BMJ 2015;351:h3297 doi: 10.1136/bmj.h3297 (Published 8 July 2015) Analysis Page 1 of 5 ANALYSIS Promoting equality for ethnic minority NHS staff—what works? NHS organisations are now being judged on indicators of ethnic diversity. Naomi Priest and colleagues look at the international evidence on how they should tackle discrimination Naomi Priest senior research fellow12, Aneez Esmail professor3, Roger Kline research fellow4, Mala Rao professor5, Yvonne Coghill director, Workforce Race Equality Standard implementation6, David R Williams Florence Sprague Norman and Laura Smart Norman professor of public health 7 8 9 1Alfred Deakin Institute for Citizenship and Globalisation, Deakin University, Melbourne, Australia; 2Centre for Health Equity, Melbourne School of Population and Global Health, Faculty of Medicine, Dental and Health Services, University of Melbourne, Australia; 3Institute of Population Health, University of Manchester, Manchester, UK; 4Middlesex University Business School, London, UK; 5Department of Primary Care and Public Health, Imperial College, London, UK; 6NHS England, London, UK ; 7Department of Social and Behavioral Sciences, Harvard T H Chan School of Public Health, Harvard, USA; 8Department of African and African American Studies and of Sociology, Harvard University, USA; 9Department of Psychiatry and Mental Health, University of Cape Town, South Africa For decades research has shown that discrimination, harassment, and exclusion are pervasive experiences for staff from black and minority ethnic (BME) backgrounds in the National Health Service.1-6 In recognition of limited progress in achieving the goals of the now decade old NHS Race Equality Action Plan,7 the NHS has agreed a mandatory workforce race equality standard. The standard requires NHS organisations to collect baseline information from April 2015 on nine indicators of workforce equality for ethnic minority staff, including representation on boards, and to publish annual updates on these metrics (box). Organisations that fail to make progress on these metrics will be in breach of the NHS standard contract, and this will affect whether regulators judge them to be “well led.”8 9 We review the international evidence on the effectiveness of diversity initiatives to assess how best to achieve the standard’s intended outcomes. Discrimination experienced by NHS staff Discrimination against BME staff within the NHS reflects wider discrimination, racism, and health inequalities in the UK10-14 and globally.15 Ethnic minority NHS staff experience discrimination in training and recruitment and are three times less likely to secure a hospital job than white doctors,16 a situation that has changed little in 20 years.17 Inequities also exist for clinical excellence awards (performance related bonuses for consultant staff) and career progression opportunities, with evidence of substantial under-representation of BME staff in senior leadership positions.1-18 Rates of discrimination, bullying, and harassment are higher among ethnic minority NHS staff than among white staff, and the behaviour may be perpetrated by managers, team leaders, colleagues, or patients and relatives.1 19 BME staff also witness discriminatory treatment of BME patients1 and employers are less aware of bullying and harassment problems experienced by minority staff than they are of incidents among white employees.19 Discrimination is harmful not only to the individual but to the wider NHS. Surveys of NHS staff and inpatients of acute trusts show that the prevalence of discrimination against BME staff is one of the strongest predictors of lower scores on multiple indicators of patient satisfaction and quality.20 The quality of healthcare and economic efficiency can also be reduced when the senior leadership of healthcare organisations does not reflect the ethnic diversity of the communities they serve.21 22 Self reported discrimination is adversely related to a broad range of health outcomes, preclinical indicators of disease (such as cortisol and inflammatory dysregulation, visceral fat, and shorter telomeres), and health risk behaviours.23-26 Evidence of effective strategies Diversity in teams has many benefits, including improved innovation, creativity, and decision making, which can lead to breakthrough discoveries and improve corporate profits.27-30 Several studies show that racially diverse groups outperform homogenous groups in decision making tasks that require information sharing.28 Positive staff experiences within an NHS trust also predict better outcomes for that trust, including