Why we need to focus on race

'Why Race? There are eight other protected characteristics that need focusing on as well', is something that anybody who has ever championed race equality will have heard.

As an organisation that is committed to being actively anti-racist and taking action against structural racism, we recognise there remains a significant case to maintain a focus on race equality.

When considering equality, diversity, and inclusion (EDI) issues in the NHS, we believe it is important to consider all protected characteristics enshrined in the Equality Act 2010, as well as a person's socio-economic background. It is also important to apply an intersectional lens, (how a combination of a number of specific characteristics can lead to or perpetuate distinct forms of discrimination or disadvantage). Analysing each of the multiple categories on their own would still not provide an accurate picture of how people's rights are respected, protected, and fulfilled, and that some accrue more privileges or power than others because of the intersecting categories in which they are simultaneously positioned.

Although there is no hierarchy within the protected characteristic groups, we must acknowledge the strong body of evidence on race inequalities. Data from across the NHS tells us that race is often associated with the worst outcomes.

Ethnic minority staff make up a significant proportion of our NHS workforce

Ethnic minority workforce representation is at 22% in the NHS, higher than in the working population overall, and making them the largest minority community within the NHS.

• 22% of NHS workforce are made up of ethnic minority staff (June 2021)
• 25% of NHS nurses are made up of ethnic minority staff (June 2021)
• approximately 45% of hospital doctors and at least 32% of GPs in the UK are from minority groups
• In England, data from September 2020 suggests ethnic minorities make up 17.8% of the lower-paid workforce and that ethnic minority staff tend to be over-represented in lower-paid, commissioned-out and outsourced roles.

In some individual trusts the ethnic minority staff count is far higher than both the local and/or national average e.g., Imperial College Healthcare NHS Trust has a 59% ethnic minority workforce against a London average of 40.2%.

The NHS workforce is disproportionately made up of women and those from ethnic minorities. Women continue to be underrepresented in leadership positions, and ethnic minority women have a disproportionately lower board presence than white women.

There is evidence of significant inequity in workplace experience for ethnic minority staff

Data from across the NHS including the NHS staff survey and Workforce Race Equality Standard (WRES) have highlighted inequities in experience between ethnic minority staff and their white counterparts across several areas including:

• Recruitment, with ethnic minority staff 1.6 times less likely to be appointed than their white counterparts
• Ethnic minority staff were more than 1.25 times more likely than white staff to enter the formal disciplinary process in 50% of NHS trusts
• An increased likelihood of ethnic minority registrants being referred to their regulators by their employers
• Higher percentages of ethnic minority staff (28%) experiencing bullying and harassment than white staff
• Lower levels of ethnic minority representation at senior levels of the NHS.

Despite years of monitoring organisational race equality data, progress towards reducing disparities continues to be slow. Our member insight tells us there is need for continued support to identify more evidence based, outcome focussed interventions.

Investing in and supporting a diverse workforce  

The NHS faces significant workforce challenges and needs to improve staff retention. The NHS is becoming increasingly reliant on overseas recruitment, 18.5% of nurses, and one in three secondary care doctors have joined as international graduates. There are ongoing campaigns to recruit more internationally educated nurses and international medical graduates to help address the shortfall. However, poor workplace experiences including inequity in access to development, also impacts on retention.

It is important that we create an inclusive and compassionate environment, and invest in supporting our increasingly diverse workforce. Increased workforce diversity, coupled with an inclusive culture makes better business sense, with increased innovation, profitability, and productivity. McKinsey found in 2019, top-quartile companies for ethnic diversity outperformed those in lowest quartile for ethnic diversity by 36% in profitability.

Being actively anti-racist and addressing racial inequalities supports the development of inclusive and compassionate workplaces

The experience of ethnic minority staff can be viewed as a good barometer of the climate of respect and the culture in an NHS organisation as they often have the worst experience among minority staff groups. In improving their experience, reducing inequity and discrimination, we make improvements in organisational culture which positively impacts everyone, and improves the experience of all minority groups.

When a significant proportion of staff are having an inequitable workplace experience, there will be loss of psychological safety. Maslow’s hierarchy of needs demonstrates that without the basics of physiological and psychological safety we cannot develop the feelings of belonging that are needed to drive us forward in our aims to become inclusive and compassionate workplaces and support of workforce to achieve their full potential.

Racism is linked to negative health impacts

In addition to this, the links between racism and its subsequent impact on health outcomes were identified many years ago and brought back into stark focus by Covid-19 in 2020. Racism doesn't just present a moral and ethical issue but it is also a public health issue, with 63% of healthcare workers who died from Covid-19 being from ethnic minority backgrounds.

Population and health inequalities are inextricably linked

The King's Fund reported: "Among ethnic minority groups structural racism can reinforce inequalities, for example, in housing, employment and the criminal justice system, which in turn can have a negative impact on health".

NHS staff belong to the communities that they serve. Improving our awareness of how to support and create a sense of belonging in our ethnic minority staff, and better understanding their needs, supports us to understand and meet the needs of our ethnic minority patients better and work towards achieving more equitable health outcomes.

Addressing racism results in better patient experience

It is evidenced that there are clear links between staff experience and patient experience. Better staff experience results in higher levels of psychological safety, improved staff health and wellbeing, reduced absenteeism, fewer mistakes, and staff who are better able to meet the needs of their patients. The civility saves lives campaign has identified and brought together evidence showing the impact of incivility goes beyond the individual who directly experienced the behaviour into the wider team and impacts on patient care. In creating organisations where the experience of diverse workforce adds to a culture of learning from one another will enable organisations to better support diverse populations and improve their experience of our service.

Our members recognise the need to lead by example

Through our member survey on race equality, only 4% of respondents felt that race equality is fully embedded as a core part of their board’s business. All respondents described their ambition to listen more closely to staff about their experience. Leaders recognised the need for greater support for their workforce, particularly for those experiencing discrimination, while only 22% have made progress in actions to retain ethnic minority staff.

NHS Providers also recognised the need to lead by example in this space and our four-year strategy made race equality a key priority. We embarked on two closely related workstreams as a result. Our first was based on a recognition that we could only credibly work on this agenda if we looked at ourselves and held the mirror up to reflect on where we are as an organisation. The second was to engage with members to understand their own self-assessments of where they are in proactively tackling race inequality and what NHS Providers could do to accelerate the pace of change.

There was pressure to jump straight into action planning and delivery. But we have intentionally taken time to discuss, listen and think. To keep our focus initially on what this means for us personally – and we've had some challenging and difficult conversations as a result.

As an organisation, we've been working on an anti-racism statement that will unite all of us behind a clear ambition, alongside an action plan which will set out how we will embed a focus on tackling racism and promoting race equality throughout everything we do – in our influencing work with the national bodies, and in the support we provide to members. It will have clear success measures so we can be held to account by staff and members for translating our commitments into tangible change.

A focus on race equality is not done at the cost of other protected characteristics, but in improving the experiences of the most affected group you improve the experiences of all.