Equality, Diversity and Inclusion in the NHS

As a qualitative researcher, I welcome the opportunity to explore in depth. So, having recently joined The Tavistock and Portman NHS Foundation Trust as Associate Director of Equality, Diversity and Inclusion (EDI) I have undertaken the considerable task of reflecting and putting in place an honest picture of the realities within which the EDI agenda is located in organisations, particularly in the National Health Service (NHS). 

The EDI agenda is conflictive: there is conflict between different rights and there is conflict between different protected characteristics that one advocates for. Also, the role is sponsored by organisations yet it must also be underpinned by a critical ethos and an understanding that contemporary organisations and forms of organising have many negative implications for and impacts on employees and society in general. As highlighted in my field of specialisation, Critical Management Studies (CMS), there is a dark side of business and organisations. CMS proceeds from the assumption that dominant theories of management and organisation systematically favour privileged groups and their interests at the expense of those who are disadvantaged by them. It regards the aggrandisement of management as an uncritically one-sided ideology of elites that becomes widely dispersed through institutionalisation and organisational culture. However, when EDI practitioners highlight systemic inequalities they are often lampooned as woke or accused of being too negative or of ignoring positive aspects of organisational experience in order to justify their roles. They get told of “diversity fatigue” – often there is no willingness to view diversity fatigue as a powerful weapon used by privileged sections of the workforce who do not want to be made to reflect on their privileges since that might make them feel uncomfortable. However, groups in the workforce who consider themselves marginalised and disadvantaged in society are expected to be resilient and to tolerate their discomfort (for life).

Whilst my role encompasses all protected characteristics including age, disability, gender identity and religion or belief, I will focus on race (not because it has primacy over other characteristics but simply because I have lived experience in this regard). In their foreword to the March 2022 NHS Workforce Race Equality Standard (WRES) report, the NHS Acting People Officer, Em Wilkinson-Brice, and Head of WRES, Anton Emmanuel, acknowledged that there has been “a worsening of the experience of staff from Black, Asian, and Minority Ethnic (BAME) backgrounds compared to white staff in key domains” since the WRES was established 7 years ago. The WRES is a workforce standard that was introduced in 2015 to ensure that employees from BAME backgrounds receive fair treatment and have equal access to career opportunities as their white counterparts. Currently:

• White applicants in the NHS are 1.61 times more likely to be shortlisted compared to BAME applicants.
• BAME staff are 1.14 times more likely to enter formal disciplinary process compared to white staff.
• 16.7% BAME staff personally experience discrimination at work from their manager, team leader or colleague (The figure was 14% at the introduction of WRES in 2015).
• As at 31st March 2021, 22.4% (309 532) of staff in NHS trusts in England were from a BAME background. However, only 12.6% of Board members in the sector were from a BAME background. BAME staff are overrepresented in precarious and insecure low level roles and are underrepresented in more secure senior roles.
• 43.5% of staff from a Gypsy or Irish Traveller background experienced harassment, bullying or abuse from patients, relatives, or the public in the last 12 months.
• 36.2% of staff from “other” Asian backgrounds (i.e. other than Bangladeshi, Chinese, Indian or Pakistani) experienced harassment, bullying or abuse from patients, relatives, or the public in the last 12 months.
• 35.3% of staff from “other” black backgrounds (i.e other than African or Caribbean) experienced harassment, bullying or abuse from other staff in the last 12 months.

Concerning health inequalities in the UK:

• Maternal care: black women are 4 times more likely to die in pregnancy and childbirth.
• Asian women are 2 times more likely to die in pregnancy and childbirth.
• Inequalities in the prevalence of mental health (what are the sources?).
• Black and Asian men: higher rates of Psychotic Disorder and rates of detention under the Mental Health Act.

Interestingly, the UK Government’s Commission on Race and Ethnic Disparities (March 2021) concluded that there was no evidence of institutional racism in Britain. If the realities presented above where government policies and working culture perpetuate inequalities in society based on ethnic background do not constitute institutional racism – what then is institutional racism? 

We need to understand that policymaking on the surface paints a very positive picture, but often there is a gap between policy statements and their faithful implementation. It is revealing that  despite a stream of policy changes since the first Race Relations Act was introduced in 1965 (nearly 60 years ago) very little has changed – structural inequalities still persist, and some indicators have worsened. This is because there is a disingenuous engagement with how the inequalities came to exist in society. Systemic problems require systemic solutions – we need to engage honestly with lack of equity and stop window dressing or papering cracks.

In Critical Theory, it is acknowledged that social patterns take shape within specific historical and cultural conditions and that the methods used to analyse those conditions are also embedded within the same historical contexts. Consequently, until the NHS addresses the question of ‘who speaks for who’ and ‘who sits at the policymaking table’ we will continue to have blind spots, group-think decisions, ironies of policy, unintended consequences of policies and perpetuation of bias. EDI practitioners will also continue to have a schizophrenic identity: pushed and pulled in different directions at the same time.

Personally, I will continue to unmask and challenge systemic injustice: ableism, ageism, heterosexism, homophobia, racism, sexism and all other forms of bigotry. However, in order not to alienate key stakeholders and allies I will tell the truth with love and grace – it is a slippery slope, a delicate balance. EDI cannot be pushed in but pulled in as it depends on people’s goodwill. You cannot force people to change. This is the approach that will inform my approaches to dismantling any forms of systemic imbalances at The Tavistock and Portman NHS Foundation Trust.