Ethnicity, Equality of Opportunity and the British National Health Service

Citation

Pilkington, A. (2002), "Ethnicity, Equality of Opportunity and the British National Health Service", Employee Relations, Vol. 24 No. 6, pp. 659-662. https://doi.org/10.1108/er.2002.24.6.659.2

This book examines the issue of equal employment opportunities in the British National Health Service. The central section of the book draws from research commissioned by the English National Board for Nursing, Midwifery and Health Visiting (ENB) carried out by one of the authors between 1996 and 1998 on the recruitment of members of minority ethnic groups into training for nursing and midwifery. The central message here is that nationally developed commitments to enhance equal opportunities have not been systematically implemented at the local level, and that “there is evidence of long‐standing racism in NHS employment practices” (p. 1). While the primary focus of the book is on nurses, the findings of this research are placed in the context of a wider consideration of racial exclusion in the NHS. The final section of the book entails a discussion of the policy implications of the research through a conceptual exploration of issues relating to both ethnic difference and equal opportunities. The authors in the process challenge some key assumptions behind conventional equal opportunities policies so far as the promotion of racial equality is concerned.

After an introductory chapter, which outlines the key themes of the book, evidence about the incidence of racism in the NHS is reviewed. While accusations of racism are post‐Macpherson now more readily accepted, the authors indicate that such claims are longstanding. What is more, studies of selection to medical school and for training in nursing and midwifery reveal not only racial discrimination but also a widespread belief that this has had a disincentive effect on potential applicants from minority ethnic groups. The response of the NHS has been to develop equal opportunities policies. The authors argue that since the late 1970s “significant advances have been made in the implementation of equal opportunity policies in the NHS” (p. 52). Pragmatism has been the primary driving force, with arguments for enhanced provision being framed in terms of the “business case” rather than moral arguments.

In an attempt to test the efficacy of equal opportunities policies, the authors examine the pattern of applications to pre‐registration nursing and midwifery courses. The data point to an over‐representation of applicants from Black groups and (continuing) under‐representation of Asian groups relative to their proportions in the population as a whole. This suggests to the authors that the predicted demise of the “black nurse” is premature and that we should treat with some scepticism the widespread belief that racism in the NHS has had a disincentive effect on potential applicants. At the same time, the outcomes of the application process do indicate that members of minority ethnic groups are generally less likely to be accepted for training than White applicants, even when variables such as education are taken into account. This suggests that racial discrimination may be occurring. The following chapter investigates this possibility by examining the selection practices of eight nurse education and training centres. This reveals variable practice, especially at the short‐listing stage, with “the intrusion of a range of potentially discriminatory criteria” often being evident. Judged against recognised good practice, the centres exhibited a number of failings, with systematic updated training for key personnel often being absent and with systematic audit of (aspects of) the selection system being virtually non‐existent. In all cases, there was a dearth of positive action, with little evidence of a clear strategy for targeting minority ethnic communities that was informed by information on those communities. Indeed the rationale for positive action was poorly understood, suggesting in turn that nationally developed commitments had not been effectively disseminated.

While this central section focuses on equal employment opportunity policies in the NHS rather than, as the title of the book indicates, equal opportunity policies more generally in the NHS, it does produce new evidence on the recruitment and selection of nurses. In addition, it convincingly demonstrates that acknowledged best practice is not systematically embedded in the selection systems of nursing education and training centres, resulting in some cases in the persistence of discriminatory practices. At various points, the authors go further and characterise various practices, including nursing selection systems, in the NHS as “racist”. It would have been helpful, however, if the authors had clarified how they are using this concept and related their claim to a discussion of the Macpherson report’s promulgation of the concept of institutional racism. This would have been particularly interesting, given the scepticism expressed elsewhere by one of the authors towards the analytical utility of the concept of institutional racism and the argument evident in sections of the book that the NHS has made some progress in the implementation of equal opportunity policies. Since one of the authors has argued in other publications that the development of such policies has been accompanied by the collective upward mobility of at least some minority ethnic groups, it is at least questionable to characterise the selection systems examined in this book as “racist”.

The final section of the book comprises a wide‐ranging discussion of both ethnic difference and equal opportunities. Moving away from an evaluation of equal opportunity policies against recognised good practice, the authors seek to challenge key elements of recognised good practice, notably ethnic monitoring and target setting. It is argued that ethnic monitoring categories do not take into account people’s complex and changing ethnic identities, while setting targets so that members of different groups are represented in proportion to their presence in the population “ignores the possibility that some of the differences between groups may result from differential occupational aspirations and choices” (p. 144).

The way forward to ensure effective implementation of equal employment opportunities in the NHS is to develop a national strategy that overcomes the difficulties posed by the organisational fragmentation of the NHS. This strategy needs in turn to be based on a rationale that links the business and justice cases for the delivery of greater equity in employment, and highlights the importance of greater workforce diversity for effective service delivery. Sympathetic to a re‐conceptualisation of the equal opportunities agenda in terms of diversity, the authors argue that the most appropriate focus is the team. A diverse team is the most suitable “mechanism to maximise culturally sensitive care and optimally meet the needs of patients in Britain’s multi‐ethnic society” (p. 162).

The final section presents an interesting critique of the conventional equal opportunities agenda and a powerful argument both for re‐conceptualising it in terms of diversity and developing a new national strategy. Nonetheless, the links between the conceptual issues discussed in these two chapters and the research outlined in earlier chapters are somewhat forced and there remains in my view a tension between the critique of key components of recognised best practice and the advocacy of a new national strategy. While the critique entails challenging conventional ethnic monitoring and targeting, the “translation of national level commitments into effective local policy would appear to require a pattern of central target setting and monitoring, and a range of potential sanctions” (p. 158). It may be possible to reconcile this tension, but I am not convinced that the authors do this. In addition, it would be interesting to know what the authors thought the prospects were for a new national strategy, given the seemingly tougher guidelines for the public sector consequent on the implementation of the Race Relations (Amendment) Act, 2000.

Overall, this book advances our understanding of equal employment opportunity issues in the NHS by producing new evidence on the recruitment and selection of nurses and midwives. In addition, it raises some interesting questions about equal opportunity issues as they relate to ethnicity and the possibilities of moving towards greater ethnic equity in employment. While this book leaves some pertinent questions unanswered and some tensions unresolved, it adds to our knowledge of how equal opportunity policies work in practice and raises a host of thought provoking questions. The book will prove, in short, invaluable both to those interested in issues relating to equal opportunities and the employment practices in the NHS.