employee engagement, improvements in workforce, and job satisfaction.31 So what is the best way to tackle discrimination Correspondence to: D R Williams dwilliam@hsph.harvard.edu For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe BMJ 2015;351:h3297 doi: 10.1136/bmj.h3297 (Published 8 July 2015) Page 2 of 5 ANALYSIS Indicators for the workforce race equality standard Workforce metrics For each of these four workforce indicators, the standard compares the metrics for white and BME staff • Percentage of BME staff in bands 8-9 (very senior managers, including executive board members and senior medical staff) compared with the percentage of BME staff in the overall workforce • Relative likelihood of BME staff being appointed from shortlisting compared with that of white staff being appointed from shortlisting across all posts • Relative likelihood of BME staff entering the formal disciplinary process, compared with that of white staff entering the formal disciplinary process, as measured by entry into a formal disciplinary investigation. (Based on data from a two year rolling average of the current year and the previous year) • Relative likelihood of BME staff accessing non-mandatory training and continuous personal development compared with white staff National NHS staff survey findings For each of these five staff survey indicators, the standard compares the metrics for each survey question response for white and BME staff • Percentage of staff experiencing harassment, bullying, or abuse from patients and relatives or the public in past 12 months • Percentage of staff experiencing harassment, bullying, or abuse from staff in past 12 months • Percentage believing that trust provides equal opportunities for career progression or promotion • In the past 12 months have you personally experienced discrimination at work from: Your manager or team leader? Other colleagues? Boards • Boards are expected to be broadly representative of the population they serve and promote diversity? Research suggests it requires multilevel, multistrategy, mutually reinforcing action.32 Evidence for mandatory standards Studies from a range of contexts indicate that mandated policy interventions to promote diversity that have legal or funding consequences are associated with better outcomes than non-mandated polices without seeming to harm significantly the economic wellbeing of white men.29-34 For example, in 2011 the UK National Institute for Health Research announced it would not shortlist any NHS or university partnership for grants unless the academic department held at least a silver Athena Swan award (recognising policies to promote sex equality). Institutions were given a limited time to achieve this equality standard. Early findings suggest large increases in women in leadership roles and in applications for Athena Swan awards since the announcement. 35 Similarly, a series of controlled experiments found compulsory diversity strategies to be effective in recruiting women for environments requiring competitive behaviour without reducing efficiency.36 Compulsory diversity policy has also been found to be effective in the US and Australian private sector,37 38 medical school enrolment,39 higher education,40-43 the police force,44 corporate boards in Norway,45 local government in India,46 and public administration in Macedonia.47 Mandatory diversity policies can take multiple forms.48 Quotas and numerical targets are often criticised because they may result in selection of unqualified candidates. Alternatively, threshold systems require all final candidates to meet clearly established minimum qualification standards, with only the ultimate selection favouring candidates from disadvantaged groups. Here the potential minority candidate is not compared with the highest achiever but assessed against a required benchmark for the job. Similarly, a tie break system, as included in the UK Equality Act of 2010,48 can be used when there are two or more equally qualified candidates, with selection based on a demographic characteristic (sex, race or ethnicity, disability, etc). A final approach that has had striking results in the US is the “Rooney rule.”49 Implemented in 2003 by the National Football League (NFL) after the failure of two decades of For personal use only: See rights and reprints http://www.bmj.com/permissions voluntary efforts, it requires all NFL teams to interview at least one minority candidate before a head coach or general manager job can be filled. Within three years, the number of black coaches recruited increased