Covid-19 has impacted communities in different ways and exacerbated health inequalities, but at the same time a new social contract between healthcare services and local communities has emerged. Udara Ranasinghe looks at how equality, diversity and inclusion (EDI) will play a crucial role in the transformation of healthcare.
After a period of immense strain and enforced change due to Covid, the UK healthcare system faces a perhaps once in a generation opportunity to reset and transform the system to tackle health inequalities. The pandemic did not create these inequalities but it exacerbated them and shone a spotlight on the need to tackle them as part of rebuilding the system after Covid. None of that is likely to be controversial but what are the levers to affecting change which for so long has eluded the system?
Leading from the front
Leadership is of course crucial when it comes to delivering on EDI. Leadership figures from public and private practice carry the decision-making authority to drive and enact change, while also serving as sources of inspiration and examples to follow.
The NHS Leadership Academy duly acknowledges that “diversity and inclusion leads to improved health and greater staff and patient experiences of the NHS; and [they] welcome the challenge of enabling staff from all backgrounds to develop and excel in their roles”.
Greater leadership diversity creates better decision-making and attracts a more diverse range of people to healthcare professions across all levels, while making a more diverse range of people comfortable in seeking or accessing care. It means that EDI issues infiltrate recruitment and hiring decisions and brings positive challenge and accountability to the wider system. Diverse leaders are more likely to develop new ways to inspire broader groups, and so the snowball effect takes hold.
Whether through having diverse figures in leadership positions, or via leaders of any background serving as EDI champions, the visibility of transformation around EDI is pivotal. Visibility is both powerful and inspirational. Showing that inclusion is being prioritised in visible ways empowers and inspires others to take action and to believe that change is possible.
“It’s really important that we think about a workforce and leadership that reflects the community it serves,” says Phil Wood, Chief Medical Officer and Deputy Chief Executive at Leeds Teaching Hospitals. “Leadership that is more recognisable to communities enhances the sense of connectivity and encourages engagement.”
In Leeds, Wood is working with providers to better understand the barriers people face in terms of getting into leadership positions.
“It’s a bit of a chicken and egg challenge,” says Wood. “You want to avoid tokenism, because that isn’t effective. What we need is a pipeline of talent development, linked to a conscious effort to recognise and address some of the EDI issues we need to work on. Senior leaders being very visibly committed to addressing those challenges is an important and powerful message.”
Relatability and reflecting the evolution of communities
Another critical element of the health inequality challenge has ironically been the (lack of) participation of the communities most affected. This focus on not just promoting EDI, but on promoting – and celebrating – it in a visible way, is likely to boost community engagement and allow patients to relate to and trust the healthcare system better.
Nnenna Osuji, Chief Executive of North Middlesex University Hospital and formerly Medical Director and Deputy Chief Executive at Croydon Health Services, as well as Joint Clinical Lead for South West London, notes that North Middlesex is a hospital where roughly 60-70% of staff come from a minority ethnic group. Those staff members are also members of the local community.
“It’s the very definition of an anchor organisation,” says Osuji. “So when we serve our staff, we also serve our local community.”
Osuji says the richness of a workforce helps to attract staff committed to making a difference.
“The opportunity to level-up care is there for us to take. That said, the historical and current experiences of our staff from diverse backgrounds has been challenging,” says Osuji. “Look at the fact that certain ethnic characteristics and gender characteristics pre-dispose a poorer outcome from Covid. But equally there is a hesitancy among people from within these communities to take up the vaccine. That poses a risk for the future in how we manage and dialogue with staff.”
Through open conversation with staff members and community members alike, breakthroughs can be made. Osuji’s emphasis on “dialogue” is important here – the conversation is two-way. Being visible and speaking to the community is not enough. Listening is as important – if not more so. Only through listening and learning can true understanding (and improvement) take place.
“One element which has been particularly enjoyable has been having direct outreach conversations with our populations. Not through the interface of a hospital appointment, but through an interface that is uniquely theirs,” says Osuji. “To be able to hear first-hand some of the real, lived experiences of what diversity means and what the history of that diversity means in terms of confidence in the system.”
The healthcare ecosystem must hear, understand and reflect the real world around it.
“It all comes back to the question of need and mutuality in serving the needs of the populations we’re responsible for. That cultural shift is enshrined in some of the legislation particularly picking up on health inequalities, so in terms of how we distribute resources and assets to deliver, that is an important incentive, indicator and driver of change,” says Osuji. “Those cultural aspects are going to be big drivers as we move forward.”
As Osuji alludes to, healthcare policy and legislation contained in the white paper, the Long Term Plan and regionally through things like the London Vision, is geared towards facilitating this cultural shift. On the workforce side, one of NHS England’s core equality objectives is to improve the recruitment, retention, progression, development and experience of its employees to enable it “to become an inclusive employer of choice”.
The Institute for Public Policy Research (IPPR), a policy thinktank, argues that improvement will come from the NHS developing its service, finance and workforce plans by focusing on questions such as “what skills mix is needed for ICSs to improve population health and reduce inequalities?”.
IPPR identifies the growth of new roles as key to tackling workforce challenges in the long term, alongside reforming education and training so that all staff have a broader range of skills enabling them to work across different care settings. It also suggests measures including widening entry routes to clinical professions, adopting shorter and more skills-focused training requirements, and increasing access to learning throughout careers.
“These reforms will increase the quantity and the diversity of the workforce in the long term,” says the IPPR’s 2021 State of Health and Care report.
Potential reform of legal frameworks around employment policies might also improve recruitment and workforce issues, says Ben Morrin, Deputy CEO of Barking, Havering and Redbridge University Hospitals NHS Trust.
“Positive action allows us to think about improving how we bring talent on. Unless we are more radical in how we think about that, we are more likely to take incremental steps in improving diversity and leadership across our systems, as opposed to the more radical options which the best organisations in commercial settings, within and beyond the UK, are taking,” says Morrin. However while the 2010 Equality Act allowed a slightly broader approach to positive action, it is still very much curtailed under current UK law and so employers need to approach positive action with care (or be on the wrong side of discrimination claims from those disadvantaged by positive action policies).
No one-size-fits-all
On the care provision side, delivery must be responsive to the needs of the local population. As my colleague Charlotte Burnett explores, successful healthcare delivery requires an appreciation for nuance. Sometimes, even local isn’t local enough.
“The city’s overall ambition around health is to improve the health of the poorest, the fastest, so actually just to talk about Leeds as an amorphous city is itself not local enough if we want to address health inequalities and improve outcomes"
