Creating a real culture of inclusion for better, more equal outcomes in the NHS
21 March 2019
Black Asian and minority ethnic (BAME) workers make up a high proportion of the NHS’s overall workforce, but their representation at the most senior levels of the organisation remains, in comparison, relatively low. The latest NHS Workforce Race Equality Standard report shows that while BAME workers account for 19.1% of all employees, just 6.9% of very senior management roles are held by BAME staff. And while that’s an improvement on the proportion in 2017, it still reveals a significant gap. Equally telling is the finding from an NHS staff survey which highlights the different perceptions of white and BAME staff. While close to 90% of white staff felt that their trust provided equal opportunities, only 71% of BAME staff felt the same.
So those are some of the statistics. But what do they really show? Overall, these findings – and others like them - show the outcomes not of a set of rules or formal structures, but a combination of behaviours and attitudes that broadly speaking make up an organisation’s culture. Changing the outcomes that an organisation achieves in terms of diversity and inclusion means, at a fundamental level, changing the culture. So how should health organisations go about doing that?
An organisation’s culture will develop over time, largely driven by the accumulation of often unconscious biases, assumptions and attitudes. But while the reasons why an organisation has developed a culture may not be immediately obvious to everyone, effecting cultural change has to be a conscious process. And that needs to start at the top of the organisation, with culture as a board-level issue of strategic importance.
A clear commitment to building the right culture is essential in order to then start addressing the changes that need to happen. A strong positive culture empowers people because it provides them with the instinctive guiding principles that they use to make decisions, rather than trying to impose a set of rules to mandate behaviour. And while the tone at the top is important, so too are those in the middle and further down. A mismatch between the values that are espoused and how people actually behave should be a red flag that something is not as it should be. That can often be spotted in specific ‘moments that matter’, the decision points where behaviour is likely to have a disproportionate influence on outcomes. For example, the Workforce Race Equality Standard report found that white applicants are 1.45 times more likely to be appointed from shortlisting than their BAME counterparts. That finding could well point to a behaviour that is misaligned with the NHS’s stated aims of promoting inclusion and diversity. It’s a challenge for all organisations.
Culture and the behaviour to which it gives rise can appear to be amorphous and difficult to assess. But it is possible to measure behaviour both qualitatively and quantitatively. That exercise can provide an insightful picture of strengths, weaknesses and blind spots for the leaders of the organisation. And from there, it’s possible to design interventions and offer the support to ensure that everyone is able to understand how their contribution can help to achieve the organisation’s purpose and support its vision and values in what they do and how they act, day in, day out. That’s why, for example, at PwC, we have taken the decision to analyse and publish our statistics related to BAME employees. This data has been produced on the same basis as our regulatory gender pay data and we know that government are considering whether to make this a legal requirement. By understanding our performance in this space, we are able to make sure that we focus on the initiatives where we can have a real impact and make sure that our behaviour aligns with our values. We think that all organisations, including the NHS organisations, should take action to understand their ethnicity pay gap because it’s a good indicator on how diverse and inclusive your organisation really is.