Don’t shoot the Messenger

Apologies for this blog being longer than usual.

The Messenger Review on NHS and Social Care Leadership? https://tinyurl.com/yszx7mb9 ?was heralded by Tory-leaning media as part of the “war on woke”.

?It is nothing of the sort.

?In fact, the Review argues for:

“a renewed sense of respect and value amongst an empowered workforce, delivered through committed, compassionate leadership from bottom to top” - precisely what research highlights as key to improved engagement, retention, productivity and improved staff care and safety.

?It recognises this is a challenge since it is not the current experience of many NHS staff (at all levels) compounded by what the report summarises as:

“short term political demands, combined with internal pressures such as staff shortages, budget issues, sectoral disparity and pandemic induced backlogs to create a very difficult backdrop for compassionate leadership and collaborative, inclusive behaviour to thrive”

?The Review rightly rejects objections that this is a luxury the NHS cannot afford

“The hard fact is that this must be prioritised alongside the pressing operational needs, and we should be ready to deploy the justification that spending time and resource on looking after the workforce will quickly repay the investment through improved support to patient and service users.”

?The Review emphasises the central importance of equality, diversity and inclusion in improving patient care and safety accepting that:

“although by no means everywhere, acceptance of discrimination, bullying, blame cultures and responsibility avoidance has almost become normalised in certain parts of the system”

It argues that

“how an organisation performs and behaves in relation to?EDI?is a clear indicator of its maturity and openness. Further, it will be a clear determinant of how an organisation fares in a rapidly changing social and work context. In this regard, we found that?EDI, which is about respectful relationships and underpins a wider culture of respect, is partial, inconsistent and elective. In some places it is tokenistic.”

Implementing fair and effective career progression

The Messenger Review is about leadership and so here are some thoughts on implementing its recommendations on EDI, talent management and career progression. In places, the Review reads like a preface to the No More Tick Boxes report published by East of England NHS last year which argued for a radically new research driven approach. https://tinyurl.com/mrbxuy6n

The report highlights five key issues on EDI and career progression.

1.??Inclusive leadership practice

The Messenger Review says we must:

“Embed inclusive leadership practice as the responsibility of all leaders…..educate leaders to ensure they understand their role in demonstrating and improving inclusive leadership. This must include a more central role for?EDI?in leadership training and development which, in turn, requires greater skills and understanding of the topic from those delivering the training

And that we must:

“Commit to promoting equal opportunity and fairness standards.”

Leaders who wish to act in this way must openly acknowledge there is a serious problem of discrimination in career progression in the NHS and social care and that they bear much responsibility for it. They means that such leaders must relentlessly become allies of those staff groups who are disadvantaged by current recruitment and career progression practices. No More Tick Boxes summarised the research on how each of gender, disability and race discrimination could be tackled in recruitment and career progression ?and all three are challenges in the NHS and social care.

Action needed. Embedding inclusion means

• ·????????applicants to management posts, especially senior posts required to demonstrate what they have personally done to promote equity.
• ·????????managers and especially senior leaders taking time to reflect on their own roles and practices, placing themselves in the shoes of those disadvantaged by discrimination and being relentlessly proactive in changing behaviours and practices contributing to discrimination, including within career progression.
• ·????????leaders who understand that embedding inclusion requires it to be seen as a core part of improvement work, underpinned by accountability.
• ·????????they must be prepared to have uncomfortable discussions, in particular about racism.

1. Appraisals.

?The Report rightly identifies these as currently flawed, calling for a

“A more effective, consistent and behaviour-based appraisal system, of value to both the individual and the system.”

Action. This is correct. But to be effective, appraisals must also:

·????????move towards a coaching framework

·????????address the risk of bias which especially arises towards women, disabled staff and Black and Minority Ethnic staff not just in appraisals, but in interview feedback and in how stretch opportunities are allocated.

·????????involve peer review to embed both scrutiny and consistency - and forms of monitoring - so that outcomes for all groups of staff with protected characteristics move towards being similarly represented in a Bell Curve of results – whilst senior managers ask why, and intervene, if they do not.

