NHS does not have the fundamentals in place to tackle discrimination, report warns

Despite considerable effort and countless initiatives, inequality between NHS staff groups is persisting or even getting worse – and the health service does not have the tools to address this. Crucial data is lacking, less high-profile groups are being overlooked, and the understanding of what actually works to improve diversity and equity is poor.

‘Attracting, supporting and retaining a diverse NHS workforce’, a new Nuffield Trust report commissioned by NHS Employers, part of the NHS Confederation, warns there is clear evidence that a lack of inclusion means worse care for patients. It also stands in the way of the health service’s ability to find and retain staff at a time when more capacity is desperately needed and targets require an additional 50,000 nurses. Yet while tremendous efforts have been made by leaders in recent years, continued even during the pressure of the global pandemic, reported discrimination has risen across race, gender, disability status, and religion. 

The report, based on interviews with NHS trusts, a review of literature and data analysis, points to a failure to recognise how many different specific groups can be subject to exclusion. While inequalities of race and gender are at least widely recognised, ethnic groups are too often lumped together and other disparities overlooked. 

The authors found several instances of good practice, including staff networks and inclusion ambassadors on interview panels. However, they warn that there is little evidence to tell whether well-intentioned approaches in wide use, such as increasing apprenticeships and trying to reduce unconscious bias, actually advance diversity or not. There has been too much emphasis to date on policies, procedures and training instead of culture. 

They call on the Cabinet Office to look into establishing an official repository of solutions backed by the evidence. The health service needs to make sure all future local schemes are properly and fairly evaluated. 

Data analysed for the report shows that:

• Black staff are more than twice as likely to experience discrimination at work from a colleague as White staff; Muslim staff more than twice as likely to experience discrimination as staff of no religion; and those who prefer to self-describe their gender are twice as likely to experience discrimination as male or female staff.
• After nine years’ service, male nurses were over twice as likely to have progressed up two pay bands (41%) as female nurses (20%)
• The proportion of staff reporting discrimination from their manager or colleagues has risen between 2016 and 2020 for people from Asian, Black and Mixed backgrounds, and for Hindus, Jews and Muslims.
• Ethnic minority staff are 27% less likely than White staff to be “very senior managers”, the highest executive grades.
• There are large disparities between trusts, with 36 where White staff are at least twice as likely to be appointed from a shortlist than someone who is Black or from an ethnic minority background, but another 32 where the likelihood was the same.
• Only 2 in 5 deaf healthcare professionals report having had the reasonable adjustments they needed at work during the pandemic.

The report notes several shortcomings in key data to understand other types of inequality, including nationality not being counted in the NHS staff survey, and people on apprenticeships only being recorded in large categories.

It recommends that each NHS trust must ensure its diversity leads have access to continuing training, and that enough resources and senior posts are allocated to address the problem. The new Integrated Care Boards being set up to oversee the service should have special leads to focus on inclusion.

Nuffield Trust Senior Policy Fellow Dr William Palmer said:

“On paper the NHS has recognised for years that disparities and discrimination among staff are morally unacceptable and disruptive to good quality care. Yet progress in actually reducing disparities has been painfully slow – and we even saw signs that bias may be getting worse.

“The good will and virtuous intentions we have seen are impressive, but they aren’t going to work alone. We need to move away from thinking about a couple of broad, high profile groups and recognise the specific issues that face individual religious and ethnic groups, and people with disabilities. The health service must be really honest about which solutions are really backed by evidence, and make sure this is widely known.”

Danny Mortimer, chief executive of NHS Employers, part of the NHS Confederation said:

“There is an absolute commitment from our members to finally address the inequities in our workplaces.  This report highlights action that is being taken but rightly reminds us that far more urgency and impact is needed in every part of the NHS.  To be clear, the link between staff and patient experience is irrefutable, and we have an obligation to improve the experience of all parts of the health service’s rich and talented workforce.”