For the NHS to thrive going forward – with its diverse workforce and empowering the next generation of healthcare leaders to think differently – there need to be conscious steps taken to embrace diversity in its leadership.

Within the NHS, Black, Asian, and Minority Ethnic (BAME) staff report covert and overt displays of discrimination. This often manifests as inadequate inductions and access to training, lack of progression, and a high workload compared to peers. The less visible aspects of discrimination are often nuanced – difficult to pinpoint and address. One example is BAME staff reporting disproportionate deployment to work on COVID wards during the pandemic.

Snow white peaks

In recruiting top talent into positions within healthcare systems, particularly the NHS, we need to ensure that the best talent, irrespective of race or creed, is put forward. For an organisation with such diversity in its workforce, the snowy white peaks in our NHS are all too evident.

We know that there is a problem with diversity at leadership levels, with only 8% of NHS chief executives and chairs identifying as BAME. The lack of systems with suitable and adequate mentorship to support the leadership development of BAME staff contributes to this outcome.

Furthermore, there are real issues relating to discrimination, bullying, and blame culture in our health and social care system, aspects that all make it hard for employees to challenge the status quo.

It’s particularly difficult for individuals to raise concerns and ‘have the ear’ of senior leadership when they don’t have lived experience of problems that staff with certain demographic characteristics face in their job.

Diversity and whistleblowing

This lack of awareness often translates into a workplace culture where people choose not to speak up for fear of repercussions. Lifting this culture of silence in the NHS requires leadership that embraces diversity and whistleblowing as aspects of a learning organisation and a good healthcare system.

Whistleblowing in healthcare remains a contentious topic and a double-edged sword. There are specific standards below which the provision of safe care should never fall, so healthcare organisations and their employees must act per the fundamental standards of care. Working within such standards has huge implications for leadership in maintaining a culture that allows for transparency in reflection and learning.

As the COVID-19 events unfolded, those NHS affected – many of BAME background – were in a ‘whistleblowing-silence’ dilemma, unsure how best to approach and challenge the directives handed down to them. According to other researchers, the paradox of such a situation is that staff from BAME backgrounds are more than twice as likely to undergo disciplinary proceedings or be referred to their respective professional regulatory council. Most of these staff have reported being uninformed about how to challenge the status quo without getting their fingers burned.

Racial inequalities

Trends show at least 45% of boards in England lack BAME representation, further supporting the reality of racial inequalities in the leadership of the NHS Workforce. There are implications for the culture of such a diverse organisation, which ultimately lacks representation in its leadership — some of these manifest as a punitive workplace culture where staff are afraid to speak up.

There is a current drive to increase diversity within the NHS leadership. The anticipated knock-on effect of such representation drive is a push to influence regulatory frameworks via diverse and dispersed leadership as well as accountability and transparency across the multi-level hierarchy in healthcare. This will ensure that the balance is tilted towards creating an open and just culture which provides time and space for conversations to brew without fear of repercussions. Where staff are encouraged to speak up, issues relating to staff or patient safety are prevented before they become full-blown issues.

The ‘playground effect’

The Messenger Report on leadership in health and social care, released in June 2022, makes a key recommendation on equality, diversity, and inclusion (EDI) concerning leadership. However, it stops short of acknowledging the potential that such EDI contributes in curating a workplace culture that supports calling out bad practices without fear or favour.

There is evidence that healthcare staff are conscious of a ‘playground effect’ and prefer indirect communication or informal channels to avoid ‘rocking the boat.’ We should be recommending the NHS focus on this seemingly mundane workplace culture to improve patient safety, staff well-being, and overall standards of care.

If we want the NHS to thrive with its diverse workforce, we must establish the requirement for organisations to increase diversity in their leadership and boards. This enhanced level of representation will help all employees feel comfortable about expressing their concerns and provide the space for constructive criticism without fear of repercussions.

Schemes which have been set up to facilitate the achievement of representation, such as the NExT Director Scheme, should be supported, with accountability demanded from the boards by BAME networks. Mentoring schemes (for career advancement) for BAME staff at all levels should also be encouraged.

There are operational and financial benefits to be yielded from a diverse workforce and conducive workplace culture. UCL Global Business School for Health is at the heart of training the next generation of healthcare leaders from across the world.

By Jennifer Egbunike (PhD), Associate Professor of Health Policy and Organisational Studies, UCL Global Business School for Health