Building an equal, diverse and inclusive NHS - Healthcare managers need a systemic approach

Building a diverse workforce and ensuring a high level of equality and inclusion in its management are of the utmost importance in nowadays NHS’ agenda. Diversity, equality and inclusion (EDI, hereafter) are not only relevant for principled reasons, but are also instrumental to attract and retain the best talents, attaining higher levels of job satisfaction and, ultimately, improving performance, creativity and innovativeness. 

This instrumentality is mostly due to one characteristic of healthcare: it is a knowledge-intensive industry, which depends on the expertise of its members and collaboration among them. By promoting diversity in the workforce, healthcare managers increase the diversity in the available knowledge, expertise and mindsets, which are conducive to higher innovativeness and problem-solving capabilities. By forging an inclusive workplace, organisations ensure these diverse voices are heard and rewarded, and individuals are encouraged to collaborate and share ideas. Though relevant across hierarchical levels, collaborative behaviour is essential among nurses, who play a pivotal role in connecting doctors and technicians within and across departments and specialities. 

In spite of these benefits of implementing an EDI agenda, issues related to EDI permeate most aspects of the life of healthcare organisations in general, and the NHS in particular, as highlighted by the 2021 Workforce Race Equality Standard report and the NHS People Plan for 2020/2021. For instance, evidence exists that members of minority groups are less likely to be shortlisted and appointed at job interviews. Likewise, they – together with women – tend to experience social isolation, and be excluded from the peer networks that are typically used to receive informal mentorship, share ideas and seek advice to solve unexpected problems. 

Another area where equality has been lacking is performance appraisal. It is well-known that the talent of members of minority groups is less likely to be identified, nurtured and rewarded, thus resulting in less frequent opportunities for career progression. It is less evident that the increase in the use of remote work arrangements for multiple tasks – e.g., remote consultations increase and meetings – in the aftermath of the COVID-19 pandemic, is thought to amplify this divide in career opportunities. Remote work reduces employees’ visibility to their line manager, making it more difficult for the latter to assess their subordinates’ performance, and leading to more negative evaluations. Being more likely to adopt these flexible work arrangements, women are also expected to suffer the most from this bias. A particularly detrimental consequence of limited career opportunities is that members of minority groups are less likely to ascend to leadership positions and be involved in decision-making processes. Hence, their views and interests tend to be under-represented at the level of executive directors. Because healthcare managers repeatedly rely on the same – homogeneous – voices, they may tend not only to underestimate the importance of an EDI agenda but also to make strategic decisions that are in general less innovative, more conservative and routinary.

Beyond goodwill and ad hoc interventions, a large amount of work is still to be done for satisfactory levels of EDI to be achieved. Most of this work lies in the hands of healthcare managers. To implement a real change, they need to adopt a systemic approach consisting in four pillars. The first is knowledge of the value of EDI and the different struggles that minority groups face both as subjects and objects of EDI policies. Knowledge needs to be contextualised and supported by data and empirics that help managers identify the actual problems. The second is culture to ensure that vision for EDI improvement is embedded in a governance structure and shared across organisational levels. The third is shared action. Besides obvious decisions like involving minorities in the change process, it has been recently found that actions taken by the board of directors to tackle EDI tend to be seen as less legitimate if there are not supported by people in majority groups. Therefore, they need to be involved as well in EDI committees and related decision-making. Finally, accountability to ensure that the progress made – or not – is measured and both organisations and their managers are held accountable.