For more information see No More Tick Boxes ?pages 91-97

2. Stretch opportunities

?Messenger argues:

“Improving?EDI?is also a way of reframing career progression. The latter frequently depends on chance, contacts, regional variation, available time and budget. By training leaders to identify where such unfairness exists, access to opportunities will become allocated more fairly, and career progression will be determined more equitably.”

Stretch opportunities, rather than just going on courses, are the most important single contributor to career progression. To ensure fairness, NHS employers must be proactive, establishing inclusive talent management access and progress ending any reliance on the “tap on the shoulder”. Most should be regarded as opportunities for positive action so under-represented groups get a more level playing field. https://tinyurl.com/bd988xh4

Action. This should mean

• ·????????every NHS organisation formalises and monitors access i.e., advertising and considering as positive action any significant project opportunities, acting up or secondments.
• ·????????Access may be via the talent pools that some organisations have developed and it should be monitored with outcomes challenged where appropriate (and good practice shared).
• ·????????Data driven monitoring should lead to challenge where access is not equitable

For more information see No More Tick Boxes pages 70-90

3. Accountability:

Messenger recommends NHS organisations should:

“More stringently enforce existing measures to improve equal opportunities and fairness”

and

“Teams and organisations should set year-on-year goals for improvement, for example by increasing the representation of under-represented groups in training, in development opportunities, and in senior roles”

Research is clear: three crucial elements of a fair, inclusive, recruitment and career progression strategy are:

• Leaders who understand discrimination and inclusion and are aware of their own crucial role and are proactive in promoting equity
• An emphasis on debiasing processes rather than primarily relying on diversity training
• The importance of data driven accountability to enable proactive interventions of support and accountability.

?That does NOT mean command and control. But it does mean we stop thinking that lots of “activity” on EDI and career progression is a substitute for evidenced interventions and strategy. For example, the NHS data on the relative likelihood of White staff being appointed from shortlisting compared to Black and Minority Ethnic staff is exactly the same as last year i.e. it is still 1.61 times more likely The NHS staff survey shows it remains twice as likely that BME staff do NOT think there are equal opportunities for career progression and promotion as white staff do.

Similarly, on Disability 59% of trusts have 5 or fewer senior staff (i.e. clinical and non-clinical staff at Bands 8C+, medical consultants, and Board members) who declared a disability whilst 59% of trusts have no Board members who declared a disability at all.

Action. NHS organisations should be expected to

• Establish real time EDI dashboards to capture data on recruitment, career progression, bullying, discipline, retention and discrimination which can enable organisations to analyse progress and challenges
• Use that dashboard so that divisions, departments, occupations and services can understand where they are making progress and where they are not. That data should then be used to provide support and challenge with an emphasis on the former, but the use of the latter via KPIs where needed.
• Specific interventions around aspects of the recruitment and career progression cycle should include scrutiny of each stage of the career cycle to mitigate bias – for example on access to stretch opportunities, and patterns of interview outcomes
• Boards need to insist on concerted efforts at positive action to build confidence and level the playing field
• Be clear that staff networks should be one way in which Boards have their feet held to the fire to act on these imperatives.

Nationally we should be

• Creating a national repository of good practice and support to NHS organisations is a priority to be properly resourced, drawing on work already underway. I struggle to understand why this was not established ages ago.
• Setting out a clear evidence-based methodology for employers to follow, albeit adapted to local circumstances
• Evaluating interventions, not as performance management, but as a learning process,

There is more information on accountability in No More Tick Boxes pages 45-64

External accountability might take a number of forms but Messenger recommends:

“Enhance CQC role in ensuring improvement in EDI outcomes”

Action. Discussions on this have been underway for a considerable time between NHS England and CQC. How is it possible that a Trust with poor WRES or WDES results is rated as “Well Led”?

Accountability involves setting a few goals with expectations of delivery at every level – internal and external - alongside support. Simply relying on “command and control” alone won’t work, but neither will keeping fingers crossed and “hoping for the best”. NHS England/Improvement must both lead by example and hold both itself and local employers to account where WRES or WDES data is flatlining or making only glacial progress.

