There are just over two weeks now until the NHS Commissioning Board takes over the running of the largest part of the English National Health Service.
But, as PCTs and SHAs prepare to close, board members resign, and huge numbers of experienced managers are made redundant or take early retirement, one glaring problem remains unaddressed.
The highest echelons of the NHS are becoming whiter. They are also becoming more male-dominated.
It's a phenomenon which signals a problem in the culture of the new organisation before it even begins.
It's a risk which was identified early in the recruitment process for the new system.
And it's an issue which the leadership appear not to have addressed in a convincing fashion.
On the agenda
The first definite signs of the NHS Commissioning Board thinking about leadership diversity came in July 2012 when the Board discussed their recruitment strategy in open session. (See video 3).
Following a presentation by National Director of Human Resources, Jo-Anne Wass, on the progress made in defining job roles and advertising posts, questions were posed about the monitoring being undertaken.
First to query the figures was non-executive director Dame Moira Gibb.
She referred to evidence of what has occurred where the Civil Service had been 'downsized'. She remarked that women had tended to be overrepresented among those departing. And she queried who would hold the ring in the NHS as a whole to ensure something similar didn't occur.
Wass replied by describing a system called the "People Tracker", which she said was being used to capture monitoring information about the 38,000 NHS staff whose jobs were potentially at risk in the reorganisation.
She explained that "sending organisations" (the existing NHS organisations which would be shedding posts) had entered the relevant details for all staff affected and that the system would be updated as people were appointed into new roles, allowing her team to track diversity characteristics closely. She also reported that a national HR Strategy Group also met monthly and was reviewing the picture.
Jim Easton (then Director for Improvement and Transformation) referred to reports in the press that day concerning the loss of Black and Minority Ethnic Nursing Directors.
He also conceded that one of the easiest places for BME professionals to obtain management posts had been within the commissioning system (PCTs); hence that demographic were "at risk of being significantly disadvantaged" by the closure of PCTs and telescoping of commissioning functions.
He said, "We will need to pay very close attention to our own appointment process and the wider system, otherwise we will be overseeing, inadvertently, a loss of opportunity".
Next, Lord Victor Adebowale, Chief Executive of Turning Point and another of the non-executive directors, pointed out that the issue regarding Black and Minority Ethnic people extended to the grade of Very Senior Manager (VSMs) … the tier of leaders which the Board had so-far been concentrating on recruiting. These are the layer below the board level executive directors like Wass and Easton.
When asked by Victor for data on the ethnicity of VSMs, Jo-Ann told the board that the figures hadn't been prepared yet. In explanation she said that the NHSCB had recruited 47 VSMs at that point (3 transfers and 44 direct appointments) but that she hadn't decided yet how to analyse them, as the parameters they would be looking for hadn't been finalised.
Key culture carriers
Adebowale described BME staff at very senior management level as "key culture carriers", and then asked for further details on how the board intended to ensure "leadership alignment".
Answers from Wass and Ian Dalton, the Director of Operations, were general however, referring to the communication of culture to whoever comes on board, rather than how cultural competence might be imported by ensuring a diverse cohort of senior managers getting appointed.
Tim Kelsey, National Director for Patients and Information also chipped into the discussion and talked about the steps taken to ensure the NHS CB had a uniform culture … seeming to miss (in the same way as the previous two speakers) the point that Victor Adebowale had set out to make.
Far from discussing how the recruitment of people with diverse outlooks could enrich the organisation with different views and understanding from the top down, this was a discussion about a disciplined line of command culture in an organisation being designed to think in one way.
Fast forward now to the September board meeting and the HSJ reported on Jo-Wass's diversity analysis on the very senior managers, which had by then been compiled.
Under the headline "NHS Commissioning Board admits recruitment diversity problem", the paper reported:
At yesterday’s public board meeting in Newcastle human resources director Jo-Anne Wass said its latest information on the proportion of appointees from different backgrounds “does not make for easy reading”… “This is a really significant issue,” Ms Wass said. She said the board had already taken action including training recruiting managers and contacting minority ethnic candidates in leadership programmes. But she said: “I’m not sure they’re enough… clearly more needs to be done.”
