TOO HOT TO

HANDLE?
WHY CONCERNS ABOUT RACISM
ARE NOT HEARD… OR ACTED ON

AND

1 ROGER KLINE
January 2024

REPORT AUTHORS

Roger Kline is Research Fellow at Middlesex University Business School.

www.rogerkline.co.uk

Joy Warmington MBE is CEO of brap and Visiting Professor at Middlesex University
Business School. She has held various non-executive positions within the NHS
www.brap.org.uk

Ghiyas Somra is People, Policy, and Research Manager at brap. He has supported
numerous organisations to understand the impact of bias on their disciplinary procedures

The authors would also like to acknowledge the contributions of Rebecca Pilliere.

© brap and Kline 2024

 Why concerns about racism are not heard… or acted on

CONTENTS

FOREWORD 4

EXECUTIVE SUMMARY 5

1. INTRODUCTION 7
1.1 ABOUT THIS REPORT 7
1.2 WHAT IS RACISM? 8
1.3 WHAT DO WE KNOW ABOUT RAISING CONCERNS IN THE NHS? 9
1.4 LANGUAGE AND TERMINOLOGY 13

2. FINDING YOUR WAY ROUND THIS REPORT 14

3. EXPERIENCES OF RACISM 16

4. RAISING CONCERNS 21
4.1 PROPENSITY TO RAISE CONCERNS 21
4.2 BARRIERS TO RAISING CONCERNS 22
4.3 ORGANISATIONAL RESPONSES TO RACE DISCRIMINATION CONCERNS 22
4.4 SUPPORT FROM UNIONS, HR, GUARDIANS, ETC 27

5. LEARNING POINTS FROM KEY TRIBUNAL CASES 29

6. WHAT DOES ALL THIS MEAN? 42

6.1 WHAT WE HAVE HEARD 42
6.2 WHY DOES RACISM PERSIST? 43
6.3 SOME THOUGHTS ON WHAT ORGANISATIONS SHOULD DO NEXT 45

APPENDIX A: SURVEY RESPONDENT PROFILE 57

APPENDIX B: LESSONS FOR TRADE UNIONS 59

APPENDIX C: EMPLOYMENT TRIBUNAL CASES REFERENCED 61

REFERENCES 62

3
 Too Hot to Handle?

FOREWORD

I welcome this report which, for the first time, sheds a clear light on race discrimination and
employment tribunals in the NHS.

Through extensive research, analysis, and consultation with Black and minoritised ethnic staff, a
bold and comprehensive overview is presented to the reader of the challenges faced by NHS staff.
From hindrances to career progression through to both subtle and overt forms of discrimination that
ultimately cause psychological harm when unaddressed or not understood by those in positions of
power, it’s clear there remains a very long way to go to. The business case of why discrimination is
harmful to individuals, teams, and organisations has been established for decades now, but NHS
staff continue to experience race discrimination at an all-time high.

Central to this report is a review of a number of race discrimination employment tribunal cases,
including my own. Some of the lessons of this are discussed in section 5.

What is apparent are the recurring themes: from poor investigations to high levels of defensiveness
where NHS organisations repeatedly dispute allegations of discrimination despite the evidence.
Organisations need to be open and curious so that Black and minoritised ethnic staff can feel
valued, respected, and included in their roles without the need for drawn-out and poorly conducted
investigations and grievances that progress to employment tribunals.

My respect goes to the authors for their time, skill, and expertise in the collation of this report. I hope
it contributes to principles of equity, justice, and the freedom to speak up without recrimination,
provide a nurturing and safe environment for all.

Michelle Cox

4
 Why concerns about racism are not heard… or acted on

EXECUTIVE SUMMARY

A number of Bermuda triangle moments served as a catalyst for this report. Firstly, the ongoing
collaboration between Roger Kline and brap (a collaboration which has included mutual criticism,
challenge, and downright arguments, but which is sustained through commitment to addressing
racism and its persistence).

Secondly, a number of high-profile tribunal cases within the NHS that made us reflect on just how
significant they were, and ask whether there was a correlation between these cases and the way in
which the NHS responds to allegations of racism. Despite the efforts of many, talking about racism
still causes fear and concern and addressing racism appears to frequently be a performative
response by the system.

What this report is not is a report which tries to prove racism is widespread in the NHS. We are
more than convinced it is and you should be too. Our intention is to support the NHS and others to
respond more fearlessly to these types of allegations.

This report brings together key learning from a number of significant tribunal cases and responses
from 1,327 people who answered our survey, relaying their experiences of raising allegations of
racism within their respective organisations.

