Anything Black Asian and Minority Ethnic (BAME) is complex, sensitive and easily divisive. No more so than in a nation, once an empire, struggling with its history, reluctant to rely on the once colonised to care for its people.
A former Secretary of State (SoS) proved the point. He ordered NHS provider CEOs to stop recruiting into Equality, Diversity and Inclusion (EDI) roles. The fierce force of X, such as it is, filled the digital ether with commentary and disdain. NHS provider CEOs signalled defiance. Experts said these things matter, even if these things aren’t working, assuming virtue posturing isn’t the aim and some shape of equality is the purpose. The SoS agenda was almost certainly political.
This essay isn’t a political position. It isn’t a dogmatic position. It isn’t denying racism; much is written about racism in the NHS. This is a reflection and a spiral to a different way of thinking about what, at first glance, looks black and white. It is no less complex.
The essay argues that organisations must understand the needs of the people they employ, whatever their characteristics, protected or not, and be inclusive and just in their actions, underpinned by becoming learning organisations not just in name or aspirational strategy but in how they organise and act—embedding learning in all work.
The lived experience
I have written about this before. I make no excuse for recounting it again. It happened not so long ago and will happen again.
It was a defining moment from my time as an NHS consultant when I was othered by a clinical director and Trust because his decision defined me. I was to be seen and characterised first by my assumed ethnicity. Only then came being a doctor; he decided that no BAME doctor was to look after the child of a racist because that was what the racist parent demanded. The Trust leadership became complicit in its follow-through actions and inactions.
For the first time, in writing and intent known to all, at least all who happened to be BAME in the hospital buildings, an ivory tower, tertiary centre of excellence and until recently rated outstanding by every manifestation of CQC, we were to be identified first for being just that. BAME. Second, came the professional skills and capabilities, hard-earned and appointed for, to serve sick children and their families. It was, at best, boneheaded and took a Board level inquiry to make the inevitable and necessary outcome more convoluted - to reverse his decision. The fact that the Trust leadership needed an inquiry revealed the maturity of the ideas of being inclusive, just, learning, institutional racism, and leadership, never mind the application of the law of the land. There is no evidence that the organisation learned anything meaningful and lasting. A recently retired colleague from the Hospital Trust reminded me that nothing had changed.
Somewhere along the 2000s, I was asked to consider joining BAPIO - British Association of Physicians of Indian Origin. A flourishing organisation all about supporting fellow medical professionals of Indian origin. Why me? Undoubtedly of Asian heritage, but not Indian and born on another continent. In any case, others had decided something about me. My inner Groucho Marx surfaced and declined, saying unhelpfully that I would be the founding and only member of BAPOOO - British Association Of Physicians Of Other Origin. How not to make friends...
Self-othering and ghettoising is a thing - a well-understood homophilic tendency. It’s a safety thing. An anthropological thing.
So if self-othering is a thing, then being othered by others shouldn’t be an issue, you’d think.
2010, I was asked to apply for a BAME-only NHS Leadership Academy programme. That was an easy ‘no thank you’ but an uneasy conversation with the person asking. The guilt trip - I was letting down a ‘community’ by denying myself something defined by my assumed kinship; something about BAME folk at the foot of career ladders, pulling them up by example. I have helped, coached, and advised many colleagues, BAME and not BAME, as they tried to navigate careers in the NHS. I didn’t feel the need to role-play or model through a BAME leadership programme. Try to pigeonhole me, and I will eventually peacock my way out.
To this day, many BAME-only leadership programmes are funded by NHS organisations, the NIHR, and more. Pray tell, what are the unique BAME-only modules that shouldn’t be part of any worthy, open-to-all leadership programme?
I did get on an NHS leadership academy programme in 2014. Melanin content was not an essential entry requirement. A mix of brilliant people, where the diversity of experiences, thinking, and debate mattered, stimulating new learning. Someone somewhere probably reported that 8% of the cohort were BAME. Perhaps I was filling an unofficial quota.
Role modelling does seem to matter. When I decided to leave the ivory tower to take on an extraordinary challenge to redesign a paediatric service between two waring District General Hospital Trusts, I was in an unexpected conversation with a paediatrician colleague on a long train journey. He asked why I was leaving for a DGH - “People like us don’t get into the ivory towers, and it was inspiring to see…” Who knew? I didn’t, at least until then. Perhaps my professional detachment from my melanin load and inherited assumptions of ethnic origin and culture are a reflection of my very personal refugee-rooted experiences and way of coping and navigating a country that didn’t feel mine for some decades. Needed-Tolerated-Accepted-Welcomed…
About my start as a refugee in England of the 1970s—a time filled with unchecked racist language on the neighbourhood streets, school playground and television. Till Death Us to Part and Love thy Neighbour determined the week’s taunting. We were chased and beaten by skinheads because we darkened their streets - thankfully rare but probably because we quickly learned to be vigilant to avoid the moments of greatest risk. The decades that followed proved a nation could change, including through law. It took decades and is far from done, with notable backward steps driven by political state failures.
