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Why is NHS staffing black at the bottom and white at the top?

Roger Kline and Brendan Martin, 30 November 2012

The NHS Commissioning Board (CB) will be the most important body in Britain’s National Health Service when it takes up its duties next April as part of the government’s NHS reforms. It received its mandate from the government earlier this month in a document that states: “The NHS budget is entrusted to the Board, which shares with the Secretary of State for Health the legal duty to promote a comprehensive health service.”

The CB’s website states that “promoting equality and equity are at the heart of the Board Authority’s values” and promises “to ensure that advancing equality and diversity is central to how it conducts its business as an organisation”.

Yet data about the ‘very senior management’ and other appointments already made to the board’s staff show that the proportion of white people being appointed to those positions is significantly higher than the proportion of white people applying for them, while the numbers for non-white applicants and appointments are skewed in the other direction.

The data published on the board’s website last week reveal that 64.7% of applicants, but 88.7% of those appointed, were white. For ‘very senior managers’ the numbers are 81.3% and 95.8% respectively. Conversely, while 32.1% of applicants identified themselves as black and minority ethnic (BME), only 7.4% of the appointments are BME, and for ‘very senior managers’ the BME numbers are 15.2% and 4.2% respectively. Yet 9% of the English working age population is BME.

The CB will have 4,000 staff, most of whom are being ‘slotted in’ from existing NHS positions or appointed through ‘ring-fenced competition’ among existing NHS staff. We asked the CB if it could explain why, so far, white applicants are significantly more likely to be appointed if they apply than are BME applicants, and – if it could not yet explain it – what steps were being taken to find out. We were promised a response within 20 days.

The CB’s website indicates that its HR director, Jo-Anne Wass, asked the board at its meeting on 8 November for permission to present a “strategy for promoting diversity in the organisation at a future meeting”. As the minutes of that meeting have not yet been posted on the site it is not yet clear whether or not that was agreed, and if so when the strategy will be considered by the board. However, as nearly all ‘very senior management’ posts have already been filled, and the rest of the staff are supposed to have been appointed by the end of the year, the timetable for the diversity strategy brings to mind stable doors and bolting horses.

Although the evidence of white advantage and BME disadvantage in the CB is shocking, it is unfortunately far from surprising, in view of long-standing imbalances in the NHS, which is far more black at the bottom than at the top. A large amount of research and data shows BME staff are disproportionately employed in lower grades, with less chance of promotion and more of being disciplined than white staff. There was just one non-white face in the last Health Service Journal list of the one hundred most influential people in healthcare. The latest NHS Staff Survey repeatedly shows significant differences in the experience of white and BME staff. 

The CB knows all this. Its transformation director Jim Easton warned in July that black and minority ethnic staff are “at risk of being significantly disadvantaged” as the system downsizes to fit within its new economic constraints.  In September, the Health Service Journal reported that the CB’s HR director Jo-Anne Wass said its then latest information on the proportion of appointees from different backgrounds “does not make for easy reading”.  Ms Wass added that she hoped publishing recruitment data would “shine a light on the issue” and lead to a change in behaviour among recruiters”.

Yet the more recent CB data suggests nothing has changed, and the Board still cannot explain it and is planning a strategy to deal with it only after it will be too late to affect its own staff’s composition.

Experience suggests that this is not only an issue of employment fairness, because inequalities in staffing affect how services are prioritised and delivered. In the context of the NHS reforms, the importance or the role of the CB cannot be overstated. From April next year it will be running the NHS.

The CB asserts on its website: “We will ensure that equality and health inequalities is one of the underpinning ‘lenses’ or themes reflecting the core processes that support the values and culture of the NHS CB.” It adds that design of “the equality and health inequalities function of the NHS CB, including staffing and budget requirements" will be one of its “key quality objectives”.

It doesn’t seem to have made a very good start.

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