Survey findings showed:

• UK trained staff are much more likely than internationally trained staff to raise concerns. 71.0%
of UK trained staff have highlighted race discrimination as an issue, compared with 53.1% of
internationally trained staff
• the most common reason for not raising a concern of race discrimination was not believing
anything would change (75.7%). 63.5% of people who didn’t raise their concerns were worried
about being seen as a troublemaker
• of those staff who have raised concerns, only 5.4% said they were taken seriously and that their
problem was dealt with satisfactorily
• the most common outcome to a race discrimination concern was nothing happening (the
outcome in 42.7% of cases). In one in five (19.1%) instances, claims of race discrimination were
treated the same as any other workplace dispute and referred to mediation. In 5.0% of cases,
the individual raising the concern were themselves disciplined
• 41.8% of respondents left their jobs as a result of their treatment

Survey findings also show racially minoritised staff face common responses when raising concerns
about race equality. These include:
• denial: in many of the cases outlined above, staff were subjected to ‘poor behaviours’ but
neither managers nor subsequent investigations felt they could name the race discrimination
that lay behind these behaviours

5
 Too Hot to Handle?

• reluctance or refusal to acknowledge race as an issue: connected with the above,

employers tend to resist acknowledging poor treatment as race discrimination often, it seems,
because of the stigma attached
• minimising of harm: organisations go to great lengths to downplay the impact of racist
behaviours
• a lack of empathy: racially minoritised staff do not always receive compassion and
understanding when raising concerns. Indeed, it is more common they are met with frustration,
defensiveness, and exasperation

In addition to the above responses, there are some very common features of race-related
investigations:
• many employers set an unnecessarily high bar requiring staff to prove any allegation of race
discrimination was ‘racially motivated’
• tackling racism is seen as too difficult and so is avoided
• the process of raising a concern and the time an investigation takes deters staff from raising a
concern
• staff lack confidence investigatory processes and other responses will be fair

As part of our response to these findings we critique our existing approaches to addressing racism
and consider why racism is not better understood (see section 6.2). We also consider what
organisations could do if they were serious in their intentions to respond more effectively to both
overt and covert forms of racism (section 6.3).

In this respect, we have thought critically about how the NHS creates a culture freer from race
discrimination. Among our recommendations we include a call for organisations to develop an
appetite for ‘race talk’ and set standards of behaviour that challenge ‘everyday’ racism. In addition,
organisations need to develop greater levels of comfort in staff speaking out about racism and in
acting on the early warning signs of racism by tackling racism more informally and being proactive
when evidence would suggest that there might be a problem. There is also a clear need to impart
the skills that all staff need to get closer to genuine anti-racist practice, with particular development
needed for boards, leaders, and professionals whose roles directly uphold the values of their
organisations.

Racism and its impact don’t have to be enduring. We have the means to address it. We can go
beyond the reporting of statistics, the constant ‘listening’ to the views of racially minoritised staff,
and the belief that representation will fix everything. Essentially, if white staff feel more confident
talking about race, are able to recognise and call out racism, and our organisations get better at
responding to the reality of racial discrimination, then we would really be getting somewhere.

6
 Why concerns about racism are not heard… or acted on

1. INTRODUCTION

1.1 ABOUT THIS REPORT

The very serious function of racism is distraction. It keeps you from doing your work.
Toni Morrison

This survey differs from other reports about racism you may have come across. For one thing, it
was never our intention to prove that racism exists. We know it exists; there is a mountain of
evidence showing it does. Instead, this report – and the unique survey it emerges from – aims to
understand the NHS response to racism, what trusts and healthcare organisations do about it, and
how effective they are at addressing it.

The importance of tackling racism in healthcare should be self-evident. In an NHS workforce where
25% of staff are now of Black or minoritised ethnic (BME) backgrounds and a significant and
growing proportion of the population served by healthcare organisations are too, this is not remotely
a marginal issue. Nor is it a new one, especially as we already have a wealth of evidence as to the
damage done to staff and to patient care by racism.

Many people contributed to the survey at the heart of this report – we had over 1,300 responses –
and we are grateful for their involvement. In conveying their experiences, participants have
overwhelmingly demonstrated that the NHS is not addressing racism effectively, and that it actually
expends a lot of energy defending and burying allegations of racism as a reactive measure. In doing
so, many organisations have created environments where it is unsafe to speak out about racism,
and this means many staff must endure their experiences of racial discrimination over a prolonged
period.

Why – after years of initiatives, programmes, plans, and policies – is this still the case?

As the responses to our survey show, there is still a paralyzing reluctance within organisations to
talk about race. Some minimize racism when it occurs, others demand evidence it exists, others still
simply ignore the issue, hoping the person experiencing it will shut up or move on (you can see
exactly how common this is in the following pages).

For many organisations, racism is just too scary to address. The complexity of the issue facing them
seems so daunting they plump for short-term, piecemeal approaches that show they are doing
something (even if it’s not the stuff change is made of). In doing so, the roots of the issue go
untouched. As a result, nothing changes and the belief that racial discrimination is intractable is
reinforced. The NHS, for all its noble intentions, is entangled in a system of ‘doing’: of addressing
the symptoms of racism, rather than addressing its causes. It is stuck in a dance routine, but not
one with the right moves.

But while racism may be big and complex, it does not have to be enduring. There is a growing
evidence base around what works in confronting it. And more importantly, we can always improve
our understanding of how racism is reproduced and maintained. A lot of the time, what stops us

7
 Too Hot to Handle?

from doing anything about racism is that awkward conversation we would rather avoid. We produce
toolkits that are of limited use because what is still required is the practice of having the
conversation. Our learning about ‘race’ remains limited to stereotypes about ethnicity, religion, and
culture. It does little to address our personal and organisational belief systems.

