Ensuring an equity-based approach to organisational restructuring

The NHS financial reset has meant trust leaders are having to make tough decisions whilst also trying to protect patient safety and deliver the best possible patient care. In the NHS Providers survey with trust leaders on the impact of the financial reset, 86% of respondents said they will have to cut substantive non-clinical posts in order to deliver their financial plan this year (NHS Providers, 2025), a further 13% have this under consideration. Over a third (37%) of respondents said their organisation will cut substantive clinical posts to deliver their financial plan and help balance the books, with a further 40% saying this is currently under consideration.

We know that the NHS workforce is our greatest asset. We also have a wealth of evidence that diverse organisations and teams with inclusive and psychologically safe cultures lead to better patient care. So, whilst restructures and redundancies may be unavoidable if the NHS is to live within its means, it has never been more important to ensure trust boards bake an equity and person-centred approach into these very challenging processes. To do otherwise risks exacerbating inequalities with the inevitable impact on staff morale and wellbeing and knock on effects on organisational culture and patient safety (Kline, 2019).

Research shows that job losses and restructures often inadvertently have a negative impact on marginalised groups (Unison, 2017) (Business in the community, 2014) including ethnic minority, disabled staff and women. Trust leaders need to start with assuring themselves that their policy and approach has been equality impact assessed, understand how redundancy may change the diversity of their workforce and what steps they can take to mitigate this risk.

In our recent NHS Providers survey, 66% of trust leaders were concerned that actions they need to take to deliver operational priorities will compromise staff wellbeing. We know that failure to provide adequate support to staff that remain can also lead to higher turnover rates in the months following a restructure, as well as increases in errors and decreases in quality and service user experience, underlining the need for focus on equity and well-being at every step of the process (The Prince's Responsible Business Network, 2024).  

A key element of our programme is equipping boards to ask challenging questions of themselves and each other. The following questions emerged from our conversations with leaders as helpful and significant when undergoing organisational restructure to bring these equity and well-being considerations to the fore. 

Questions for boards

1. Does the redundancy policy comply with legislation? 
   The policy /procedure should make clear how the trust will meet its duty in respect of the Public Sector Equality Duty (S149 of the Equality Act 2010).
   
   
2. Has the redundancy policy been the subject of a thorough and robust equality impact assessment (EIA) to ensure fairness and consistency in the treatment of all employees?
   EIA’s assist in assessing the likely or actual impact of policies on people with protected characteristics. A robust EIA process can assist in identification of opportunities to promote equality that may have otherwise been missed and increase awareness of and facilitate removal or mitigation of adverse impacts wherever possible.

3. Has the planned change/decision, including selection criteria, been evaluated for equality purposes?
The planned changes and the anticipated impact of the decision and identified selection criteria should be evaluated for equality impacts. The selection criteria should be scrutinised to ensure they do not unintentionally identify a disproportionate number of individuals with one or more protected characteristic, e.g., not basing criteria on performance, sickness absence or time served. Where a policy or procedure is found to have a negative impact, what alternative criteria and procedures could be put in place as a mitigation (NASUWT, 2017)?

4. What data sources have informed our understanding of the workforce impact? 
Ensuring you have an up to date understanding of the current diversity of your workforce is essential (The Prince's Responsible Business Network, 2024) . Trust leaders should use available workforce diversity data, including Workforce Race Equality Standard, (WRES), Workforce Disability Equality Standard (WDES) and NHS Staff survey to understand the diversity of profile of those being impacted and any disproportionality that may occur. All information should be clearly documented.

5. Will the proposed changes result in a change to the organisational diversity profile and if so, what will the long-term impact of this be, both to staff morale and against organisational commitments on Equality, Diversity and Inclusion?
We know that inclusive, diverse teams where staff feel a sense of belonging and psychological safety is linked to improved levels of patient safety. The board should consider how this may be affected if the diversity of the workforce is changed substantially.

6. How do the service changes as a result of the restructuring impact on marginalised groups and those who are more likely to experience health inequalities?
Alongside the impact on staff, has the equity impact of the proposed changes on service users and patients been considered and any mitigations explored in the current financial circumstances and acted upon?

7. How will processes maximise inclusion and tackle existing structural inequalities? 
Trust leaders should consider insights on related processes, including the likelihood of a white or non-disabled candidate/ being appointed from shortlisting over an ethnic minority or disabled candidate (NHS Providers, 2024), and consider the opportunities to develop more inclusive processes as part of the raft of support measures implemented.

8. What support will be offered to those who may be affected by the restructure, such as wellbeing, training or redeployment assistance?
The impact of restructures can have significant effect on employee wellbeing. Clear plans should be in place to support this and minimise loss of trust for staff who remain in the organisation.  Work to address existing inequalities should be considered in the context of the restructure so progress made thus far is not lost. 

9. How have the equity impacts of the restructure and redundancies proposals been captured within the risk register? 
Does the risk register provide evidence and assurance that you’ve considered the equity implications of your change programme and have robust mitigations for each step of the process?

10. Has the trust identified how they will measure the impact of the restructure and any key learnings to be identified?
What processes are in place to monitor the change/ impact of the restructure on patient outcomes, staff experience, morale and workforce diversity beyond any expected pay related savings.