Is Inclusive and Compassionate Leadership in the NHS a Calculated Delusion?

Despite my abiding respect for the National Healthcare System (NHS): its strength is its resilience yet it is all too often treated like a political football – every political party that comes into power kicks it in a different direction, thereby creating a state of tension and flux. The NHS has the best of values and a daunting social purpose, but this is not reflected in the government’s funding models that are underpinned by a New Public Management ethos and neoliberalism where primacy is given to economic growth and performance cultures that have created highly volatile conditions and unintended negative consequences because of the aggrandizement of leadership and management as the panacea of its perceived ills.

While I am in awe of the NHS, both as a patient and as an employee, I am aware that the sector is not an innocent or passive victim: it is made up of different organisations (Trusts): these are consciously coordinated social entities that have patterns of beliefs, practices, espoused values, cultures and philosophies that guide them towards achieving certain goals. Some of the challenges are self-inflicted and deep-seated. On several occasions I have found myself conceptualising the NHS through the African analogy of “the mouth that ate itself” and through the idiom, “when you act like a rotten plum, bats will eat you”.

Therefore, this critical reflection is a moment for discomfort, learning and respectful understanding. Everyone who reads it will benefit. But those who will benefit particularly are the ones willing to explore how social power and privilege work within NHS organisations. My perceptions are influenced by the field of Critical Management Studies (CMS), a movement that critiques established social practices and institutional arrangements; a discipline that proceeds from the assumption that the dominant theories and practices of management and organisation systematically favour some (elite) groups and their interests at the expense of those disadvantaged by them. CMS argues that aggrandizement of management and positive representation of management and organisations is an uncritically one-sided ideology of elites – there is often a dark side of contemporary organisations and their leadership: both have many negative implications and impacts on society which merit scrutiny (Alvesson et al, 2009).

A couple of weeks ago whilst on my summer holiday on a boat cruise on Loch Ness in the Scottish Highlands – I found myself reflecting and trying to make sense of the dominant culture in the NHS, the way things are done, and about things that are taken for granted and never questioned. When the tour guide talked about the elusive large, long-necked Monster with humps that protrude from the dark water of Loch Ness, I couldn’t help but conceptualise the NHS through the lake and ‘Nessie’:

• Loch Ness is majestic: stretches for about 23 miles in length (approximately 37km), 1.7 miles (2.7km) wide and 755 feet (230m) deep.
• It is believed that there is a monster (Nessie) in the lake – the first sighting was made by Saint Columba an Irish monk in the 17th Century, and the first photograph taken in 1933.
• Several million tourists have visited Loch Ness to spot the water monster – there is anecdotal evidence, photographs, videos, sonar readings and over 1000 sightings that have been added to the official Nessie register and there have been three in 2023.
• The scientific community is still baffled and unable to confirm Nessie’s existence.
• Out of curiosity, I sought the perspectives of five elderly natives of the Scottish Highlands when I was in Inverness, and they were convinced that there is an “unexplained object that lives in the still dark waters of Loch Ness”.
• However, upon my return to England, I was told by many that “Nessie is a hoax, it’s a tourist trap, its wishful thinking, it’s just folklore…”

So, why did my tour of Loch Ness transport me back to work in the NHS whilst I was on my holiday?

Every news channel on TV covered the sentencing of Lucy Letby, the 33-year-old Neonatal Nurse who was convicted of murdering seven babies and attempting to kill six more at the Countess of Chester Hospital when I was on holiday.

Therefore, in my world Loch Ness represented the NHS – the magnanimous institution that hides several monsters in its deep dark waters. However, in this piece I will only juxtapose the deep-seated racism and white privilege: these realities were unmasked by Lucy Letby’s saga. If Lucy Letby were Black – she was never going to be enabled to become the UK’s most prolific baby serial killer, she was going to undergo formal investigation and face disciplinary action the moment there was a whim or suspicion of malpractice. In her case, Paediatricians who used their professional judgement to “spot the monster” bedevilling the NHS were made to apologise to her – that is how white privilege works in the NHS, you are enabled and protected because of your race and ethnicity.

I appreciate that this is a considerable charge to level at the NHS, so to help you visualise the scale of the challenge let me give you key findings of the 2022-23 Workforce Race Equality Standard (WRES) – you might also spot the ‘NHS Monster’. On paper, the NHS has the People Plan and the People Promise; both declare a commitment to creating and maintaining a compassionate and inclusive culture where diversity is valued and celebrated as a critical component, and not just a desirable one. Also, there was an Increase of over 27, 500 staff from a Global Majority background in the last year – this places the increase in number of staff from minoritised ethnic backgrounds over the last 5 years at 100,000, they now constitute 24.2% of the overall NHS workforce.

However:

• In all NHS trusts staff from minoritised ethnic groups experience more bullying harassment and abuse from colleagues than their white counterparts.
• In all NHS trusts, a higher percentage of BME staff than white staff experienced discrimination from their managers, team leader or other colleagues.
• In all regions except London, a higher percentage of staff from Global Majority backgrounds have been harassed, bullied, or abused by patients, their relatives or the general public than white staff.
• Staff from minoritised ethnic backgrounds are 1.14 times more likely to enter the formal disciplinary process compared to white staff.
• White applicants are 1.54 times more likely to be appointed from shortlisting compared to applicants from Global Majority backgrounds.
• In all regions, there is a lower proportion of Black Asian and Minority Ethnic board members compared to the overall percentage of Black, Asian and Minority Ethnic staff in the workforce.
• 35.4% of staff from a Black background believe their trusts provide equal opportunities for career progression or promotion – this figure is lower than those of other ethnic groups and this has been the trend since the introduction of WRES in 2015.
• In 99.5% of NHS trusts, a lower percentage of staff from minoritised ethnic backcgrounds feel that their trust provides equal opportunities for career progression or promotion than white staff.
• In all regions, a lower percentage of staff from minoritised ethnic backcgrounds feel that their trust provides equal opportunities for career progression or promotion than white staff.
• Almost 50% of the NHS workforce in the London region comes from a Black Asian and Minoritised Ethnic background. With board representation of 16.4%, London has the largest disparity. However, this negative trend is seen in all regions - Exec Board Member representation nationally is 9.6%, yet staff from a Global Majority background constitute 24.2% of the overall NHS workforce.

Just like ‘Nessie’, the deep dark water monster, some have sighted or witnessed racism in the NHS, some have experienced it and some live through it each day. There is overwhelming evidence that it exists, but some continue to question or deny its existence, gaslight those with lived experiences or minimise their accounts. ?

One is reminded of an African proverb that says, “The cockroach cannot be innocent in a court where the hen is judge” and the maxim that is espoused in the legal discourse that says, “Who comes into equity must come with clean hands”. If you are tired of hearing my complaints and emotional disquiet about racism or perceive yourself as colourblind and conceptualise racism through the lenses of a Eurocentric media and have never engaged critically with literature on Black History, Slave Trade and colonialism and thus become fragile in difficult conversations about racism – you are part of the problem. Educate yourself about racism and become an active ally. Racism is not individual acts of meanness; it is a system of advantage that is based on race and is backed by authority hence the WRES data presented above and the phenomenon of Lucy Letby.? ?