I am not denying racism in people and organisations. You can read about the feathers I collected, lacking the courage to challenge whilst climbing the career ladder.
Resisting efforts to corral me to suit someone else’s needs is a thing that probably explains so many obstacles slipped past, climbed over or just not worth the effort. Asian continent heritage, African colony-born, refugee-landed. “...where are you from? No, really, where are you really from...” I welcome that icebreaker every time.
Either I am a professional first or BAME first. Either I am a citizen first or BAME first. If it matters that I am BAME first, to whom does it matter? If it matters to someone, what are they doing beyond words and virtue signalling with BAME things?
Top Cat Top 50
We have the annual ritual of the Health Service Journal NHS top 50 BAME leaders.
It is good to see BAME folk reach influential positions. The message is that you can make it even if you carry more melanin than most; skin colour a proxy for a presumed tough life and career. We must be celebrating the top 50, reaching the top 50 despite the challenges, injustices and racism loaded on because of being a BAME.
There are BAME folk who send their kids to Winchester, don’t have friends from the working classes, get to Oxford and get to lead us all. Is it a BAME issue, or is it inequalities defining opportunities? At one spectrum of class and wealth, it's irrelevant. At the other end, it’s everything.
There isn’t a non-BAME annual top 50 list. There is a general, all-inclusive top 50 CEO list—a mix of people from any number of ethnic or presumed ethnic backgrounds. BAME folk get two hits at getting on a top 50.
How might one rank one list over the other? It is a ranking game, after all.
You are good enough to be in the all-inclusive top 50, or you are not and need a BAME-only category to get you into a top 50. Am I the only one who thinks there is a problem?
If we can’t address the underlying drivers of career inequalities - see WRES - we can at least feel good with a list that makes all sorts of folk feel better about themselves: BAME and not BAME.
Shorting the ranking
If we are to stick with physical characteristics as proxies for inequalities, let us try a thought experiment.
Short people are disadvantaged in leadership attainment, among other built-in shortism inequalities; strong short leaders are often denigrated as displaying ‘Napoleon syndrome’. Napoleon, who was, in fact, 5ft 6in., got things done. Why not a short leader’s top 50? Unlike BAME, presumably not objectively measured by the HSJ in-house spectrophotometer, being short can be defined by a number and objectively measured. It reminds me of a recently appointed site medical director of South Asian descent and somewhat shorter than Napoleon's French height measurement, who in 2018 said, "I don’t like you because you are tall and your height is imposing". WTAF.
History month
Perhaps the need for BAME-only lists and related things is revealing a truth about the nation, its institutions and its history. The 400-year history of industrial-scale slave trading and colonial conquests struggles to surface in school curricula to reflect and define the open and honest narrative of the state of the nation today and how it treats its people. Marketing a history one month a year is presumably doing something.
District General Hospitals have long been worthy of several anthropology PhDs on the influence of British colonial history on the social and cultural shape of organisations, leadership, services and the quality of care. The once ‘colonised’ are coming here like never before, enabled by Brexit, state failures and that long colonial cord. Needed. Tolerated. Accepted? Welcomed? In any case, the NHS post-Brexit is blacker and browner than ever before. So, perhaps BAME things matter if only because those crossing the continents keep the culture gaps open and so need constant attention, othered through EDI committees and WRES. The organisation is at least doing something - complying with the regulator's demands, reporting the WRES, and drowning in action plans.
Perhaps BAME stuff acts as a necessary reminder that the barriers that are structural, racist, and unjust exist and need constant effort to overcome.
We also know this. If you are not educated to a particular standard and speak with a hint of ancestral continent origin, assumptions and presumptions of you and your inequalities will weigh you down, and your peer will likely win by dint of homophilic or racist reasons. Even with a private education in the bag, the Queen's English honed, you will always have to work harder, work the system and be strategic - all because the organisation is not inclusive, not just and not rooted in learning.
Realism points to continuing to need BAME-only things as long as we remain some distance from being inclusive and just. If EDI directors, EDI leads, EDI committees and the WRES show little or no impact on the injustices in the buildings, then we have to rethink what and how to address not the physical manifestations of but the inequalities staff carry into the building. We can’t wait another 400 years of top 50 BAME lists.
Changing society is a long game. Generations long. People right now can’t wait generations. They need to have their needs met now. Organisational change takes years. Things regulator-driven - EDI, BAME, history months.... are not enough; they might even be divisive and distracting from the actual work required.
Inequality
Let's put BAME things to one side. The answer then must be E and I in EDI.
When thinking about patients and populations served, lists for the causes of health inequalities often include being Asian and black, as though these are factors that can be changed. Yet we know that aside from inherent medical reasons, and being BAME is not one, 80% of the causes of inequalities are social factors - education, economics, environment, culture - sure, being Bangladeshi in Newham puts you at higher risk of poor health outcomes. So does being poor and white in Knowsley. You cannot change being white English or brown Bangladeshi.