4.??Who should be responsible for this work?

The Messenger Review states:

“We advocate a step-change in the way the principles of equality, diversity and inclusion (EDI) are embedded as the personal responsibility of every leader and every member of staff.

Health and social care must work harder at?EDI, recognising it is important in its own right, and key to how seriously an organisation treats the lived experience in the workforce and upholds practices that deliver equitable outcomes for all. Beyond mainstreaming, we also recognise the need for positive action.

It is the task of leaders at every level to cultivate the conditions for individuals to overcome entrenched and often unacknowledged disadvantage, by ensuring staff recognise and remove subtle exclusionary practices, and by working to remove the set of unspoken assumptions that favour certain groups in terms of career advancement. Dedicated?EDI?professionals exist to enable this transition. We would anticipate the numbers of dedicated experts to reduce as they successfully instil such awareness in leadership at all levels.”

Contrary to the spin from some Tory media outlets, Messenger is not suggesting abolishing EDI professionals. It is a mistake to not acknowledge that in most organisations they also have a responsibility for health inequalities.

Action

• ·????????Support for these staff with proper training, support and recognition and recognition of their role is crucial but the role must also change to being an improvement role, not just a compliance one. Their workforce expertise should be consolidated as a crucial part of the work of HR, OD and quality improvement professionals with direct Board oversight
• ·????????There must be sufficient EDI resource to support health inequalities work given that these have finally become a top policy priority

·????????Priorities?

The Messenger Review states:

“There is widespread evidence of considerable inequity in experience and opportunity for those with protected characteristics, of which we would call out race and disability as the most starkly disadvantaged (my emphasis)”

Disability is acknowledged as a major challenge but the work of the WDES team seems under-appreciated. They are capable of decisively shaping effective interventions and we should insist that is what happens.

But race is the issue leaders and managers at all levels find it hardest to have honest discussions about and where we know the data has hardly moved. Individual and collective discussions are too often characterised by a relentless defensiveness. Racism is morally offensive, contrary to the NHS Constitution and the employment contracts of staff, but the NHS often still fails to act decisively. Moreover, there is a wealth of evidence that discrimination (notably on race) against staff impedes not only staff health, well-being, opportunities and retention, but undermine organisational effectiveness and above all, undermines patient care and safety https://tinyurl.com/4n59vbsf ?

When a house in a street is on fire, the fire engine doesn’t stop at every house, it starts with the house on fire.?Race (and to a substantial degree disability) are the houses we must especially pay attention to at the moment whilst challenging all forms of discrimination not least because intersectionality makes that impossible anyway. ?But unless we can address race and disability, we will fail to address the greatest current EDI challenges.

The suggestions (which I have heard) that “we’ve put loads of effort into race and it’s time we put equal effort into other EDI issues” will only have one result – a downgrading of work on the most challenging aspects of discrimination.

Conclusion

Messenger is not, as some have suggested, “just another report like the Rose and Kerr reports”. Those reports failed to understand the cultural change, especially on EDI, that is needed and advocated.?

But Messenger’s emphasis on EDI and culture is like a breath of fresh air and reflects what research says must underpin effective leadership and staff management in health and social care. The recommendations on EDI, and career progression and talent management should be near the top of every ICS agenda.

There is reference in Messenger to a Review Implementation Office “to provide and drive the pace and scale of the implementation of this review.” but unless there is direct relentless sponsorship from the very top, with serious representation of those who will “hold feet to the fire” based on lived experience, and driven by evidenced interventions, Messenger’s recommendations will sink into the sand.

My greatest fear is the stellar ability of the NHS in particular to proceed at snail’s pace on this issue and sink into a morass of working groups, policy pronouncements, turf wars, fudge, caution and PR.

It is nearly two years since The NHS People Promise was published and we are no further forward on equitable recruitment and career progression. ?

Research tells us what is most likely to work. Messenger is a green light to get on with it. Can we please do that, for the sake of patients as well as staff?

Roger Kline is Research Fellow at Middlesex University Business School.