The NHS, like many organisations is a mirror of our society spending little or no time on this stuff,
and because there isn’t investment in learning, reflection, and practice, the system doesn’t really get
any better at understanding the issue. It is a deliberate blind spot; an unspoken reluctance to
confront racism built on the acceptance of data which continually shows inequities of experience
and outcome. All of which means racism remains shrouded in silence – or mediated through
employer networks or the routine of Black History Month. Until, that is, the issue erupts in the
workplace in ways which cannot be hushed-up or ignored.

But this report is not about pointing fingers; it's about unravelling the mystery behind the cover-up.
By talking about this systemic blind spot and how it affects NHS staff, we hope to encourage more
open environments where conversations about racism are seen as necessary to systems change,
environments where cultivating our personal and shared understanding of racism becomes part of
an overall improvement culture. Moreover, we hope that by challenging the belief that racism is
something that ‘just needs to be accepted’ we will pave the way for lasting change and true equity
within our healthcare system.

We believe that it is possible to end racism.

1.2 WHAT IS RACISM?

There is still a heated discussion about what really qualifies as racism and the various ways it can
show up in the workplace (see, for example, Roberson, 2023). Many still believe racism is upfront,
hostile verbal (or physical) abuse (Braveman, 2022). However, there's increasing recognition that
racism is becoming more subtle and ambiguous (Levy, 2017). Indeed, despite some recent high-
profile incidents of overt racism, a growing number of healthcare organisations are increasingly
trying to understand racism as a systemic issue.

Understanding racism as systemic means understanding how it operates through formal and
informal habits and norms that subtly and consistently disparage, limit, and dehumanise individuals
who are racialised as non-White. Tackling systemic racism requires us to identify and address the
drivers of this way of thinking, not just deal with the symptoms. This means looking at uncovering
the ideas that are held consciously and unconsciously by all of us socialised into a racially unequal
society. For organisations, it also means looking at patterns in our cultural practices that support the
status quo.

Racism is complex. Our unwillingness to engage in this complexity can mean that we don’t really
give ourselves an opportunity to recognise racism and how it is perpetuated. A somewhat more
accessible way of thinking about this is illustrated in figure 1, below. It shows four mutually
reinforcing fields through which racism operates: personal, inter-personal, institutional, and
structural. The individual and systemic sides of the diagram act a little like a call-and-response.
Racialised social structures shape our sense of agency and the choices we make, and the choices
we make and the action we take in turn remakes (or disrupts) these social structures.

8
 Why concerns about racism are not heard… or acted on

Fig 1: The four fields of racism

Taken from: https://newwestschools.ca/deia-parent-toolkit/introduction/the-4-levels-of-racism

1.3 WHAT DO WE KNOW ABOUT RAISING CONCERNS IN THE NHS?

Raising concerns in the NHS can still prompt a defensiveness Robert Francis (2015) first noted a
decade ago:

there lurks within the system an institutional instinct which, under pressure, will prefer
concealment, formulaic responses and avoidance of public criticism and an institutional
culture which ascribe[s] more weight to positive information about the service than to
information capable of implying cause for concern.

As many staff have found out, this is especially true when raising concerns about race
discrimination, despite the supposed contractual protection of the national NHS Staff Contract and
the exhortations of the 2020-2021 NHS People Plan:

We all need to feel safe and confident when expressing our views. If something concerns us,
we should feel able to speak up… Many staff have felt unable to speak up, or they have
been ignored. This is another area in which BAME staff have been particularly affected. We
need to look beyond the data and listen to the lived experience of our colleagues. NHS
England.

NHS England (2022) recently revised its Guidance on Freedom to Speak Up for NHS leaders but,
as the House of Commons Health Select Committee noted (2013), whistleblowing is:

only necessary because of the absence of systems and a culture accepted by all staff which
positively welcomes internal reporting of concerns.

Recent research argues that while improving clarity, fairness, quality, and transparency of policy,
process, and procedure is important the addition of further layers of formal policy may provide a

9
 Too Hot to Handle?

veneer of order without enhancing understanding (Wu et al, 2021). Other research (Reitz and
Higgins, 2020) agrees and highlights the…

power imbalance in organisational roles (as) perhaps the most important factor that makes
employee silence such a common experience

and goes on to argue that leaders should not focus

their attention and efforts predominantly on those who feel silenced, urging them to ‘be
brave’, ‘speak up’ and have the ‘courageous conversations’ that are required… [Instead] we
need to stop trying to ‘fix the silenced’ and rather ‘fix the system’.

Reitz and Higgins conclude that:

instigating whistleblowing lines and training employees to be braver or insisting that they
speak up out of duty will achieve little therefore without leaders owning their status and
hierarchy, stepping out of their internal monologue and engaging with the reality of others.

In summary, a reliance on policies, procedures, and training ‘will not, in isolation, reduce bullying,
improve the effectiveness or safety of whistleblowing, (or) create a disciplinary environment focused
on learning’ (Kline, 2023).

A decade ago, Public Concern at Work, the independent whistleblowing charity which ran the NHS
whistleblowing helpline until 2012, commissioned research on the experiences of 1,000 whistle
blowers in a cross-sectorial analysis and concluded that the NHS is at least as unsafe an
environment to raise concerns as other sectors (Wim, 2013).

