Differential attainment (DA) is the term used to describe a gap between different groups undertaking the same assessment based on factors related to gender, race, ethnicity, disability, protected characteristics as defined by the Equality Act of 2010, other socio-economic factors or country of origin.1 Differential attainment exists within and outside the medical profession extending to many walks of life and reflects inherent inequalities that exist in society.2
The UK National Health Service (NHS) has one of the most diverse workforces in the world with up to 40% from ethnic minority groups. However, majority of leadership positions in the NHS are usually taken up by white employees rather than those from ethnic minorities and there exists similar disparities in respect to gender, sex, race and protected characteristics.3 Several studies have highlighted that white and ethnic minority staff have different experiences in terms of career progression.4 The NHS recruitment processes have been shown to favour white, male applicants.5 Compared with their white colleagues, ethnic minority staff are more likely to report bullying, harassment and referred to a formal disciplinary process.6 Ethnic minority doctors are also less likely to be shortlisted and appointed as consultants, indeed they hold 57% of staff grade or associate specialist posts.7 Ethnic minority consultants also earn 4.9% less than their white counterparts.8 This may be further compounded for female staff. Although women make up 77% of the NHS workforce, they only constitute 42% of NHS board members9 and there exists a 23% gender pay gap across the NHS.10
In this review we will explore in depth, the current data surrounding differential attainment in leadership roles in the UK NHS, possible reasons for these disparities and what interventions may address this inequality. This scoping review forms part of the Alliance for Equality in Healthcare Professions project on DA chaired by the British Association of Physicians of Indian origin (BAPIO) and will be integrated into the Bridging the Gap project undertaken by BAPIO Institute for Health Research (BIHR).
Why is this important?
The UK NHS was founded upon the principle that every person is treated fairly, equally and free from discrimination regardless of their ‘gender, race, disability, age etc.’11 There is strong evidence that diversity and equality in leadership has a positive impact on the performance and culture of an organisation,12 including non-profit organisations.13 Further benefits of an equal and representative leadership is a widening of the leadership talent, better understanding or engagement with local communities or partners and priorities.14 It can help to cultivate a culture of care and values, ensuring that the NHS adheres to its pledges and guiding principles. Furthermore, it has been shown to help deliver a better standard of care with more sensitivity to patients and their families. 14 As the NHS is perpetually in a workforce challenge, improving diversity and inclusivity will play an important role in becoming a better place to work and develop careers.15
What are the latest figures?
In 2014, Roger Kline assessed the progress of racial equality in the NHS following the NHS Race Equality Action Plan.16 His survey of the leadership in London’s NHS trusts showed a large gap between the NHS Trust’s governance and leadership and the communities they served.17, 5 The report found that despite years of support for initiatives aimed at addressing barriers to progression of Black Asian and Minority Ethnic (BAME) staff, little progress had been made.5 In 2015, the Workforce Race Equality Standard (WRES) was created to improve transparency of data, increase awareness and tackle the inequalities.18-19 In addition, NHS England and NHS improvement (NHSEI) have committed to monitoring their own performance on race equality.20 In March 2020, Sir Simon Stevens announced that NHSEI would be committing to a target of 19 % representation of ethnic minority employees at every pay band within the joint organisation by 2025 to reflect the make-up of the wider NHS, where 19.7% of NHS trust and commissioning staff are from an ethnic minority background.6,21
The most recent analysis of the national data was carried out by WRES in NHS Trusts. 6 Here we evaluate the key results for the following five measures:
● Representation of ethnic minorities in leadership roles
● Impact of gender in leadership roles
● Impact of Ethnicity and Gender on Pay
● Clinical Excellence awards
Ethnic minorities in leadership roles
Ethnic minorities are over-represented in NHS Agenda for Change (AfC) pay band 5 and significantly underrepresented above band 8a, which includes very senior managers (VSM) i.e. chief executives, executive directors, and other senior managers with board level responsibility. As the pay bands increase there is a demonstrable reduction in the proportion of ethnic minority staff, from 24.5% in band 5 to 6.5% at very senior manager levels (Figure 1). 6 This is significantly lower than the 19.7% of NHS staff who are from BAME groups across the country.
