Representation

Participants frequently linked representation to visibility, belonging and confidence in leadership progression. While diversity within the wider NHS workforce has increased over recent years, many respondents described a perceived lack of representation within senior leadership positions. The findings suggest that representation extends beyond numerical diversity alone, influencing aspirations, confidence in progression opportunities and perceptions of organisational commitment to race equality.  

The importance of representation within NHS leadership has been widely recognised throughout the literature, particularly in relation to visibility, aspirations, belonging and confidence in career progression. The Snowy White Peaks of the NHS report (Kline, 2014) first highlighted the underrepresentation of ethnic minority staff within senior leadership roles, while more recent evidence from the Workforce Race Equality Standard (WRES, 2025) and the NHS Race and Health Observatory (2024) suggests that progress has been uneven across organisations and leadership levels. Despite increasing workforce diversity, ethnic minority staff remain underrepresented within many executive, board and senior decision-making positions. Previous research also suggests that visible role models can strengthen aspirations, increase confidence in progression opportunities and reinforce perceptions that leadership positions are attainable (NHS England, 2017; Wales Centre for Public Policy, 2021; Blake et al., 2025).  

Survey findings

Survey findings highlighted widespread concerns regarding leadership diversity across NHS organisations.

Overall, 72 per cent of respondents disagreed with the statement: ‘I regularly see people from my background in leadership roles.’

Disagreement was evident across all ethnic minority groups and salary bands, suggesting that concerns regarding representation were widespread rather than isolated to specific groups. 

Perceptions of underrepresentation were consistently high among respondents in senior roles. Among band 8 respondents, 74 per cent disagreed that they regularly saw people from their background in leadership roles with similar findings among band 9 and VSM respondents (72 per cent). These findings may reflect differences in how leadership is perceived across grades, with more junior staff potentially viewing band 8 colleagues as senior leaders, whereas those already occupying senior positions may look towards board and executive-level representation. For respondents at band 9 and VSM level, the findings may also suggest experiences of isolation and a sense of being one of very few people from their ethnic background within senior leadership environments. 

Respondents also reported concerns regarding diversity across leadership structures more broadly. Approximately one third of respondents disagreed that they worked within an ethnically diverse environment, with disagreement increasing at higher salary bands. While 27 per cent of bands 1 to 5 respondents disagreed with this statement, this increased to 37 per cent among band 8 respondents. 

The findings suggest that while diversity may be visible within parts of the NHS workforce, many participants continued to report a lack of visible role models and questioned whether leadership positions were realistically attainable. This finding reflects wider evidence suggesting that the absence of visible role models can influence leadership aspirations, career confidence and perceptions of progression opportunities amongst underrepresented groups.  

Representation has improved in some areas of NHS leadership, but progress has been uneven and many ethnic minority staff continue to report that leadership does not reflect either the diversity of the NHS workforce or the communities it serves (WRES, 2025).  

Importantly, the findings also highlight the need to avoid treating ethnic minority staff as a single homogeneous group. Wider NHS evidence suggests that black staff remain particularly underrepresented within senior leadership positions and continue to experience less favourable career outcomes across several workforce indicators, including: 

• lower representation at board and VSM level
• lower likelihood of appointment from shortlisting
• higher rates of formal disciplinary action
• poorer experiences of discrimination and career progression.
  (WRES, 2025; NHS Race and Health Observatory, 2024). 

These differences highlight the importance of understanding where inequalities persist and ensuring that interventions are informed by the experiences of specific groups, rather than assuming a single ethnic minority experience. 

Interview findings

The qualitative interviews reinforced the importance of representation within NHS leadership. Participants frequently reflected on the impact that visible leadership role models can have on aspirations, confidence and perceptions of what is possible. Two interviewees described how seeing people from similar backgrounds in leadership positions can provide reassurance that progression is achievable and that leadership pathways are accessible. 

Interviewees also highlighted the distinction between representation and inclusion. While participants acknowledged examples of increasing diversity within leadership structures, several questioned whether representation had translated into meaningful influence, equitable opportunities or changes in organisational culture. 

One participant described the importance of building representation throughout leadership structures rather than focusing solely on senior appointments:

Participants suggested that representation should be evident throughout leadership pathways and decision-making structures rather than being concentrated within a small number of senior positions.  

The interviews also highlighted the additional pressures that can accompany underrepresentation within leadership environments. Several interviewees described heightened visibility, increased scrutiny and a sense of responsibility to represent the experiences of wider communities. As one participant explained:

Several interviewees reflected on the emotional labour associated with being a ethnic minority leader within NHS organisations. Participants described carrying additional responsibilities, including representing diverse communities, challenging inequity and supporting other staff, often alongside the demands of their substantive leadership roles. Several interviewees described this as an additional emotional burden that contributed to fatigue and thoughts of leaving. This reflects the findings of Race 2.0: Time for Real Change (The NHS Alliance, 2022), which highlighted the ‘double burden’ often experienced by ethnic minority staff and leaders, who are frequently expected to champion race equality and support others while also undertaking their substantive leadership responsibilities. 

Overall, the interviews suggest that representation is important not only because of who occupies leadership positions, but because of the messages it sends regarding opportunity, belonging and organisational commitment to equity. The findings indicate that increasing representation remains an important priority, but that meaningful progress also requires leadership environments where ethnic minority staff feel included, influential and supported to succeed.

Summary

Representation remained an important issue throughout the findings. While participants recognised examples of progress, many continued to report a lack of visible diversity within senior leadership roles. Representation was closely linked to aspiration, belonging and confidence in progression opportunities, but participants consistently emphasised that representation alone is insufficient unless it is accompanied by inclusion, influence and equitable access to leadership opportunities. 

For many participants, the question was not simply whether ethnic minority leaders were present within leadership structures, but whether leadership environments genuinely reflected, understood and supported the experiences of ethnic minority staff. Two participants also described the additional burden of championing race equality, representing wider communities and supporting colleagues alongside their substantive leadership responsibilities. The findings suggest that this ‘double burden’ cannot continue to rest disproportionately with ethnic minority staff and leaders alone. Instead, participants highlighted the importance of greater allyship and shared leadership responsibility, with race equality viewed as a responsibility of all leaders rather than those with lived experience alone.