The National Guardian Office (NGO) Freedom to Speak Up Index 2021 found very substantial
differences between organisations on whether staff reported significant barriers to speaking up and
whether managers were a source of detriment when staff did try to speak up with almost half of
Freedom to Speak Up Guardians (48%) reporting that line managers were a source of detriment in
most cases.

In their recent aptly named report Fear and Futility, published 2023, the NGO concluded:

there is a growing feeling that speaking up in the NHS is futile – that nothing changes as a
result… They fear experiencing negative consequences if they do… When they speak up
about matters including the impact of understaffing, their leaders themselves may struggle to
be heard when trying to address these concerns.

Of concern are the responses to the questions about whether workers have witnessed an
incident which could harm patients or colleagues and whether they feel they will be treated
fairly or that preventative action would be taken if they do report it. There is a disconnect
between the encouragement which workers feel in reporting (very high) and the perception
of how fairly those involved are treated.

10
 Why concerns about racism are not heard… or acted on

In summary, NHS England’s approach to staff who have concerns has not achieved its stated goals
and has left it unsafe and/or ineffective for individuals in many organisations to raise concerns
despite the Francis Freedom to Speak Up Review (Francis, 2015).

New guidance in the Freedom to Speak Up guide for leaders in the NHS and organisations
delivering NHS services (NHS England, 2022) states leaders should:

work hard to understand the barriers that colleague from minority ethnic communities or
people who have been recruited from abroad might face.

Section 3.3 of the Francis Freedom to Speak Up Report (2015) considered the experience of
workers from a BME background. At the time, one author of this report was told by DHSC that they
had initially not requested analysis of data by ethnicity as ‘they had no evidence that this was an
issue’. In fact, Francis found that, compared to White respondents:
• a higher proportion of BME respondents reported fear of victimisation as a reason for not raising
a concern
• BME staff were more likely to have reported concerns about harassment and appeared less
satisfied with the response to their concerns

After raising a concern, BME staff were:

• more likely to report being victimised, or ignored by management than worker from a white
background
• slightly more likely to report being victimised by co-workers than workers from a white
background
• less likely to report being praised by management than workers from a white background

In addition, after supporting a colleague who had raised a concern, BME workers were:
• more likely to report having suffered detriment
• more likely to report having been victimised by management
• less likely to raise a concern again if they suspected wrongdoing than white workers did

The NHS National Staff Survey 2020 reported a significant difference between White and BME
workers views on raising concerns. It found that staff with long-lasting health conditions or illnesses
and staff from BME backgrounds were less likely to feel safe to speak up about any concerns they
have, compared to White staff (NHS Staff Survey, 2023).

The COVID-19 pandemic highlighted the role played by BME staff in frontline services and the
factors which contributed to their disproportionate mortality. There was extensive media coverage
with additional issues affecting overseas recruited staff. For example, Nursing Standard reported
(2020):

Filipino nurses and their families have raised concerns that social and cultural factors might
be putting healthcare workers in their community at heightened risk from COVID-19. They
fear that marginalisation and a possible tendency to 'keep quiet and be extremely
hardworking' may, in part, account for what looks like a disproportionate tally of deaths
among Filipino nurses in the UK.

11
 Too Hot to Handle?

Kline and Somra (2021) asked staff surveyed if an issue they had raised as a concern involved
people – workers or patients – being treated differently because of their race, nationality, or
ethnicity. BME respondents were far more likely to say their concern involved some element of race-
based inequality. They found some Freedom to Speak Up Guardians (FTSUs) reported particular
issues with overseas-trained staff who can be anxious about raising concerns due to fear of the
consequences (especially if they felt their visas would be jeopardized) or if they had previously
worked in a culture in which concerns were not raised.

Confirmation of the specific challenges facing BME staff racing concerns came from both BME and
White FTSU Guardians interviewed:

“It became clear that being a BME Guardian appeared to give staff more confidence to raise
issues – ‘you’ll understand what I am saying to you.” BME Freedom to Speak Up Guardian.

“In our trust, there was certainly an issue about overseas staff not speaking up, and the
culture of the Trust was generally not conducive. That might be made worse if staff had
concerns that raising a concern might have implications for their visas or if there was a
culture of not raising concerns as highlighted in COVID.” White Freedom to Speak Up
Guardian.

“I thought I was doing well although I could tell from individual cases that there were specific
issues with BME staff raising concerns. When evidence of more serious problems within the
trust was provided I realised I had not sufficiently understood the perceptions or experiences
of BME staff.” White Freedom to Speak Up Guardian.