substantially, and three of six division titles went to teams with black coaches.49 Research also indicates that mandatory policies are more effective at achieving diversity than alternative approaches. Systematic analysis of corporate diversity policies of 708 US private sector organisations from 1971 to 2002 found legal establishment of leadership responsibility for representation of women and ethnic minorities in management positions had greater effects on managerial diversity than other strategies.37 In the UK voluntary reporting programmes have been ineffective in redressing gender pay gaps.50 Other predictors of success in increasing diversity in higher education in the US are core leadership support, resource allocation, evaluation, and rewards for diversity.51 52 For example, in less than a decade, a mandate implemented at the University of Michigan in 1988, doubled enrolment of minority students, increased minority faculty, improved rates of promotion, and increased appointments of minorities to university leadership positions.53 With this initiative, the university president had linked diversity and excellence as the two most compelling goals of the institution, established a campus-wide implementation committee comprising the second highest ranking official in each academic unit, and allocated 1% of the university’s budget, annually, to diversity initiatives.54 Beyond mandates Workplace diversity training programmes are ubiquitous but do not improve diversity in isolation.18 However, such programmes that move beyond awareness raising to focus on development of practical personal skills, ownership, and commitment should be part of a comprehensive diversity strategy alongside organisational processes and policies.18 55 Recruiting a critical mass of minorities is also important to reduce negative experiences of minority staff and see benefit.56 57 A Norwegian study of 317 corporate boards found at least three women were needed on boards for increased innovation.56 Subscribe: http://www.bmj.com/subscribe BMJ 2015;351:h3297 doi: 10.1136/bmj.h3297 (Published 8 July 2015) Page 3 of 5 ANALYSIS It is also essential to support minority staff and deal with the effects of any workplace discrimination. Organisational leaders need to create environments that are psychologically safe, support diversity through policies and processes that encourage open communication between employees without fear of negative consequences,58 and reduce isolation and exclusion. All staff should be trained in strategies to reduce conscious and unconscious biases, stereotypes, and discriminatory behaviour.59 Lessons for the NHS Most evidence on interventions to promote diversity comes from studies outside healthcare. Nonetheless, the consistency of findings across a broad range of organisational, national, and cultural contexts suggests there is much that may be applicable to the NHS. The evidence shows that success depends on the following: • Core leadership support that articulates diversity as a high institutional priority and organisational investment in supportive communication to all relevant stakeholders • Multiple strategies at organisational, workplace, interpersonal, and intrapersonal levels used simultaneously over a long period • Mandated targets or actions. At a minimum, the race equality standard states that NHS organisations should reflect the diversity of the nation at all levels within the organisation. Although some local communities may lack ethnic diversity, national organisations should strive to reflect the diversity of the wider UK population to optimise innovation and decision making. Use of a mandated diversity policy with contractual consequences is supported by the available evidence and is a recognition that the previous voluntary approaches have failed. However, a mandate is not sufficient to ensure that staff feel respected, valued, engaged, and supported. Implementation of multilevel policies should be underpinned by research documenting the experiences of staff and consequences of discrimination across the NHS for individuals, teams, and organisations and to examine the effectiveness of different strategies. Committing to change is imperative to ensure that the NHS is a workplace and healthcare provider that upholds human rights and social justice principles and is safe and healthy for all staff regardless of their backgrounds. Doing so is likely to benefit all patients, irrespective of their ethnic origin, as well as help redress ethnic health inequalities across the UK. Competing interests: We have read and understood BMJ policy on declaration of interests and declare AE and RK have both been involved in the development of the WRES since its announcement. NP was supported by an Alfred Deakin Research Fellowship, Deakin University, and by the Victorian Health Promotion Foundation (VicHealth). DW was supported by grant P50 CA 148596 from the National Cancer Institute. Provenance and peer review: Not commissioned; externally peer reviewed. 