Clearly the largely passive approach of speaking to recruiters simply measuring the diversity of appointments after they had been made had not worked.
Questions in Parliament
This admission led to a series of written questions in Parliament.
In November 2012, Rosie Cooper MP (Lab, West Lancashire) tabled the following question for written answer:
To ask the Secretary of State for Health
- what information and assurance he has received from the leadership of (a) the NHS Commissioning Board, (b) Health Education England, (c) Public Health England, (d) the NHS Trust Development Agency, (e) Monitor and (f) the Care Quality Commission that the workforce, including senior management, will be diverse and proportionately representative of the communities that they serve;
- what steps he has taken to ensure that the current reorganisation of the NHS does not result in a disproportionately negative outcome for existing NHS staff in the groups protected by the Equality Act 2010 and the Public Sector Equality Duty;
- what steps he has taken to ensure that after the current reorganisation of the NHS, the composition of both management and frontline staff in the NHS reflects the communities that they serve;
- what directions he has given to the chief executives and boards of (a) the NHS Commissioning Board, (b) Health Education England,© Public Health England, (d) the NHS Trust Development Agency, (e) Monitor and (f) the Care and Quality Commission on (i) diversity in general, (ii) groups protected by the Equality Act 2010 and (iii) the Public Sector Equality Duty;
- what steps he has taken to monitor the diversity of the organisations which will assume responsibility for the oversight of the NHS workforce development and national and local commissioning decisions from April 2013 for the purpose of ensuring that the NHS reflects the communities that it serves.
Parliamentary Under-Secretary of State for Health, Anna Soubry replied:
The HR Transition Framework, published in July 2011 sets a duty on employers to pay due regard to relevant employment law, equality legislation, and the public sector equality duty to ensure that decisions made during the transition that affect staff are fair/transparent, accountable, evidence based and consider the needs and rights of the workforce. In addition, the proposed changes offer a real opportunity for employers to put the advancement of equality and fairness at the heart of decision-making, demonstrating their commitment to diversity and ensuring the skills and competencies reflect the organisation's future needs. To further support the national health service and new organisations during the transition period, the Department provided bespoke Equality Protocol guidance to complement existing Equality legislation. A copy of this has been placed in the Library.
Under the public sector Equality Duty, public authorities are required to publish information to demonstrate their compliance with the public sector Equality Duty at least annually. This information must include, in particular, information relating to people who share a protected characteristic who are its employees (public authorities with fewer than 150 employees are exempt); and people affected by its policies and practices. Equality objectives must be published every four years, and be specific and measurable.
The Department and the former Equality and Diversity Council have actively raised awareness of and provided information about the Equality Act 2010. This includes the publication of the Equality Delivery System (EDS) in 2011, a tool kit developed by the NHS to support NHS organisations to meet the public sector Equality Duty of the Equality Act.
The quality of care is closely related to how well organisations engage, manage and support their own staff. The NHS Constitution includes important pledges to staff who provide NHS care, and the NHS Commissioning Board (NHS CB) is required to promote the NHS Constitution in carrying out its functions. The NHS CB also has a statutory duty to promote education and training, to support an effective system for its planning and delivery. The NHS CB should support Health Education England in ensuring that the health workforce has the right values, skills and training to enable excellent care.
As part of the authorisation process for Clinical Commissioning Groups (CCGs), CCGs must declare that they will be compliant with the public sector equality duty and can demonstrate the use of the Equality Delivery System or equivalent to help attain compliance and ensure good equality performance. The NHS CB has published supporting information for CCGs about this.
The NHS Operating Framework 2012-13 also made clear, that all NHS organisations must comply with the Equality Act 2010 and the public sector Equality Duty. NHS Employers has also made guidance on the Act, including information on employment issues, available to NHS bodies.
David Behan, the then Director General of Social Care, Local Government and Care Partnerships at the Department of Health, wrote to Senior Responsible Officers for the Transition Programme on 23 May 2012 outlining the need to ensure Equality and Diversity was embedded within their respective programmes. He also offered guidance, support and training from the Department's Equality and Inclusion team to assist in the compliance of their respective programme with Equality legislation.