Kline and Somra also found:

Respondents referred to workplace discrimination being subtle and hard-to-define, and

therefore difficult to explain to someone who had not experienced it first-hand. Given this, a
respondent said they would prefer to speak to someone who was ‘more likely to understand
the nuances of working dynamics’

We know that (NHS England, 2023) in addition to facing additional obstacles to raising concerns
BME staff are:
• more likely than their White colleagues to be bullied by their managers and colleagues
• more likely that their White colleagues to enter the formal disciplinary process
• much more likely to experience discrimination from managers and colleagues

Sir Robert Francis’ Freedom to Speak Up Review (2015) found NHS staff in general may be
reluctant to speak up because of fear of being:
• blamed or scapegoated
• discriminated against
• disbelieved
• seen as disloyal
• seen as disrespectful in a hierarchical system
• bullied
• and the wider consequences for their career

12
 Why concerns about racism are not heard… or acted on

These conclusions were similar to the academic literature that preceded it (see, for example, Carter,
2013).

Empirical research consistently shows that the two main reasons why people do not report
perceived wrongdoing are fear of retaliation and a belief that even if they do the matter would not be
rectified (Lewis, 2013).

The National Guardian Office Freedom to Speak Up Index (2021) found that less than half (48%) of
the respondents said people in their organisation did not suffer detriment for speaking up. However,
almost a fifth of respondents (19%) felt individuals did suffer detriment for speaking up in their
organisation.

When staff raise concerns of any kind there is always a risk that retaliatory steps may be taken by
colleagues or managers, as was recognised by Francis in his Freedom to Speak Up report. If
concerns about performance or behaviour that had not been mentioned previously suddenly surface
when discrimination is an issue, alarm bells should ring. The issues arise repeatedly in Employment
Tribunals when BME staff have raised concerns about their treatment.

1.4 LANGUAGE AND TERMINOLOGY

Please note that this report does not censor the verbal racist abuse some staff have been
subject to.

We use the term ‘BME’ to refer to people who identify as Black or as part of a minoritised ethnicity,
community, or group. We recognise that this is a contested term and not everyone will identify with
it. We also recognise that because it is a broad term, it may not accurately express the views of
those who experience discrimination on the basis of skin colour. However, for the purposes of
analysis, we have used the term so that we can draw comparisons between people from White
British and BME backgrounds.

13
 Too Hot to Handle?

2. FINDING YOUR WAY ROUND THIS

REPORT
2.1 OUR APPROACH
The mixed-method approach was undertaken in six distinct phases.

We undertook a brief review of relevant literature related to the experience of

Phase 1 NHS staff in raising concerns in general, and of Black and minoritised (BME)
Jump to
section1.3
ethnic staff raising concerns in healthcare environments. It is worth noting that
there is considerable literature on the former, and very little on the latter.

We identified a number of employment tribunal cases taken by NHS staff as

litigants against NHS employers. We selected three ‘landmark cases’ between
2011 and 2016 and then the five most prominent cases in 2023. We are
Phase 2 confident they are reasonably representative (rather than comprehensive) of the
Jump to shortcomings tribunals have identified, not least because the authors are
section 5 familiar with other cases where similar themes are identified. We are thankful
for the expertise of Shazia Khan, Founding Partner at Cole Khan, who is an
experienced lawyer very familiar with race discrimination cases across most
sectors, including in the NHS and healthcare.

Between May and July 2023, an online survey was sent to NHS staff. A link was
circulated to the report authors ’contacts and disseminated through social
media. NHS staff were encouraged to share the link with their colleagues.

The survey was designed to be completed by BME staff. Participants were told
the purpose of the survey was to:
• draw a picture of the lived experiences of BME staff in the NHS and
• signpost what the NHS could (and should) be doing to recognise and
address racist/discriminatory experiences
Phase 3
Jump to
section 4
We allowed individual respondents to answer questions with their own definition
and interpretation of racism, on the understanding that it may differ from our
own. This was to ensure we captured the range of experiences affecting staff
which they deem to be racist. It is worth re-emphasising that the purpose of this
survey was not to establish the existence of racism in the NHS: numerous
reports have already demonstrated its presence. Rather, our objective was to
concentrate on understanding both personal experiences of racism and the
institutional responses that followed when allegations of racism are raised.
In total, 1,327 people responded. A breakdown of survey respondents is
outlined in Appendix A.

14
 Why concerns about racism are not heard… or acted on

Following the survey responses, we conducted a review of the literature on bias

(and specifically racial bias) in investigations, and the challenges staff face in
raising concerns about racism. It seemed important to understand more about
Phase 4 the reasons why so many allegations of racism within the NHS are deemed to
be flawed, or don’t even get off the starting block. The findings from the review
are summarised in the report, but an expanded version will be published as a
separate guide on‘ Avoiding Racial Bias in Investigations’.

We hypothesised that there was a correlation between the themes identified

through our analysis of the employment tribunal cases, and the experiences of
Phase 5
staff described by the staff survey. We then interrogated that data to explore
and expand our hypothesis and understanding of the issues.

Finally, drawing on our findings and the wider literature we then set out our
Phase 6 recommendations for NHS employers – and specifically its Human Resources
Jump to
section 6
community – on how to enable better challenge and mitigation of race
discrimination within the NHS.

