Key points
Racial inequalities persist within NHS services. Notably, black British mothers face up to five times higher mortality/death rates than white mothers during pregnancy or within the first six weeks after childbirth. The Race and Health Observatory found that in comparison with white British people – with the exception of Chinese people – people from minoritised ethnic groups experienced worse outcomes, waited longer for assessment times and were less likely to receive a course of treatment following assessment.
To address persistent racialised health inequalities, it is imperative to embed anti-racism within the operations of the NHS. This report highlights the efforts undertaken by our members to enhance services for healthcare workers and patients, recognising anti-racist work as an integral service improvement tool aimed at reducing racial inequalities.
We are encouraged by the examples of anti-racist action included in this report being led by our members. However, further anti-racist initiatives are necessary to eradicate health inequalities for racialised communities.
The examples shared by our members underscore the imperative for collaborative programmes aimed at effectively addressing racism within the NHS workforce and improving patient outcomes. Moreover, efforts to combat racism should be community-driven, with management empowering commissioning teams to lead interventions that guarantee adequate resources to address the needs of the population they serve. Also important are collaborations with clinical leaders to facilitate shared data and knowledge, to understand referral pathways, and to engage participants, (both staff and patients) in the process.
It is essential that anti-racist work receives funding that is integrated into mainstream budgets instead of being assigned as one-off grants. This guarantees sustained implementation and lasting impact, as without mainstream funding there is a risk of discontinuity and instability in the implementation of these programmes.
Background
Since its inception, the NHS workforce has included individuals from racialised groups. In 1948, select committees in 16 British colonies recruited nurses and midwives, with 63 hospitals accepting colonial recruits. However, racialised staff faced discrimination, limiting their career paths and perpetuating the systemic issues we see today, where racialised individuals are less likely to attain leadership roles within the NHS.
In 1983, the Commission for Racial Equality (CRE) found that the NHS neglected to promote Asian and other overseas doctors, while young black British individuals were often steered toward the State Enrolled Nurse qualification, which is less clinical and has limited opportunities for progression compared to the preferred State Registered Nurse status.
The history of the NHS continues to shape the diversity of NHS leadership and patient outcomes today. Ethnic inequalities persist in healthcare access, experiences and outcomes spanning mental health, maternity care, neonatal healthcare and the NHS workforce.
A report from the NHS Confederation’s BME Leadership Network (BLN) found that despite some progress highlighted by the Workforce Race Equality Standard (WRES), views on local NHS leadership diversity and trends captured across staff surveys remain stagnant.
Additionally, racialised patients encounter disparities, exemplified by the fact that black British mothers experience mortality rates up to five times higher than those of white mothers during pregnancy or within the initial six weeks after childbirth. The Race and Health Observatory also found that in comparison with white British people – with the exception of Chinese people – people from minoritised ethnic groups experienced worse outcomes, waited longer for assessment times and were less likely to receive a course of treatment following assessment.
Despite efforts to address disparities faced by racialised staff and patients, systemic discrimination continues to exist and more comprehensive measures are necessary to eliminate such healthcare inequalities.
This report comprises examples of anti-racist initiatives from BLN members. The network aims to strengthen the voice of black and minority ethnic communities and support the development of an NHS that meets the needs of all communities it serves, predicated on the three core principles of the NHS:
- It meets the needs of everyone.
- It is free at the point of need.
- it is based on clinical need, not ability to pay.
The NHS also rests on the notion of universality, where the integration of anti-racism helps to uphold its core values.
Such values foster an environment where diverse voices are heard, barriers are dismantled, and healthcare access becomes genuinely equitable for all individuals, regardless of race or ethnicity.
Definitions
Universality - involving or being shared by all people or things in the world or in a particular group.
Racialised communities – groups identified by race or ethnicity within a society, often facing systemic discrimination and marginalisation based on their racial or ethnic background.
Advancing equality
This report highlights the efforts undertaken by members of the NHS Confederation’s BME Leadership Network to enhance services for healthcare workers and patients, recognising anti-racist work as an integral service improvement tool aimed at reducing racial inequalities.
The scalable examples in this report have been compiled to assist members in advancing equality within the workforce and for service users. Aligned with the NHS Confederation’s anti-racism strategy, we aim to position anti-racism as a quality improvement discipline, integrating it into decision-making processes. Our approach emphasises mainstreaming anti-racist practices, fostering a culture of peer support for sharing best practices, and establishing evidence to show that tackling inequality through anti-racism is a tool for quality improvement. Our goal is to empower leaders to move beyond dialogue and take concrete actions.
