An investment not a drain: healthcare leaders’ views on EDI in the NHS
Key points
Tackling the issues that cause disparities in health and staff experience improves productivity, efficiency and outcomes. This helps healthcare systems to achieve financial and operational goals and to improve performance.
Systematic work to eliminate inequalities in the NHS, known as equality, diversity and inclusion (EDI), has wide-ranging impacts and requires skilled, strategic leaders to deliver change.
Current estimates put NHS annual spending on dedicated EDI roles in the range of £40 million. This accounts for less than 0.03 per cent of the NHS’s annual resource budget for 2023/24.
In 2019, the annual cost to the NHS of bullying, harassment and discrimination was estimated at £2.281 billion, with staff from minoritised backgrounds bearing the brunt. These negative experiences can lead to a mistrust of services, affecting staff and patients, with patients from minoritised backgrounds likely to present later, with more severe conditions, or not at all. The NHS can ill afford the cost implications of bullying and harassment, or of eroding trust with the communities it serves (as seen during the COVID-19 pandemic).
Disinvesting in EDI, as some have called for, could risk the financial health of the NHS and compromise its ability to improve and transform care and services.
To gauge the views on NHS leaders on these issues, we surveyed senior leaders and clinicians across our membership in England. We received more than 500 responses. This briefing captures what we found, what healthcare leaders need as a result and how the NHS Confederation is providing support.
One overarching message from our survey was clear: investment in EDI is key to improving the NHS across a wide range of issues.
Background
Financial sustainability in the NHS and efforts to improve equity across the service are, at times, positioned as conflicting agendas, yet they are two sides of the same coin. Tackling the issues that cause disparities (in population health and within the workforce) improves productivity, efficiency and outcomes, helping local health and care systems to achieve financial and operational goals.
While the NHS has a legal responsibility to tackle workforce and health inequalities under the Equality Act 2010 and Health and Care Act 2022, reinforced in the NHS Long Term Plan and annual planning guidance, disparities still exist. This is due, in part, to a limited appreciation of the strategic value of equality, diversity and inclusion (EDI) and a narrow view of its objectives. Reductive debates around resourcing, for example, argue that EDI is a financial drain, when less than 0.03 per cent (£40 million from £168 billion of the NHS’s annual budget) is spent on dedicated EDI roles.
EDI is an investment that can improve workforce wellbeing and experience, and enhance service design and delivery
Far from being a drain, EDI is an investment that can improve workforce wellbeing and experience, and enhance service design and delivery. It also ensures patients are involved in designing care. This is much needed. The 2023 NHS Staff Survey found an increase in staff experiencing discrimination from the public and no change in the levels of discrimination from managers or colleagues. A report from the Red Cross stated “[…] that high-intensity use of A&E is fundamentally a health inequalities issue”. Dedicated, strategic EDI leads with accountability for tackling inequalities are key to delivering change, enabling patients to navigate their way through a services and care pathways.
Given the wider context, we sought the views of healthcare leaders to understand their perspectives on the value of an EDI approach to tackling inequalities in the NHS. This briefing captures what we found and what leaders need as a result. It also details our support for members on this issue.
Methodology
Between September and October 2023, we surveyed chief executives, chairs and HR directors across our membership in England - acute, community, mental health, ambulance, primary care and integrated care systems member organisations - and members of our EDI leadership networks. We wanted to understand their views on the opportunities EDI presents to tackle inequalities at workforce level and to transform service design and delivery. We received responses from 560 participants.
What we found
There was broad agreement that EDI is central to providing equitable care and enabling improvements in access, experience and outcomes. Far from being seen as a drain, investment in EDI was deemed essential to transformation. The survey revealed six core themes:
1. Investing in EDI is key to improving the NHS
100 per cent of board-level leaders agreed that investing in EDI is a key part of improving the NHS. Leaders were of the view that investing in EDI not only contributes to improvement but acts as a key enabler for improving services. This suggests that the absence of a strategic and concerted approach to EDI could render improvement efforts less effective. Members also pointed to the value of workforce and leadership being representative of local communities, with an inclusive culture free from discrimination.
2. An organisation’s approach to inequalities is a key factor in attracting board-level leaders
70 per cent of board-level leaders said they considered their organisation’s approach to tackling inequalities when applying for their current role (only 44.2 per cent of this cohort identified as belonging to a minoritised group themselves). This underscores the importance of organisations’ EDI strategies and leadership in attracting quality candidates to the NHS – at board level and across the wider workforce.
Leadership plays a pivotal role in addressing inequalities, as stated in the Messenger review: “EDI must be embedded and mainstreamed as the responsibility of all regardless of role, and especially leaders and managers from front line to board”. However, the Messenger review also makes clear that “dedicated EDI professionals exist to enable this transition”.
3. There is more work to do to address inequality and discrimination in the workforce
97 per cent agreed that ‘The NHS still has issues of discrimination to overcome in its workforce.’ Improving workforce experience could reduce the estimated £2.281 billion costs of bullying, harassment and discrimination and improve sickness absence and turnover. This in turn could decrease the spend on temporary staff and reduce the cost of repeated recruitment drives. This could see more funds available for improving services.
Questions could be raised over whether the NHS is inadvertently exacerbating inequalities within its workforce. Workforce Race Equality Standard (WRES) data points to a decrease in diversity within higher bands, reflecting the often lower wages of black and minority ethnic staff. Meanwhile NHS Charities Together found that out of 34 surveyed NHS charities, 21 per cent confirmed they had active foodbanks for NHS staff, or were in the process of implementing them. Another 35 per cent were exploring the possibility. These inequalities are complex and require strategic EDI planning and delivery to address them.