2.2 LIMITATIONS
The reader should keep the following in mind when engaging with the findings and analysis
presented in this report:
• We did not set out to demonstrate the NHS is institutionally racist. Our assumption that it is, is
well-founded and based on a wealth of available data and research, much of it espoused by the
NHS itself.
• The employment tribunal cases we present are limited in number and therefore not
comprehensive. However, we are confident our findings are representative, based in part on our
knowledge of other NHS cases, and in part on the expert input of Shazia Khan (who has 20
years’ experience working on these cases and issues). In addition, a significant number of
claims will have been settled subject to confidential terms being agreed, and so would not form
part of the available data.
• The survey itself has one important limitation – we are unable to demonstrate the survey
respondents are representative of NHS staff as a whole, or of those who have raised concerns.
However, their reported experiences do match those outlined in NHS survey data, peer-
reviewed, and grey literature. Moreover, the size of the sample gives some assurance of
sufficient representation and reliability.
• There is one other inherent limitation, and that is the collective denial of the existence and
proliferation of racism, both within our society and in institutions like the NHS. Consequently, we
believe there will always be a challenge to any data intended to confront racism. We offer this
not as an excuse or substitute for robustness, but to illuminate another pattern of systemic
racism – that of always asking for more data and more evidence of its existence prior to any
action addressing it.

15
 Too Hot to Handle?

3. EXPERIENCES OF RACISM

This section outlines some of the different forms of racism survey respondents experienced. As
stated above, this report does not aim to show that racism exists in the NHS. However, before
moving on to look at how organisations respond to claims of racism, it is important to illustrate the
different behaviours and actions staff are subject to.

Participants in the survey were asked if they had experienced racism and what form it took. Figure 2
(below) shows the most common responses.

Fig 2: If you have experienced racism, what form did it take?

My performance or behaviour is subjected to greater scrutiny than White colleagues 63.4%

I have heard someone make an assumption about another person based on their race or 53.2%
nationality

I have not been offered development opportunities 52.5%

I suggest ideas, but they don’t appear to be heard or taken up 51.1%

I have heard someone make a generalisation about a particular race 51.0%

I don’t get the same information as everyone else 49.3%

I have been denied promotion opportunities 49.0%

I have heard someone make a race-based joke [not necessarily about your race] 38.2%

As a manager my staff question my authority and/or competence in ways they are unlikely to 33.9%
challenge a White manager

Colleagues speak to me rudely/in a different tone compared to how they speak to other 33.8%
people

My manager speaks to me rudely/in a different tone compared to how they speak to other 30.6%
people

People call me another version of my name because they feel my name is too difficult to 26.6%
pronounce/learn

I don’t get the opportunity to choose my work areas or shift as other staff are 23.3%

I was unsupported when a patient was racist towards me 23.2%

I’m often allocated to work with people who look like me 15.4%

Other 22.2%

16
 Why concerns about racism are not heard… or acted on

‣ Scrutiny
63.4% of BME staff feel their performance or behaviour is subject to greater scrutiny than their
White colleagues. This is particularly true for BME staff in bands 8 and above: 71.3% report this as
an issue (see figure 3).

Race as a factor in regulator referrals has been explored for both the NMC and the GMC (see
Atewologun and Kline 2019; West et al 2017). A small number of respondents reported being
referred to their regulatory body (such as the GMC or NMC) for minor issues or concerns the
significance of which have been exaggerated. The punitive natures of these referrals is evidenced
by the regulator’s rejection of them. Other respondents discussed how managers punitively used
performance management procedures, often despite evidence such measures were having a
detrimental impact on employee wellbeing:

“My line manager put me on a performance management process. I was diagnosed with
depression, [and] started taking medication. I told my manager [that] the performance
management process was adversely impacting on my mental health, but she was insistent
[that] I follow through. She treated me like a child…she was unforgiving... White colleagues
experience[d] a leniency and compassion which wasn’t extended to me. My every error was
pointed out, in an unconstructive, quite punishing way. I was exhausted by it. I worked late
into the night, doing things twice, sometimes three times over, to ensure my work was
accurate… [I] left the team in the end - but have bought that bad experience with me. It
impacts on my relationships and how I see myself. Sometimes, I don’t feel I deserve my seat
at the table. She made me feel like an imposter.”
(Asian/Asian British, Band 8b)

Some respondents discussed how accounts of BME staff’s ability by white colleagues hold greater
credibility to concerns raised by BME staff themselves:

“Punishment is more severe than white colleagues. Complaints from white colleagues and
juniors are taken as true but never verified before punishment! Whereas BME complaints
are brushed aside by line managers, directors and even the CEO.”
(Black/Black British, Band 8a)

‣ Assumptions and generalisations

Over half of BME staff (53.2%) have heard a colleague or patient make an assumption about
someone based on their race/nationality, with another 51.0% hearing someone make
generalisations about racial groups. Assumptions and generalisations can cover a range of issues,
such as presumptions about where someone went to school, the type of food they like, or, more
seriously, their competence (often connected to assumptions about their communication skills or
language proficiency). Survey respondents also talked more generally about assumptions made
about who they are ‘as a person’. For example:

“A colleague made assumptions that I was a patient who lived in a black neighbourhood. We
had never had a conversation to this effect so the assumption could only have been based
on 'who' they saw standing in front of them.”
(Black/Black British, Band 8a)

17
 Too Hot to Handle?

Fig 3: If you have experienced racism, what form did it take? (by band grouping)