We asked BLN members from across the healthcare system to provide examples of work that demonstrates the role of tackling inequality as a service improvement tool. We gathered evidence across five categories of finance; quality improvement; safety of services; community trust/engagement; and recruitment and retention of staff. We collated examples that describe mainstream activity incorporating an anti-racist approach, where negative outcomes for racialised communities have been identified and service amended to rectify that, rather than specific projects or initiatives that augment existing service provision.
Examples shared by BLN members form the backbone of this report, demonstrating successful anti-racist strategies in action.
Anti-racism as quality improvement: Examples of good practice
Parallel Learning Partnerships Programme, Nottinghamshire Healthcare NHS Foundation Trust
Nottinghamshire Healthcare NHS Foundation Trust (NHFT) identified persistent disparities in the experiences of BME (black and minority ethnic) colleagues compared to their white counterparts, as evidenced by NHS Staff Survey results and WRES data. Previous initiatives had failed to bring sustained improvements. In response, the Parallel Learning Partnerships (PLP) Programme was developed to foster reciprocal relationships and mutual understanding that addressed racial inequalities while building a more compassionate and proactive workforce.
NHFT launched the PLP Programme in April 2021. The initiative was open to all members of the trust’s executive and senior leadership teams, as well as staff from a BME background. Participants submitted a matching profile with three questions or statements for facilitators to pair participants as partners. Partners received a guide for learning partners and were encouraged to attend optional, quarterly virtual check-in sessions for sharing experiences and monitoring progress. Partnerships were advised to last between 12 and 15 months. The programme aimed to foster mutually beneficial learning partnerships and provide a platform for BME voices to be heard by senior leaders, promoting frank discussions and reflection in a safe environment.
NHFT’s research and evidence department conducted an evaluation of the PLP Programme after the 15-month period. The assessment revealed positive outcomes, including the establishment of non-hierarchical partnerships fostering support and safe spaces for BME colleagues and senior leaders. Participants experienced increased confidence, leading to career progression and a better understanding of racial inequalities. The programme also improved mutual understanding of roles, contributing to a heightened sense of belonging. Positive feedback on the matching process and programme resources showcased the programme’s effectiveness compared to traditional mentoring. Initiatives such as open participation, optional check-in sessions and an emphasis on long-term development were well received.
Additional results included positive changes in patient care, demonstrating the programme’s impact on the broader healthcare environment. Addressing obstacles, the programme facilitated professional insight visits to address hierarchy concerns, and time constraints were overcome with commitment and flexibility. Vigilance ensured the programme’s distinctiveness and mutual benefit, preventing it from deviating into traditional mentoring or coaching models.
The (PLP) Programme enabled the trust to foster collaboration among colleagues, transcending ethnic boundaries and effectively addressing systemic inequities.
Reflections, learning and outcomes
Data-driven identification of disparities: Begin with a thorough examination of organisational data, such as NHS Staff Survey results and WRES data, to identify and understand persistent disparities in experiences among different ethnic groups within the workforce.
Recognition of past failures: Acknowledge and learn from past failures of initiatives that did not bring sustained improvements. A critical reflection on previous attempts informs the development of more effective and targeted anti-racism programmes.
Reciprocal learning partnerships: Establish programmes that focus on reciprocal relationships, equality, and mutual understanding. The PLP Programme exemplifies how fostering such partnerships can contribute to addressing racial inequalities and building a compassionate, knowledgeable and proactive workforce.
Evaluation and continuous assessment: Implement an evaluation process to continuously assess the impact and effectiveness of anti-racism programmes. The evaluation of the PLP Programme revealed positive outcomes, showcasing the importance of ongoing assessment for improvement.
Long-term development focus: Emphasise a long-term development focus within programme implementation. The PLP Programme's approach involved open participation, matching profiles, optional check-in sessions, and a commitment to long-term development, contributing to sustained positive outcomes.
Cultural Inclusion Network in Coventry and Warwickshire
The Coventry and Warwickshire Cultural Inclusion Network (CIN) empowers grassroots organisations, particularly those serving ethnic minority communities, within the voluntary, community, and social enterprise (VCSE) sector. Through collaboration and innovative funding, including projects like the long Covid initiative, the CIN exemplifies effective healthcare partnerships while ensuring support for small organisations. The network’s efforts highlight the importance of inclusivity and advocacy in addressing health disparities while promoting diversity within the sector.
CIN’s approach focuses on strengthening representation in strategic meetings, improving public sector relationships, and increasing opportunities for small organisations to shape decision-making to reduce health inequalities.