The Department has also issued information to support NHS bodies to implement the ban on age discrimination in health and care services, which came into force in October 2012.
… an answer which, you'll note, completely avoids answering the substantive question.
Also in November, however, the NHSCB published some actual analysis of the diversity of staff recruited at that point, as part of the next board papers.
The figures show that, among very senior managers appointed to the NHS CB at that time, the numbers of Black and Minority ethnic people were considerably down on the outgoing NHS structure and significantly less diverse than the general population.
95.8% of the NHS CB's senior management were White, compared with 91% of the English working age population.
The figures looked better when analysing all grades within the organisation (88.7% white); however this underlines a tendency that has long been reported, for BME staff roles to be concentrated in lower level appointments.
Among the 38,000 staff affected by transition, 81.9% are white. Regardless of grade, therefore, the figures show a significant drop of non-white staff overall.
Hard on women
When it came to gender, the November analysis showed that among the 38,000 NHS staff with jobs at risk, 28.3% were male and 71.5% female (0.2% did not disclose).
Among the very senior managers who had been appointed to the NHS CB at this time, 59.2% were male and 39.4% female.
Taking staff at all grades, the proportions were 49.8% male and 47.2% female.
This may look more balanced; however remember the pools to begin with, where three quarters of the staff at risk were women.
Data on the other diversity characteristics is also contained in the report.
The figures from the NHS CB also indicate the diversity of applicants, compared with the diversity of appointments.
Here (and you'll need to study the numbers for this) it becomes very apparent that there was no shortage of applications from BME staff.
32.1% of applications had been from non-white british staff in the sending organisations; however only 7.4% of the overall appointments at that time had been BME, and only 4.2% of the very senior management appointments.
By comparison, 64.7% of all applications for posts had come from white NHS staff; however 88.7% of all appointments by November had been white.
It seems that if you were white you stood a significantly higher chance of bagging a job.
For gender, the picture was rather different.
71.5% of the 38,000 NHS staff affected by the transition are women; however, only 47.7% of the applications by the time of the analysis had come from women and 47.2% of the appointments were female.
These figures suggest a very different phenomenon affecting the gender diversity in the reorganisation, compared with the racial and ethnic diversity.
For staff who are not white and British, the figures suggest something about the recruitment process which had made it significantly harder for applicants to be successful in securing posts. There was no lack of applications … the issue lay in selection.
The women, it would appear (if I've interpreted the figures correctly) that the issue has lain in application.
One could speculate whether this is because the roles were unsuitable (in a different location perhaps); or because the grades of post available didn't match existing seniority; or perhaps the jobs were less part time compared with before … clearly some analysis is required here to explain the anomaly.
Fast forward to the present
That was an analysis of the recruitment position in November 2012, when there were jobs in the NHS Commissioning Board that were still to be advertised.
I have not yet seen any more recent analysis, and the November analysis doesn't tell us what has been happening in the other NHS bodies, such as Health Education England and Public Health England (which is essentially a Department of Health centred body, as far as I can see at present).
The figures from November are enough to ring loud alarm bells, however.
As I've shown, the NHS Commissioning Board were aware of the risks of losing diversity of the managerial and leadership workforce as long ago as July 2012. They even acknowledged the negative consequences which a loss of diversity would bring.
Unfortunately, finding out after the event that it's happened makes it too late to do anything.
Look around the table at those videos of NHS CB board meetings or check the who's who of leaders and you'll see a body which is overwhelmingly white and predominantly male. Indeed, take away the non-executive directors from outside the organisation, and the picture becomes even starker among the executive directors.
These are the men who will be planning the NHS which a very diverse English population needs. They will tend to do that from their own world view of what is required.
When the very experienced Victor Adebowale extolled the importance of the culture that people bring to an organisation, the response of those men was to talk about the command and control culture … of ensuring everyone spoke with a single voice … an identikit point of view.
What Victor meant was the complete opposite, of course. He was referring to an organisation having the diversity of experience and ideas among its leaders which would widen the pool of ideas and understanding.
You get the impression he was pissing in the wind.