Table 16 does show that there has been an increase in the proportion of VSM staff in NHS Trusts from 5.4% in 2016 to 6.5% in 2019. However, the proportion of BAME staff increased from 17.7% in 2016 to 19.7% in this period, which has led to a greater differential between the proportion of overall BAME staff and representation at VSM (Table 2).6 This highlights the need to accelerate opportunities for BAME staff representation at senior levels across the workforce, as set-out in the NHS Long Term Plan.
Overall, there has also been an increase in the percentage of BAME board members within NHS Trusts from 7.4% in 2018 to 8.4% in 2019. There has also been a decrease in the proportion of NHS Trusts with no BAME representation on the board, from 96 in 2018 to 73 in 2019. 6 More data is required for primary care along with more granularity of the data from secondary care. This will help us understand further the extent of this differential representation.
Impact of Gender in leadership roles
Ruth Sealy’s report, ‘NHS women on boards: 50:50 by 2020’ found that although women make up 77% of the NHS workforce, the percentage of women on NHS boards is only 42%. Currently there are still 209 NHS Trust boards that do not demonstrate gender equality in the constitution of their boards. The report suggests the need for an additional 500 women in NHS Trust boards would be required to achieve gender balance by 2020.9
Currently there is no data showing the percentage of BAME women that hold leadership positions.22
The Athena Swan Charter is a framework which is used across the globe to support and transform gender equality within higher education (HE) and research. Established in 2005 to encourage and recognise commitment to advancing the careers of women in science, technology, engineering, maths and medicine (STEMM) employment, the Charter is now being used across the globe to address gender equality more broadly, and not just barriers to progression that affect women.
A study looking at the effectiveness of the Athena Swan initiative found that 90% of Athena Swan champions agreed that it had impacted positively on gender issues and 65% agreed that there had been a positive impact on women’s career progression.23 Women felt that the Athena Swan had helped to improve their self-confidence and enhanced their leadership skills. The initiative also was found to impact positively on institutional practices by helping them to identify challenges to gender equality, supporting women returners and facilitating factors for delivering institutional change.23 There are fears however that the Athena Swan initiative may be scrapped.
Impact of Ethnicity & Gender on pay
NHS Digital equality and diversity statistics show that in 2019, 34.1% of the consultants in England were from BAME groups compared to 56.4% white.24 Doctors from ethnic minority backgrounds, working in the same roles are paid substantially less than their white colleagues.8 In senior positions, such as consultant posts, BAME staff earn 2.3-3.3% less than their white colleagues. While in management positions African, Caribbean, and British black managers earn 14.2% less and Asian managers 7.9% less than their white colleagues.8
Currently women make up 36% of consultants in the UK, although they represent two-thirds of doctors in training. The current gender pay gap for women doctors is 17%, while the overall NHS gender pay gap is 23%.10 There is no data on the gender pay difference related to BAME women.
Clinical excellence awards
Clinical Excellence Awards (CEAs) recognise and reward medical consultants, dentists and academic General Practitioners who provide evidence of clinical excellence and demonstrate achievements that are significantly over and above, what would normally be expected for their roles. The Advisory Council on Clinical Excellence Awards (ACCEA) is an independent body which reports annually the figures from the clinical excellence awards allocations.25
The ACCEA sub-committees currently have 336 members, with only 19.9% from BAME backgrounds. Out of the 14 medical vice-chairs and 14 chairs, only 14.3% and 7.1% were from BAME backgrounds, respectively (Table 3). Only 32.7% of the members, and 7.1% of the medical chairs or vice-chairs were female (Table 4).25
In 2018, from 36% of consultants from BAME backgrounds, made 22% of the applications and received only 16% of the awards. The number of BAME recipients and applicants was lower than in previous years, and the lowest since 2014. The likelihood of success for BAME applicants was 23.3% compared to 31.8% for white applicants and the gap between the two had increased in the last few years (Table 5).25
The gender pay gap has been magnified further as majority of CEA awards (77.9%) were given to men. There is an even bigger gap for the higher awards; (only 17% for silver and gold and 14% of platinum awards were given to women), amplified by the lower proportion of women making up the eligible consultant workforce (36%) but the likelihood of success was similar, (Table 6).25