Social determinants are politically determined. Politics and society could choose to do something about the social determinants. Take the growing number of rough sleepers, a cohort of the population living with the most extreme of inequalities, and thereby the worst of health inequalities. How we address this most extreme end of our population in terms of needs suggests we, as in the state and those we elect, choose not to do enough about the social determinants that lead to rough sleeping and all that follows. Yet, we must do something about health inequalities across the population, which we know are the outcome of the social determinants—dealing with the symptoms, not the cause, again.
What of inequalities closer to home - the organisation and its employees?
Organisations employ staff from the very population they exist to serve. This includes poor white families. They walk into their work buildings, carry no acronym and probably don’t want to be othered for being white and poor, but there isn’t a BAME equivalent focused on the needs that come out of their inequalities. When a BAME person walks in, the organisation, driven by regulator demands, sees them as different and a problem that needs solving - so let’s have a director, a committee, and an annual report on the numbers game.
All staff carry-in two bags every day they walk into their work buildings - their skills bag and their human needs bag, which includes that most challenging collection of inequalities that directly impact on being able to do the work.
What of everyone else and their needs? If you are not BAME, or living with a disability, the organisation has nothing much to offer. Has the EDI industry become divisive?
We worry about population inequalities, yet the institutions that talk of inequalities and try to do something about them are structured and led through disparities of inequalities, power and privilege, staffed by local people, BAME and not BAME, who do the work walking in with unexplored needs and their inequalities, invisible to the leaders.
Might inequalities as a frame and not skin colour matter more? How about a top 50 leaders who did not benefit from private education and private club memberships? Graft over privilege. A meaningful signal. A real story. Social mobility breaking through inequalities despite the odds. Whatever the characteristics, protected and invisible.
For that to work, organisations need new capabilities.
A learning organisation
In 2000, Professor Sir Liam Donaldson published a report that changed how the whole NHS organised itself. The report sparked a focus on quality improvement and clinical governance. Things that become industries aiming to improve outcomes. A lot has happened in the almost quarter century since - good, bad and ugly. It is a report worth revisiting, asking where we are now and why we still need help with the idea of a genuine learning organisation when it comes to something as fundamental as learning from preventable clinical harm to prevent harm.
Perhaps what has happened is a distraction and focus on the negative set against functions added to organisations that carry the responsibility to learn through governance and quality improvement teams but not embedded in all an organisation does, from Board to ward. The Letby story reveals that challenge, as does the Edenfield Panorama exposé and almost every maternity unit in the land.
Perhaps we are in the same distracting trap with BAME, EDI and WRES; things added to organisations to solve a problem. Disconnected industries that have yet to show value.
What is the paradigm shift needed so people feel valued, welcomed, and developed to the point of making the add-on disconnected industries redundant - as the Chair of an ICB said - WRES proves every year that if you can measure it, you can also do nothing to improve it. Or we game the system - Ever looked at Trust Board memberships - NEDs vs executive diversity? Thank goodness for NEDs - without whom most executive teams would be invisible in a snowstorm. Set a number, and we can play the numbers.
Positive discrimination and equality of numbers for the sake of numbers are divisive and let the organisation off the hook for doing the hard graft of becoming a learning organisation, learning built-in Board to ward.
At the individual level, perhaps you are not progressing because you need new skills, but do you know that? Does your employer know that? Will the employer help you get those skills? The answer is not the annual appraisal. If belligerent discrimination surfaces, the inclusive, just learning organisation applies the rules and the law - take action and focus on everyone else who is serious about being inclusive and learning.
At the organisation level, do you really understand your people, their needs and how to meet those needs? Have you taken all it takes to become a learning organisation and made learning in all the the organisation does - from Board, to ward?
There isn't a magic bullet or standard template that quickly gets an organisation to a mature learning organisation. Adding Qi, governance functions, EDI committees... still leave organisations transacting, not learning.
Good quality literature is limited. Academic and pragmatic experts such as Roger Kline have written a great deal, underpinned by evidence of what, why and even how to shift the dials and yet we struggle to do what they recommend.
Peter Senge's Fifth Discipline, first published in 1990, remains a crucial canon for those serious about what it takes to be a learning organisation. In it you will find Senge reflecting on what Deming concluded in his 9th decade, after a life filled with learning, reflection and many hard truths:
"Our prevailing system of management has destroyed our people. People are born with intrinsic motivation, self respect, dignity, curiosity to learn, joy in learning. The forces of destruction begin with toddlers - a prize for the best Halloween costume, grades in school, gold stars - and on up through the university. On the job, people, teams, and divisions are ranked, reward for the top, punishment for the bottom. Management by objectives, quotas, incentive pay, business plans, put together separately, division by division, cause further loss, unknown and unknowable." Deming
Deming's work, at least in the NHS, distilled down to the PDSA—a symptom of a failure to learn.
If leadership has just one job, it is just this: take advantage of inherent human curiosity and desire to learn and build a learning organisation.
What would matter first if I worked in a learning organisation? My skills or my skin? My ability or my disability?
I had to work harder. I had to work to integrate. I had to deal with every shade of ethnic strife and even comical heightism. I was not going to wait for organisations to change. Today's generation, rightly, is less patient, less forgiving, less loyal. So organisations have to change.
Dr Nadeem Moghal
December 2023