In response to community needs, CIN implemented an expression of interest (EOI) for fair shares funding for community organisations, fostering a safe space for discussions. CIN organisations influenced mental health policies, gained seats on influential boards, and collaborated on core organisational programmes like the successful long Covid initiative. The CIN overcame funding challenges through sustained advocacy, improved relationships over time, and a co-created redesigned Peer Support Worker pathway, demonstrating expertise and trust-building in the process.
These efforts not only address community needs but also demonstrate a commitment to anti-racism by working in partnership with healthcare organisations. Such partnerships provide platforms for racialised voices to influence policy and fostering inclusivity in decision-making processes.
Reflections, learning and outcomes
Increased opportunities for small organisations: The CIN worked towards creating opportunities for small organisations within the VCSE sector. This focus on inclusivity and equal opportunities contributed to a more diverse and representative sector.
Collaboration on projects: Collaborative projects like the long Covid initiative highlight the CIN's ability to work collectively with healthcare partners on important core issues, extending its influence beyond individual organisational efforts.
Improved public sector relationships: A key achievement of the CIN was improved relationships within the public sector and particularly across healthcare. Such improvement facilitated better collaboration between grassroots organisations and government entities.
Strengthened representation in strategic meetings: The CIN played a vital role in strengthening representation in strategic meetings, particularly within healthcare, ensuring that the voices of grassroots organisations were heard and considered in decision-making processes.
The NHS Confederation Coventry and Warwickshire Partnership NHS Trust collaboration on Mental Health Act detentions
The Coventry and Warwickshire Partnership Trust commissioned the NHS Confederation to address the disproportionate use of the Mental Health Act on the black and Asian populations that it serves. The Coventry and Warwickshire Mental Health Needs Assessment survey 2021 identified inequalities in access to mental health services for people with protected characteristics.
Financial security concerns, fuel poverty and homelessness are increasing demand for mental health services. People living in the 20 per cent most deprived areas in Coventry and Warwickshire are three times more likely to be admitted to hospital with severe mental illness (SMI) than people living in more affluent areas. Racialised individuals are far more likely to be among those experiencing poverty and deprivation than their white counterparts.
As a result, access rates into NHS talking therapy services are lowest in Coventry, with high deprivation and the highest rates of racial diversity, and highest in Rugby, with low deprivation and far fewer racialised inhabitants.
Racialised communities face barriers in accessing mental health support, often only receiving assistance when their conditions escalate to the point of detainment. This can lead to heightened distrust towards mental health services and diminished productivity among those grappling with untreated illnesses. Addressing this preventable disparity not only fosters healthier community outcomes but also proves more cost-effective, as providing early intervention and talking therapy for mild conditions is far less costly than detention measures.
Using the Core20Plus5 health improvement framework, Coventry and Warwickshire Partnership NHS Trust and the NHS Confederation’s Partnerships and Equalities directorate co-designed a five-step model to offer a systematic approach to tackling health inequalities. System leaders expressed a desire to transition from merely describing health inequalities to having a practical, structured framework for support.
The steps of the model are:
- Intelligence gathering – build up your insights from a range of data sources.
- Analysis and interpretation – compare and cross-reference data with existing strategies and benchmarking.
- Defining problems – consolidate collected data.
- Co-designing solutions – involve and delegate to communities.
- Critical actions – review, measurement and assurance.
The five-step model is being used to investigate why individuals from black backgrounds are over three times more likely to be detained under the Mental Health Act in Coventry and Warwickshire. The model provides a systematic approach to examining inequality and any decisions taken, identifying ‘the challenge’ and co-developing solutions to create change. By using the model, CWPT revisited assumptions on step one of the model /intelligences gathering, and step two of the model / analysis and interpretation.
Critical emphasis is placed on the model being owned by the community, driven by clinical expertise, and empowered by management to implement patient-centric programmes aimed at effectively addressing healthcare disparities.
Reflections, learning and outcomes
The NHS Confederation’s work to date with CWPT has helped to develop and pilot a new meaningful approach to tackling healthcare inequality. Lexi Ireland, strategic lead for health inequalities at CWPT stated that:
“The five-step model has proven itself to be flexible, enabling us to use the methodology to build upon existing work, and offered a structured approach to drive forwards new pieces of work that may feel daunting at first.”
The NHS Confederation is supporting health systems to deliver equity and address health inequalities for the populations they serve by facilitating application of the model across locally targeted workstreams.
Public health in London
Professor Kevin Fenton, regional public health director for London, aims to position London as the world's healthiest global city. This goal is being pursued from 2018 to 2028, in part through the implementation of new and evolving health and care structures that will be integrated within the existing frameworks of local government and the NHS.
