What do you think would be the main outcomes of having more black people at board-level and other more senior roles within the NHS?
If you look specifically at black chief executives in the NHS, I believe that there are only four out of 288 UK NHS provider organisations, and it was once an even lower number than that. For my part, it is getting on for two decades that I have had a senior position in either a local government or an NHS organisation. If you had said to me 15 years ago that by now I would still be one of a small minority of black and/or BAME chief executives, I would have said “no, that’s not going to be possible”. But here we are in 2020.
There will be some who say that “we’ve seen some percentage growth and we should be positive about that”, but as Natasha Cloud (Washington Mystics) says, we need to stop accepting “crumbs” from the table. People like myself and others have proven that we can do these jobs. Therefore I strongly believe that we should not be overly complimentary of small steps in 2020.
So why does this matter and what are the main outcomes – well with a slight adjustment to James Carville’s famous economy quote: “it’s the diversity, stupid”. When it comes to those “wicked problems”, as defined by Rittel and Webber many years ago, if you have more diversity around the board table you will be able to deal with more complex issues and avoid recurring groupthink – which is especially crucial in the era of Covid-19.
The disproportionate impact of Covid-19 on black and minority ethnic communities and health care staff has further highlighted racial inequalities in the UK and their root causes. In what ways should this be a catalyst for the NHS to move towards a new era of greater equality?
When you think about Covid-19, in March and April people in a variety of leadership positions seemed initially surprised that we were seeing, for example, the numbers of BAME colleagues who were dying trying to fight this pandemic. The question is, had there been more of a diverse leadership, would that have come across as the surprise it seemed to be?
For my part I use an acronym (it assists my fading memory), developed by a good guy called Ben Jupp around inequalities in general, and that is “SURE”.
The ‘S’ is to ‘see it’. If you are a systemic racism or inequalities denier, then you have already got a problem with addressing inequalities, in that you just can’t see that certain people are more disadvantaged than others, and that they may need support to level up and make progress. So open your eyes and see.
The ‘U’ is to ‘understand it’. For example, we see with Covid-19 that a particular group of people are more likely to die from it, but why is that the case? We know through index of multiple deprivation analysis that you are more likely to have people from higher deprivation areas turn up to A&E on a frequent user basis. Yet even before Covid-19 and when, for example, we were experiencing a deterioration of four-hour standards in A&E, much of that was attributed to financial resource availability and increasing demand. However, we tend to view demand in aggregate numbers rather than through a more granular and place-based understanding, which you are simply forced to consider if you are serious about reducing health inequalities and managing demand better.
The ‘R’ is about how you respond to the problem. The important thing is to get yourself and others out of the big organisations and institutions, and work alongside communities and the voluntary and community sector to co-produce what a good response would look like. You/we need to further develop those co-production skillsets, which does not just apply to people in secondary and tertiary care, but also in primary care. If you work on the hypothesis that we haven't got time now to focus on diversity and address inequalities because we are in a crisis, well we did not seem to have time before. So when will we ever find the time?
The ‘E’ is about evaluating. See it, understand it, respond, then evaluate.
What has been the impact of the Black Lives Matter movement on attitudes to racism within NHS leadership?
Interestingly, leaders from across multiple public and private sector organisations and a number of chairs/CEOs within the NHS felt the need to express themselves and give unequivocal support for Black Lives Matter. Particularly on the back of George Floyd, we had a conversation in our organisation – I asked colleagues from all sorts of backgrounds whether they were expecting to see a similar sort of commitment from me personally as a chief executive. The consensus we came to was “let’s see what life is like three months after George Floyd’s death”.
As time elapsed from the shock of George’s death, and when we started to see in late June to August a degree of control being established around combatting Covid-19, I felt that the metaphorical volume relating to the importance of the BLM movement seemed to be turned down, and in certain instances became politicised by some.