4. There is more to do to overcome discrimination in access, experience and outcomes for patients/service users
96 per cent agreed that ‘The NHS still has issues of discrimination to overcome in access, experience and outcomes for patients/service users.’ In contrast to the view that EDI is wasteful, the Patients Association makes the case that “ensuring that services meet patients’ needs minimises money wasted on ineffective services, or on services needed to rectify problems arising from inadequate care and treatment.” The association recognises that: “In a well-resourced system, patient involvement enhances services and drives them towards excellence” with benefits being realised in quality and outcomes, cost effectiveness and safety. EDI professionals lead invaluable work engaging with patients and communities.
5. A diverse workforce can better meet communities’ needs
94 per cent agreed that ‘having a diverse workforce allows their organisation to better meet the healthcare needs of the communities it serves’. Yet less than half believed their organisation’s workforce to be representative of the communities it served, and less than a fifth believed their organisation’s leadership to be so. A skilled and diverse NHS workforce that helps to reduce health inequalities is essential.
With 24 per cent of NHS trust staff identifying as black and minority ethnic in 2022, compared to only 13 per cent of board members, we know that the NHS’s leadership is not representative of its workforce by this metric alone. This can have an adverse effect on organisational decision-making.
There was a correlation between the percentage of survey respondents reporting that their organisations had EDI roles tackling inequality in their workforce and the percentage who said that their organisation was accountable to the population it served.
The 2022 Workforce Disability Equality Standard (WDES) results conveyed that only “51.3 per cent of disabled staff believed they had equal opportunities for career progression or promotion”. 2022 WRES data stated that 44 per cent of black and minority staff believed they had equal opportunities, with good reason: black and minority board membership stood at just 13 per cent while staff from a black and minority ethnic background made up 24 per cent of the overall workforce.
6. Engagement with different communities is vital to high-quality care
96 per cent agreed that engagement with different communities is essential to informing high standards of care for all. The results saw a consensus that a diverse workforce allows a better understanding of the communities being served. Co-producing services enables informed transformation of services.
Through designing services that draw on the expertise and lived experience of a diverse workforce and effective community engagement, outcomes can improve and financial rewards realised.
What healthcare leaders need
- Investment in strategic EDI leadership to develop a diverse workforce, representative of the communities it serves. Through strategic investment, positive actions should be identified to improve opportunities and address discrimination in the workforce, improving retention and recruitment. The knowledge and understanding of a diverse and skilled workforce should be drawn on to engage with communities, enhancing opportunities for partnership working to tackle inequalities in service access, experience and outcomes. Realistically, this can only happen with the capacity created in having dedicated senior EDI specialist roles. Such workforce expertise, used in partnership with local organisations, can help implement meaningful changes to services. These changes improve everyone’s care through better patient flow, lower A&E attendances and lower emergency admissions.
- An end to the false narrative that investment in strategic EDI leadership is wasteful. Leaning into myths that tackling inequality is expensive and a distraction from more important priorities is unhelpful and untrue. Healthcare leaders want to see a more constructive narrative focused on the evidence. By investing in tackling inequalities, NHS organisations can inform service design and deliver improvements for the benefit of all.
Viewpoint
Investing in EDI strategy and dedicated leaders tackling inequality is key to transforming co-designed patient services. This investment alone facilitates the development of an inclusive workforce, further enabled to deliver high-quality care. A workforce that can also draw on specialist skills to interpret key information, understand communities, and influence boards and senior leaders to implement key actions informed by people and communities.
The focus for NHS leaders is to tackle inequalities as a vehicle for transforming the NHS, enabling improvement and meeting objectives – including achieving financial balance. As Joan Saddler, director of equality and partnership at the NHS Confederation argues: “To disregard the professional skills and expertise required to ensure local communities are at the heart of co-producing services tackling inequality is to discount the NHS workforce and the communities they serve.”
EDI professionals read between the lines and understand what matters to individual patients from all walks of life
Organisations that are intent on tackling inequalities are also influential in recruiting diverse board-level leaders. Additionally, to recruit quality candidates, organisations need to improve EDI practices and ensure leaders demonstrate and set the culture for the workforce.
Identifying potential improvements is not simple: it requires dedicated leadership to drive forward service design, development and delivery to meet the needs of the communities to which the NHS is accountable. It is not a case of simply analysing and interpreting available data or ensuring boxes are ticked, but of drawing on expertise to understand the personal, everyday stories that are not told.
Through time spent with patients nurturing relationships, EDI professionals read between the lines and ultimately understand what matters to individual patients from all walks of life, and the improvements required. Where equity in either access, experience or outcome is not being achieved, tailored actions for improvements can be effectively designed and delivered supported by professionals tackling inequality.
How we are supporting members
- We offer equality, diversity and inclusion support for leaders through our EDI Directors Programme and for organisations through NHS Employers’ Diversity in Health and Care Partners Programme
- Our bank of case studies spotlights the positive effects of adapting services to tackle inequalities, often resulting in reducing pressures in urgent and emergency care.
- Our Tackling Inequalities hub hosts a range of further resources.
- Our Health and Care BME Leadership Network; Health and Care Women Leaders Network; and Health and Care LGBTQ+ Leaders Network provide networking, development and vital peer support for 5,500 members and allies.
