Trevor Phillips, chairman of the Commission for Racial Equality,
calls the problem "snowcapping" - and the word is a
shockingly accurate description of how the NHS in England looks. It
is a mountain of an organisation. At the base among its 1.3m
employees, there is a wide ethnic diversity. People from black and
ethnic minority communities make up 35% of its doctors and dentists,
16.4% of the nurses and 11.2% of non-medical staff.
But at the top of each NHS organisation, the boss is almost always
white. There are more than 600 NHS trusts, health boards, local
health boards and health and social services boards in England,
Scotland, Wales and Northern Ireland, and fewer than 1% of them have
a black or minority ethnic chief executive. The contrast between
snowcapped summit and the mountain base could hardly be more
stark.Sir Nigel Crisp, the NHS chief executive, has put considerable
energy and commitment this year into devising a strategy to correct
this problem. But a Society Guardian investigation has shown how hard
it will be for him to achieve the organisational change he seeks.
Our first surprising finding was that the Department of Health did
not know how many ethnic minority chief executives it had, who they
were, or where they worked. When we identified five (including one in
Scotland), the department confirmed our findings. It turned out that
not all the five knew each other. Most were aware of only one or two
ethnic minority chief executive colleagues: an exclusive club indeed,
which seems even smaller to its members than it really is.
The club's five members are: Prem Singh, Janet Soo-Chung, Wai-yin
Hatton, John James and Rose Gibb, the chief executive of Maidstone
and Tunbridge Wells NHS trust (who was unable to be interviewed for
this article). Not a great statistic, admits Elisabeth Al-Khalifa,
head of the DoH's equalities and human rights group. "It's very,
very low. And it's extremely disappointing that we seem not to be
able to get the sort of breakthrough we need."
Sir Nigel has a 10-point race equality action plan. Half the plan
is about improving services for the minority ethnic communities. The
other half is about developing the staff.
"We need to address the issue of bringing more people from
these communities into the leadership of the NHS," he says.
"They make up something like 11.5% of the workforce and 5.5% of
senior management, compared with about 7% in the population as a
whole. But we also know we have a problem of snowcapping."
There were, he said, plenty of doctors from black and minority
ethnic communities making their way into senior clinical positions,
and the NHS made a considerable effort to achieve diversity among
non-executives on trust boards. "But yes, we have a real issue
to deal with, because here is a part of the community that we are not
drawing on for our senior leadership." It was a problem for the
individuals who were denied promotion, but also for the service that
was deprived of perspectives it needed to do the job professionally.
This week, Sir Nigel is overseeing the shortlisting of candidates
for a new pounds 95,000-a-year position as NHS "equality
tsar". He says: "I am looking for somebody experienced in
making change happen inside the NHS, or from outside it, who is going
to add energy and pace to the whole agenda around equality."
Sir Nigel brings proof of his commitment to all his meetings with
NHS trusts. She is called Yvonne Coghill, an Afro-Caribbean nurse who
has worked for the NHS for 28 years. The chief executive brought her
into his private office on a one-year contract and is mentoring her
progress with a view to developing her management career. In
February, he asked all the trust chief executives to follow this lead
and mentor a minority ethnic manager. By the end of April, 300 had
done so and he expects the total to reach his target of at least 500
He has developed a "Breaking Through" programme, run by
the NHS Leadership Centre, instructing it to identify black and
minority ethnic managers in the NHS with the talent to move higher
(there are 60 black and ethnic minority managers at director level in
the NHS in England) - and to plan recruitment strategies to attract
others from outside. Other initiatives include a strong diversity
message in the new induction programme for staff, which will be
announced at the NHS Confederation conference in Birmingham on
Sir Nigel admits that 1% is not enough, though he doesn't have a
target figure. "We are in the foothills here, as we were three
years ago when we noted that only 1% of the workforce in the London
ambulance service was from black and minority ethnic communities. We
put programmes in place, and now that is 3%. That's a big leap
forward, but there's still a long way to go. In the long term, I
would expect the leadership of the NHS to reflect the make-up of the
country as a whole.
"What we need to do is understand why this group is not
appearing in the top echelon and how we can create opportunities for
it to move up through the system," says Sir Nigel. "If you
want to call that affirmative action, so be it. But it is not
Phillips says the NHS is "not doing terrifically well" at
addressing diversity, although it is not that different to other
organisations of its type and size. "I wouldn't single out the
NHS, except to say it has a larger number of ethnic minority
professionals in the workforce for longer, so you would have them to
There should be better statistics on the ethnicity of those
promoted, seconded, taking up training opportunities and so on, he
says. Phillips says the "patterns of racial bias that emerge in
employment and service delivery aren't because there are thousands of
either overt or covert racists", but are the effect of many
small decisions made by people who, for example, recruit staff in
ways that can exclude ethnic minorities.
There is a level that people get to in most professions where the
next promotion doesn't depend on actual qualifications or experience
but on the confidence of peers and managers. This, he argues, is
where people from ethnic minorities lose out.
"No one has the confidence that they'll use the right fork at
the right dinner - they don't speak in the right way," Phillips
says."We tend to replicate ourselves when we're recruiting
people. People tend to be informally groomed for jobs - what they
call succession planning. Unless a champion is ready to groom you . .
. you haven't got a hope in hell."
The point is echoed by John James, chief executive at Hounslow
primary care trust. There are several factors hindering the rise of
black managers, he says. One of the hardest to quantify is a feeling
among black staff that they are not given the opportunity to
progress; it's like professional football, James says, where there
are many talented black players, yet almost no black coaches or
managers come through. "People seem to get to a point and no
further," he says.
By contrast, Wai-yin Hatton, chief executive of NHS Ayrshire &
Arran, in Scotland, is not exercised by the lack of ethnic minority
faces at the top. "I don't see it as a problem - in that any
organisation should be recruiting the right person for the post,
irrespective of gender or race, and so on," she says.
Instead, she argues, ethnic minority managers should examine
"opportunities for self-exploration to see what could be getting
in their way. It's not just the work environment where you may
encounter a blockage. There's definitely a black and ethnic minority
'glass ceiling' from within our own background."
Janet Soo-Chung, chief executive of Sheffield South West PCT, says
role models are important to show black and ethnic minority staff
they can have aspirations to the top jobs. Mentoring can also help
staff move up. But she adds: "You have to make the right balance
between something tailored for minority groups and getting into the
mainstream. When it comes to getting a job, you're not going to be in
a room full of black and ethnic minority people."
The Department of Health says that networks are bringing together
black staff in many trusts, offering development and opportunities to
engage with management as well as promoting race equality in service
delivery. The NHS Confederation and the Royal College of Nursing have
set up a forum for black and ethnic minority managers.
The NHS management training scheme recruited only 3% of entrants
from black people or ethnic minorities last year. In 2004 it is up to
17%. However, there is still much to do.
Ratna Dutt, director of race equality charity REU, says:
"Monitoring is everything. Nigel Crisp must tell people what
he's expecting them to do - and make it clear he will check what has
Full interviews with the NHS's black and ethnic minority chief
executives at SocietyGuardian.co.uk/nhsstaff. For live news, comment
and debate from the NHS Confederation conference, go to