Therefore I guess my challenge to myself and others is that putting words on letters is one thing, but I believe the role modelling of good behaviours is frankly much more important. So for example, across West Yorkshire and Harrogate, a prominent piece of work was launched recently looking into BAME communities and staffing. I have described this as a shrewd piece of work because, not only does it have the words, but it has been designed in a way that has accountability and encourages stakeholders to place more emphasis on trying to ‘walk’ as opposed to just ‘talk’.
For me, Black Lives Matter is not about wanting to get more attention or favours at the expense of any other group of people. It is more about levelling up and trying to get to a place where other people consciously do think we matter and demonstrate this through their actions and what they do. If you are a black person, you find it baffling to hear people say that “systemic racism doesn’t exist”. The intent of Black Lives Matter is right, but to get everyone moving in the same collaborative direction there is still clearly much work to do.
The term ‘black and minority ethnic’ groups together anyone who is not white. Do you think there would be any benefits from an increased focus on how black people experience health care, as opposed to the term BAME?
There is always an ongoing debate among some people around “don’t call me BAME”. Certainly, when we think about continuity of care in the context of maternity and the mortality of infants, there is evidence about poorer outcomes for specific ‘Black and Asian’ groups, as opposed to ‘Minority Ethnic’. Therefore in certain circumstances there may be a need to focus on specific groups or population subsets. But when you are trying to deal with systemic racism, the concept of BAME is important because, as Don Lemon the CNN broadcaster would say, there is “power in numbers”.
Quite rightly, when you need to disaggregate and think about things such as intersectionality and breaking things down to a more modular level, have that conversation. But understand there are some conversations when you do want to come together, because it is more influential to be working under a BAME context than if you break into subsets.
In what ways do you think medical training in the UK could better meet the needs of black patients?
In a modern-day society, we should expect that medical training is not just progressed through a monocultural lens, but through something that demonstrates that we get that we increasingly live in a multicultural world. Articles that I have reviewed through my own doctoral research suggest that a third of the population by 2050 in the UK will be BAME. Therefore you want to make sure that the next generation training and migrating through to clinical practice are underpinned by skills and competencies that are reflective of the patient population reality that exists.
But it is not just about training. It is also culturally competent communications and I know that, when I look at my own organisation's website or at NHS Choices, there is work to do.
For example, take the condition of acne. It may be fine to advise some people to look out for signs of red, blotchy skin and show pictures of what their skin may look like, but applying the same descriptors and imagery to someone who looks like me may be more problematic. This need for broader culturally competent thinking also needs to be applied, for example, to the typical ethnicity of simulation mannequins (dummies) that clinical colleagues use for training, right through to how certain skin cancers might be visibly recognised in a black patient versus the signs that might be seen in a white patient. After all, this is 2020.
What would you say to young black people thinking of a career in the NHS?
I would say grab it if you can. Do what you need to do to become the next generation of leaders in the NHS. Let us get to the position where no one remembers or even talks about relics like me because I am just one of dozens of BAME leaders who have come and gone over time.
Young black people are already talented and have all the attributes to be successful in the NHS – they just need a fair chance. If they meet the job specification, they just need access to the same levels of interviews with culturally competent interviewers. I believe the rest will take care of itself. But if we still occupy a world where by having a non-typical English name or by putting down your ethnicity on an application form you feel that you are less likely to get an interview, then that is problematic.
As far as the NHS is concerned, we should be an international leader in this field, in terms of the diversity of our workforce and in extracting the untapped benefits of properly embracing our intersectionality.
What do you think is the most important lesson from history with regards to race and the NHS, and what related policy change would you most like to see in future?
When I think about the history of the NHS, some of the conversations we are having now are not new – they have been had at various stages before. You look at the NHS Constitution, and it is pretty clear about the responsibility that anybody who works for the NHS has with regard to reducing inequalities. This is also true for the 2012 Health & Social Care (Lansley) Act.
So, for me it is not necessarily about policy change, it is about doing what it says on the existing tin. We are either serious about moving from inequality to equity or we are not? In a world rocked by this pandemic, it is time to get serious.
Dr Owen Williams OBE is the Chief Executive of Calderdale and Huddersfield NHS Foundation Trust.