1 Stevenson J, Rao M. Explaining levels of wellbeing in BME populations in England. African Health Policy Network. 2014 www.leadershipacademy.nhs.uk/wp-content/uploads/2014/ 07/Explaining-levels-of-wellbeing-in-BME-populations-in-England-FINAL-18-July-14.pdf. 2 Limb M. NHS doctors face racism, exclusion, and discrimination, report finds. BMJ Careers 2014 31 Jul. http://careers.bmj.com/careers/advice/view-article.html?id=20018682. 3 Kline R. The “snowy white peaks” of the NHS: a survey of discrimination in governance and leadership and the potential impact on patient care in London and England. 2014. www.england.nhs.uk/wp-content/uploads/2014/08/edc7-0514.pdf. 4 Harris R, Ooms A, Grant R, et al. Equality of employment opportunities for nurses at the point of qualification: an exploratory study. Int J Nurs Stud 2013;50:303-13. 5 Archibong U, Darr A. The involvement of black and minority ethnic staff in NHS disciplinary proceedings. University of Bradford, 2010. www.nhsemployers.org/~/media/Employers/ Documents/SiteCollectionDocuments/Disciplinary Report Final with ISBN.pdf. For personal use only: See rights and reprints http://www.bmj.com/permissions 6 Kline R. Discrimination by appointment: how black and minority ethnic applicants are disadvantaged in NHS staff recruitment. Public World 2013www.publicworld.org/files/ Discrimination_by_appointment.pdf. 7 NHS. Race equality action plan. 2007. http://webarchive.nationalarchives.gov.uk/+/www. dh.gov.uk/en/Publicationsandstatistics/Bulletins/DH_4072494. 8 NHS England Equality and Health Inequalities Team. The NHS workforce race equality standard—the defined metrics. 2015. www.england.nhs.uk/wp-content/uploads/2015/02/ wres-metrics-feb-2015.pdf. 9 Passman R, Kline R. Technical guidance for the NHS workforce race equality standard (WRES). 2015. www.england.nhs.uk/wp-content/uploads/2015/04/wres-technical-guidance2015.pdf. 10 Kelly Y, Panico L, Bartley M, et al. Why does birthweight vary among ethnic groups in the UK? Findings from the Millennium Cohort Study. J Pub Health (Oxf) 2009;31:131-7. 11 Hollowell J, Kurinczuk J, Brocklehurst P, et al. Social and ethnic inequalities in infant mortality: a perspective from the United Kingdom. Sem Perinatology 2011;35:240-4. 12 Bhopal R, Humphry R, Fischbacher C. Changes in cardiovascular risk factors in relation to increasing ethnic inequalities in cardiovascular mortality: comparison of cross-sectional data in the Health Surveys for England 1999 and 2004. BMJ Open 2013;3:e003485. 13 Soljak M, Majeed A, Eliahoo J, et al. Ethnic inequalities in the treatment and outcome of diabetes in three English primary care trusts. Int J Equity in Health 2007;6:8. 14 Bansal N, Fischbacher C, Bhopal R, et al. Myocardial infarction incidence and survival by ethnic group: Scottish Health and Ethnicity Linkage retrospective cohort study. BMJ Open 2013;3:e003415. 15 Williams DR, Mohammed SA. Discrimination and racial disparities in health: evidence and needed research. J Behav Med 2009;32:20-47. 16 Jaques H. White applicants are more likely to get NHS jobs than those from ethnic minorities. BMJ Careers 2013. http://careers.bmj.com/careers/advice/view-article.html? id=20012803. 17 Esmail A, Everington S. Racial discrimination against doctors from ethnic minorities. BMJ 1993;306:691-2. 18 Kalra VS, Abel P, Esmail A. Developing leadership interventions for black and minority ethnic staff: a case study of the National Health Service (NHS) in the UK. J Health Organ Manage 2009;23:103-18. 19 Bécares L. Experiences of bullying and racial harassment among minority ethnic staff in the NHS. Better health briefing paper 14. 2008. www.better-health.org.uk/briefings/ experiences-bullying-and-racial-harassment-among-minority-ethnic-staff-nhs. 20 Dawson J. Does the experience of staff working in the NHS link to the patient experience of care? An analysis of links between the 2007 acute trust inpatient and NHS staff surveys. 2009. www.gov.uk/government/uploads/system/uploads/attachment_data/file/215457/ dh_129662.pdf. 21 Salway S, Turner D, Mir G, et al. High quality healthcare commissioning: why race equality must be at its heart. Better health briefing 27. 