Professor Fenton devised an anti-racist framework for public health in London, comprising five pillars:
- Asking leaders to commit publicly.
- Workforce diversity and inclusivity.
- Health equity programmes.
- Organisations use their power as anchor institutions.
- Strengthening work with communities.
The COVID-19 pandemic illuminated enduring social and health disparities while underscoring the significance of localised strategies in tackling contemporary public health issues equitably and sustainably. It highlighted the necessity for community-centred and culturally sensitive public health initiatives, emphasising community involvement across all stages from conception to assessment.
Professor Fenton’s framework reflects the relevance of insights gleaned from the COVID-19 vaccination campaign, which effectively tackled vaccine hesitancy and rebuilt confidence in the NHS among specific demographics through data-driven strategies, focused interventions, efficacy assessments, and community engagement. The programme was significantly bolstered by outreach work and collaborative community efforts, highlighting the importance of investing in communities alongside healthcare infrastructures to nurture resilience.
Reflections, learning and outcomes
Professor Fenton's London Health Inequalities Strategy underscores the importance of
cooperation among local authorities, primary care networks, and the voluntary and community sector to address healthcare disparities.
It reinforces the use of community-centered and asset-based approaches, along with outreach and engagement strategies, to enhance health outcomes and address disparities.
Moreover, it advocates for well-funded, multi-tiered, equity-focused public health frameworks that prioritise pandemic preparedness and robust emergency response systems.
Patient and Carer Race Equality Framework
NHS England has introduced the Patient and Carer Race Equality Framework (PCREF) to drive an anti-racist approach to improving mental health services in trusts across England. This mandatory framework guides trusts to implement anti-racist practices, with a focus on co-production and targeted actions to reduce racial inequalities.
Integrated into Care Quality Commission (CQC) inspections, the PCREF holds trusts accountable for the enduring health disparities highlighted by the COVID-19 pandemic, particularly within mental health. It aims to address stigma, exclusion and racism, targeting barriers faced by ethnically diverse groups.
Led by Dr Jacqui Dyer, NHS England's mental health equalities adviser, the PCREF aligns with the Advancing Mental Health Equalities Strategy and key recommendations from the Independent Review of the Mental Health Act 2018. NHS England, alongside national and local partners, oversees PCREF implementation, fostering transparency and commitment to ending racial inequalities.
PCREF supports improvement in three main areas:
- Leadership and governance: trusts’ boards lead on establishing and monitoring concrete plans of action to reduce health inequalities.
- Data: a data set is published on improvements in reducing health inequalities, as well as details on ethnicity in all existing core data sets.
- Feedback mechanisms: visible and effective ways for patients and carers to feed back are established, as well as clear processes to act and report on that feedback.
South London and Maudsley Trust three-way governance for PCREF
PCREF has been used to help tackle racial inequalities in a range of trusts, including South London and Maudsley Trust (SLaM).
A thorough examination of SLaM's data revealed significant discrepancies in access, outcomes and experiences among black service users and their caregivers. The trust established a PCREF partnership group focusing on tackling race inequalities experienced by black communities accessing mental health services. Over the years, the trust has fostered a collaborative approach with local black African and Caribbean communities, laying the foundation for the PCREF governance model. The objective was to transition this collaboration from the periphery to the core, ensuring that all aspects of the PCREF programme were jointly developed and executed.
The PCREF Partnership initiative began with initial meetings involving two local black-led voluntary and community sector organisations, Lambeth Black Thrive and Croydon BME Forum, alongside the trust, to explore potential collaborative avenues. These organisations were termed ‘host organisations,’ tasked with aiding the development of borough-based independent advisory groups (IAGs). Subsequently, a PCREF Community Action Group was established, comprising the host organisations and the IAG chairs, meeting regularly to devise communication strategies.
Recognising that effective partnerships require both joint and individual efforts, the PCREF Partnership established distinct governance structures to engage with the black community, black service users, their caregivers and all staff members. This autonomous governance element is crucial for empowering black communities and has been instrumental in dismantling historical barriers. The trust's approach emphasises co-designing and co-delivering the PCREF, ensuring a fair distribution of power and accountability, albeit requiring continuous attention to maintain balance. True collaboration with black community leaders and service user/carer representatives has led to ongoing insights and the acknowledgment of the necessity for adjustments. However, the time commitment involved in implementing the PCREF programme posed challenges, especially for leads holding triple leads and balancing their roles with full-time jobs, resulting in delays if meetings didn’t have enough attendees.