Other 25.0% 16.2% 27.3%

Allocated to work with similar ppl 16.5% 17.9% 13.8%

Assumptions based on race 54.9% 54.3% 52.2%

Colleagues speak rudely 31.1% 34.2% 37.8%

Development opps 41.5% 57.7% 56.0%

Generalisations 53.0% 53.8% 50.1%

Ideas not heard 34.8% 53.4% 57.2%

Lack of info 42.7% 50.4% 54.5%

Manager speaks rudely 26.2% 32.9% 32.3%

Not called by name 21.3% 32.5% 25.8%

Promotion opps 30.5% 55.1% 54.0%

Race-based jokes 42.7% 35.5% 37.2%

Scrutiny 52.4% 62.4% 71.3%

Staff question authority 11.0% 35.9% 47.8%

Unsupported folowing pt racism 29.3% 26.5% 17.3%

Work areas/shifts 29.9% 24.4% 19.4%

1-5 6-7 8 and above

‣ Lack of development opportunities

A lack of access to development opportunities is the third most common form of discrimination,
experienced by 57.7% of staff in bands 6-7 and 56.0% of staff in band 8 or over. Many participants
argued that opportunities for growth and advancement are distributed unfairly and inconsistently.
This means that individuals, despite their qualifications, experience unequal access to
developmental resources and support both institutionally and from management.

“[I am a] Black male [who was] denied promotion. [I saw] students less than 2 years after
qualifying getting positions higher than myself who mentored them… No one will tell you ‘you
are [a] Black man and you are not welcome’. They tell [you] when you apply for 20+ senior
positions after nearly 30 years [of experience] … I have 3 degrees and [a] diploma [but] I am
still at the same band I was on [in] 1995. I have attended a major NHS leadership course,
and inequalities still unfold before me 39 years later. The same issues, the same subjects,
and the same agenda”.

18
 Why concerns about racism are not heard… or acted on

(Black/Black British, Band 5)

Often this form of racism manifests as white colleagues, sometimes with significantly less
experience or qualifications, advancing at a faster rate, receiving more opportunities, and enjoying
greater support (even when things go wrong). For example:

“A white colleague who has no governance or managerial experience whatsoever was given
the manager role in the governance team. I am ethnic and have been in my role in
governance for over eight years but was not even given the opportunity to apply for the role
as manager. The role was not even recruited too, it was handed to the white colleague. I
also found out that when this colleague was Business Manager they were on a band 7. I
have the same title but am on a band 6.”
(Asian/Asian British, Band 6)

Those affected often find themselves excluded from the same career-enhancing opportunities and
promotions, despite possessing the necessary expertise and skill.

Survey respondents also witnessed and experienced the unequal distribution of development
opportunities, regardless of funding status; unequal access to or exposure to opportunities that may
lead to promotion; and having their expertise and experience disregarded, belittled, and
undermined. Less qualified white colleagues are prioritised when it comes to opportunities that may
lead to progression – even when they have demonstrated incompetence in their role:

“Wanting to change job from being a nurse (Band 7) to service delivery manager (Band 7) in
the same trust. Applied for 21 jobs within a year and had seven interviews but was told that I
had no experience as a service delivery manager. I have an MSc and PRINCE 2
qualification. A white nurse who completed [redacted] programme was given a similar role
and now she is a General Manager in the same trust. She told the nurse who was seconded
to her post while she was on [the programme] that she was not coming back because she
already has a job waiting for her.”
(Black/Black British, Band 7)

‣ Interpersonal relationships with colleagues and managers

BME staff often encounter pervasive bias, discrimination and racism originating from both
colleagues and managers. Discriminatory behaviour, ranging from covert to overt racism targeting
lower-band employees, can lead to bullying, harassment, and micro/macro-aggressions, creating
routine distress. Some staff talked about how their health and wellbeing is valued less than their
White colleagues’:

“When I call in sick (which I very rarely do) my managers doubt that I’m really sick and tell
other team members I just wanted a day off. When I am struggling with mental health,
managers tell me I’m being over sensitive and I need to be productive (even though I still
am) but white members of staff are signposted to well-being teams.”
(Multiple heritage, Band 5)

19
 Too Hot to Handle?

An equally common complaint was white staff receiving greater support around professional
development.

“I was bypassed for promotion. I was a band 7 specialist nurse and worked in the capacity of
lead nurse. My manager advertised a band 8b post without informing me about it. Other
colleagues saw the advert and encouraged me to apply for it as they explained that I was
already working in a band 7 capacity anyway. I approached my manager to have an informal
discussion about the post, but they avoided me several times. When I finally got to meet her
she asked me if I thought I met the essential requirements. She was quite dismissive and
suggested I lacked particular skills. I applied anyway, but was not shortlisted. I later
approached her for feedback about how I could improve my chances of being shortlisted in
the future but she never responded to my requests verbally and in writing by email. She then
directed me after several months when I persisted to another manager from a different
organisation who she said was responsible for shortlisting. This person never responded to
my requests. I contacted the chief nurse who also did not respond to me.”
(Black/Black British, Band 7)

20
 Why concerns about racism are not heard… or acted on

4. RAISING CONCERNS

4.1 PROPENSITY TO RAISE CONCERNS

67.2% of respondents have highlighted concerns of race discrimination to their organisation. Figure
4 shows the proportion of staff who have raised concerns by band. 76.8% of staff in bands 8 and
over have raised a concern, compared with only 54.3% in bands 1-5.

