to ‘initiatives that put a few people on boards and then peter out. The danger is the WRES will do the same if we don’t see it as a just part of the puzzle.’

‘Joan is right,’ said Ms Irwin. ‘We must have the institutional maturity to talk about race, to use lived people’s experience in a way that doesn’t damage or blame but to say “here is an issue and a set of things your organisation is facing”. And we have to think about how we can use inclusion to drive productivity, to achieve better outcomes for patients.

‘At the moment these conversations don’t feel safe – it feels loaded. There’s a vulnerability we all have to share’.

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