2013. www.raceequalityfoundation.org.uk/ publications/downloads/high-quality-healthcare-commissioning-why-race-equality-mustbe-its-heart. 22 NHS Leadership Academy. 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Sci Am 2014;311:42-7. 29 Herring C. Does diversity pay? Race, gender, and the business case for diversity. Am Soc Rev 2009;74:208-24. 30 Hunt V, Layton D, Prince S. Diversity matters. McKinsey and Company, 2014. 31 West M, Dawson J, Admasachew L, et al. NHS staff management and health service quality: results from the NHS staff survey and related data. 2012. www.gov.uk/government/ uploads/system/uploads/attachment_data/file/215455/dh_129656.pdf. 32 Paradies Y, Chandrakumar L, Klocker N, et al. Building on our strengths: a framework to reduce race-based discrimination and support diversity in Victoria. 2009. www.vichealth. vic.gov.au/search/building-on-our-strengths. 33 Herring C, Henderson L. From affirmative action to diversity: toward a critical diversity perspective. Crit Soc 2012;38:629-43. 34 Holzer HJ, Neumark D. Affirmative action: what do we know? J Policy Anal Manage 2006;25:463-90. 35 Blandford E, Brill C, Neave S, et al. 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Subscribe: http://www.bmj.com/subscribe BMJ 2015;351:h3297 doi: 10.1136/bmj.h3297 (Published 8 July 2015) Page 4 of 5 ANALYSIS Summary points Discrimination is harmful not only to individuals but to the wider NHS The workforce race equality standard has set measures of ethnic diversity for the NHS Mandatory policies have been shown to work elsewhere and to be more effective than voluntary measures Such policies need to be backed by committed leadership and strategies across all levels of an organisation 46 Beaman L, Duflo E, Pande R, et al. Female leadership raises aspirations and educational attainment for girls: a policy experiment in India. Science 2012;335:582-6. 47 Risteska M. Insiders and outsiders in the implementation of the principle of just and equitable representation of minority groups in public administration in Macedonia. Int J Pub Admin 2013;36:26-34. 48 Noon M. The shackled runner: time to rethink positive discrimination? Work Employment Soc 2010;24:728-39. 49 Collins BW. Tackling unconscious bias in hiring practices: the plight of the Rooney rule. NYU Law Rev 2007;82:870-912. 50 Syal R. Just four companies reveal gender pay gap under coalition scheme. Guardian 2014 Aug 12. www.theguardian.com/money/2014/aug/12/gender-pay-gap-coalitionscheme. 51 Rowley LL, Hurtado S, Ponjuan L. Organisational rhetoric or reality? the disparities between avowed commitment to diversity and formal programs and initiatives in higher education institutions. 83rd annual meeting of the American Educational Research Association, New Orleans, LA, 2002. 52 Turner CSV, Gonzalez JC, Wood JL. Faculty of color in academe: what 20 years of literature tells us. J Diversity Higher Educ 2008;1:139-68. 53 Roach R. Remembering the Michigan mandate. Diverse Educ 2005. http:// diverseeducation.com/article/6264/. 54 Duderstadt JJ. The Michigan mandate: a strategic linking of excellence and social diversity. University of Michigan, 1990. 55 Kowal E, Franklin H, Paradies Y. Reflexive antiracism: a novel approach to diversity training. Ethnicities 2013;13:316-37. 56 Torchia M, Calabro A, Huse M. Women directors on corporate boards: from tokenism to critical mass. J Bus Ethics 2011;102:299-317. 57 Moss Kanter R. Some effects of proportions on group life: skewed sex ratios and responses to token women. Am J Soc 1977;82:965-90. 58 Singh B, Winkel DE, Selvarajan TT. Managing diversity at work: Does psychological safety hold the key to racial differences in employee performance? J Occ Org Psych 2013;86:242-63. 59 Devine PG, Forscher PS, Austin AJ, et al. Long-term reduction in implicit race bias: a prejudice habit-breaking intervention. J Exp Soc Psychol 2012;48:1267-78. Accepted: 12 May 2015 Cite this as: BMJ 2015;350:h3297 Related links thebmj.com • Allowing patients to choose the ethnicity of attending doctors is institutional racism (BMJ 2014;348:g265) • Academic performance of ethnic minority candidates and discrimination in the MRCGP examinations between 2010 and 2012: analysis of data (BMJ 2013;347:f5662) • Listen to a podcast from the BMJ. Tackling racism in the NHS © BMJ Publishing Group Ltd 2015 For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe BMJ 2015;351:h3297 doi: 10.1136/bmj.h3297 (Published 8 July 2015) Figure [Image: GETTY IMAGES] Page 5 of 5 ANALYSIS For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe