The illusion of meritocracy continues to spark considerable debate about the value of equity, diversity and inclusion (EDI) agendas. At their core, legal, policy and practice frameworks that advocate for EDI recognise that systems of power in society curb equity of opportunity and outcomes. In the context of health, such injustice manifests in workforce and patient experience and outcome differentials. Let's take a look at some of the facts:
• women employed as hospital doctors earn 18.9% less than their male counterparts. This is in spite of progress in narrowing the gender gap in highly skilled health careers
• while the NHS continues to become a diverse employer with over 26% of staff identifying with a minority ethnic heritage, diversity at very senior levels is just over 11%
• black women are three times more likely to die during pregnancy or within six weeks after childbirth
• avoidable death continues to be high among those living in deprivation
• health research, a pathway to solutions, continues to under-represent those with the most potential to benefit from innovation.
Avoiding detours
The current sociopolitical context has once again brought into question the necessity of EDI leadership, roles and initiatives. This has the potential to undo progress against addressing stubborn realities and to distract from much needed action.
Critics suggest woke EDI agendas are wasteful and unnecessary. This argument falls flat when we consider the cost of doing nothing. Failing to advance inclusive recruitment, not implementing programmes to dismantle poor workplace behaviour and halting strategies to prevent or slow down ill health among the most marginalised in society would be a huge mistake.
The social justice and economic case are both well made. For example, incivility in the workplace costs the NHS £2bn a year due to direct and indirect factors such as sickness absence. From a population perspective, modelling has shown the cost of health inequalities is £31bn per year from lost productivity alone. Comparatively, to address these big challenges, the NHS spends less than 0.03% of its annual budget on EDI related roles.
The change we need is not to reverse the energy but to double down on translating words into sustainable action for better health workforce and patient and public experience. The context is there. The NHS people strategy and, for patients and the public — the national CORE20Plus5 framework, are examples of approaches that set insight driven ambition for the future. Solutions, however, need strong leadership to avoid admiring problems and plastering over challenges.
EDI is a complex landscape. The issues are multifaceted and stubborn. There is plenty of potential for noise in an ever evolving, highly sensitive social, political and economic context.
Driving inclusive practice therefore requires leadership that is skilled with a toolbox to navigate through messy grounds. To stay on course, we need:
• The right narrative: Lord Darzi's report highlights the critical state of the NHS. Against this backdrop, further protracted narrative on the value of EDI to population health and health workforce itself is wasteful and only adds to pressure in the system. Challenging this narrative is part of responsible leadership rather than a task that is reserved for those impacted by injustice
• Consistency in EDI leadership, scope of practice and impact: There is considerable heterogeneity in the workforce. Consequently, those with EDI roles vary in their agency within organisational structures. This makes a difference to what can be reasonably achieved. We need leaders with the right training, development, strategic skills and authority to drive sustainable change. Subject specialism in the field of equitable cultural change and experience in bringing about meaningful impact matters
• Use data to drive resourcing and action: Since need is unequal, it follows that resourcing and effort should be directed accordingly. This avoids the perpetual cycle of insufficient action scapegoated in high workloads and lack of knowledge and insights. Window dressing issues (the practice of creative dishonesty) helps no one
• Have logic action: Too often the solution places the burden of action back in the hands of those managing disadvantage. Theorising logic in action is necessary to avoid wasted time, effort, and morale.
Change needs to be driven from authenticity, drawing on data and insights, and the right roles, policies and transformative initiatives to drive promises into reality.