Moving forward, SLaM plans to initiate the first developmental evaluation cycle to assess the programme, including development of an annual PCREF report, highlighting the trust's performance against all PCREF metrics and outlining plans for the upcoming year.
SLaM is also examining patient experience and outcome tools through a racialised lens, alongside its focus on leadership, governance, and data transparency. Patient outreach efforts, such as sending letters for demographic updates, and using outcome dashboards filtered by ethnicity, have significantly improved data completeness and accuracy, reflecting a comprehensive understanding of the local population. Consequently, SLaM has achieved 100 per cent data completeness for the ethnic category and no invalid submissions.
Reflections, learning and outcomes
SLaM’s work to tackle racialised inequalities showcases how efforts aimed at addressing these inequalities in healthcare prominently feature community engagement, co-production, and leadership commitment.
The critical importance of involving affected communities in decision-making processes is also recognised, fostering collaborative partnerships between organisations and community groups, and empowering community leaders to drive meaningful change.
By prioritising inclusivity, transparency, and shared accountability, such initiatives seek to dismantle systemic barriers, foster trust, and promote equitable outcomes for all patients.
Viewpoint
While BLN members have provided examples of anti-racism initiatives with their organisations, there remains a notable scarcity of information regarding anti-racism efforts within the broader healthcare sector, making it challenging to find relevant studies and examples.
The examples in this report highlight co–production and collaboration as pivotal strategies towards reducing healthcare inequalities through an anti-racism approach. By fostering partnerships among healthcare systems, community stakeholders and external entities, collective action becomes possible, establishing a shared responsibility for driving substantial and meaningful change.
Moreover, the collective efforts showcased in these collaborations underscore the necessity of collaborative partnerships, community engagement and systematic approaches that prioritise inclusivity, transparency and accountability. To facilitate more effective anti-racist work within the NHS, it is essential that programmes receive sustained funding rather than just a one-off grant, ensuring their continuity and lasting impact.
Simply increasing ethnic representation does not necessarily challenge racial injustice and inequality. Focusing on ethnicity can obscure the shared experience of racism among racialised communities and promote conflict over representation. It is imperative to avoid individualising the problem of racism and to focus on the need for systemic change.
The BLN is dedicated to addressing racism and health inequalities by fostering more diverse leadership, seeking not only to achieve representation but also to instigate genuine cultural transformation within the healthcare landscape. This involves not merely placing individuals from diverse backgrounds in leadership positions, but actively fostering an environment where diverse perspectives, experiences and voices are valued, respected and integrated into the core fabric or organisational change. Through this approach, the network endeavours to create lasting systemic change that reflects the richness of diversity and promotes equity in healthcare access and outcomes for all patients.
Recommendations
The NHS Confederation's engagement with our members pinpoints common themes that facilitate effective anti-racism approaches. From these themes we have developed recommendations for board-level leaders across NHS organisations, as a guide towards addressing racism within healthcare.
Race equality strategy
Develop a thorough race equality strategy outlining anti-racism initiatives across the organisation, with specific measures and regular evaluations. The NHS Confederation adopts a ‘commit, understand, act’ framework, prioritising clear leadership commitment before addressing racism. Progress against racism requires sustained effort and an understanding that change takes time. Leaders must invest continuously in anti-racism initiatives, allocating resources and being accountable for meeting key targets and overall outcomes.
A systematic approach
Adopt a systemic approach to examining inequality, recognising that addressing racism requires a comprehensive understanding of the root causes and a commitment to systemic change. Frameworks like the five-step model used in the Coventry and Warwickshire initiative exemplifies this.
Co-production
Anti-racism programmes should actively involve racialised communities at all steps of the commissioning cycle, from data collection and analysis, developing appropriate interventions and implementing such solutions across the population. By actively involving communities in the commissioning cycle, from data collection to intervention development and implementation, projects ensure a community-centric approach that is fundamental to anti-racist efforts.
Knowledge exchange and evaluation frameworks
Addressing racial inequalities requires robust, structured frameworks that enable seamless knowledge dissemination and provide platforms for sharing both successes and failures among partner organisations.
Such frameworks must assess the impact of programmes on communities, foster collaboration and learning, and uphold accountability.
By establishing channels for open dialogue and implementing rigorous evaluation mechanisms, these initiatives can cultivate a culture of continuous improvement and drive meaningful change towards tackling inequality.
More information
Join the BME Leadership Network
If you are interested in joining the BME Leadership Network, read more on the network’s web pages.
Get support from the NHS Confederation
Find out more about the NHS Confederation and how to join on our membership web page.
Share your examples
If you have an example of good practice that you would like to share with us, please email: bln@nhsconfed.org