Fig 4: Have you ever highlighted race discrimination as an issue? (by band grouping)

Bands 1-5 54.3% 45.7%

Bands 6-7 60.9% 39.1%

Band 8 and over 76.8% 23.2%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Yes No

UK trained staff are much more likely than internationally trained staff to raise concerns. 71.0% of
UK trained staff have highlighted race discrimination as an issue, compared with 53.1% of
internationally trained staff (see Figure 5, below).

Fig 5: Have you ever highlighted race discrimination as an issue? (by training location)

Abroad 53.1% 46.9%

UK 71.0% 29.0%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Yes No

21
 Too Hot to Handle?

4.2 BARRIERS TO RAISING CONCERNS

The most common reason for not raising a concern of race discrimination was not believing
anything would change (fig 6). 63.5% of people who didn’t raise their concerns were worried about
being seen as a troublemaker, while 57.3% were worried about repercussions from their line
manager or other organisational leaders.

Fig 6: Reasons for not highlighting race discrimination despite experiencing/witnessing it

I didn’t believe anything would change 75.7%

I didn’t want to be seen as a troublemaker 63.5%

I was worried about repercussions from my line manager/other leaders 57.3%

I didn’t think my trust would take my concerns seriously 54.5%

I was worried about repercussions from my colleagues 38.2%

I didn’t think my trust would understand my concerns 27.8%

I felt pressured not to make a fuss 25.4%

4.3 ORGANISATIONAL RESPONSES TO RACE DISCRIMINATION CONCERNS

Of those who raised concerns, only 5.4% said they were taken seriously and that their problem was
dealt with satisfactorily (see fig 7, below).

The most common outcome to a race discrimination concern was nothing happening (the outcome
in 42.7% of cases). In one in five (19.1%) instances, claims of race discrimination were treated the
same as any other workplace dispute and referred to mediation. In 5.0% of cases, the individual
raising the concern were themselves disciplined.

Fig 7: Outcome when raising concerns

Nothing happened 42.7%

Seen simply as a disagreement – and referred to mediation 19.1%

My concern was taken seriously and the problem satisfactorily dealt with 5.4%

I was disciplined unfairly 5.0%

I was told it was my problem 4.9%

I was dismissed 2.2%

Other (please specify) 19.8%

41.8% of respondents left their jobs as a result of their treatment, and the survey highlighted a
number of specific issues in relation to raising concerns.

22
 Why concerns about racism are not heard… or acted on

‣ Retaliatory investigations
Staff report that they have an elevated risk of experiencing racism and discrimination when they
raise concerns related to racism.

“I was told that there has been a 'breakdown in communication', [and] asked to work
elsewhere. [I was] investigated for my behaviour towards colleagues making it unsafe for
patients.”
(Black/Black British, Band 4)

“I was told that I had misunderstood the situation, and I was accused of being the reason for
the way the other party had behaved. I was told that my tone and language was aggressive,
and my concerns were dismissed…even after my complaint was upheld. None of my
suggestions [were] implemented, and I am still sitting next to [a] person who continues to
interfere in my work.”
(Multiple heritage, Band 8a)

A number of survey respondents discussed how the standard of evidence required by grievance
investigations allowed perpetrators of discrimination to escape censure:

“I was basically ignored, not taken seriously, asked to move to another ward, judged and
looked upon as a challenging harasser. I should be seen and not heard and even told at one
point to stop talking.”
(Black/Black British, Band 2)

“My manager… denied everything in my submitted report. He then tried to prove that I was
not competent in my job and made my life so difficult, that I would leave. I was told to change
my behaviour and put on a disciplinary process.”
(Asian/Asian British, Band 7)

“When I finally decided to say in a meeting with [a] manager that I feel I am being treated
differently due to the nit-picking. I was told, ‘If you are going to play the race card, I will shut
this meeting down’. That statement was then ignored in feedback info and stated as not
being said!”
(Black/Black British, Band unknown)

‣ Epistemic injustice
‘Epistemic injustice’ refers to how an individual’s testimony regarding their experience can be
dismissed (see Fricker, 2007). The term references beliefs about what constitutes knowledge and
opinions. For example, attempts to discuss racism within a belief system that presupposes it does
not exist won’t get off the ground. And, indeed, this was a common theme amongst survey
respondents: poor and discriminatory behaviour is routinely excused, explained away, distorted
and/or overlooked. Often, attempts are made by management to disregard and obscure complaints
against repeat offenders; they are consistently protected and face little sanction or accountability:

23
 Too Hot to Handle?

“I was victimised. My work and job plan [were] suddenly scrutinized, although I had a perfect
record. My complaint was never investigated. The manager moved and was promoted
elsewhere at another Trust. HR are often supporting the racist behaviour by managers and
supportive in the victimisation... It’s as if HR see it as their role to cover up racist behaviours
within trusts.”
(Asian/Asian British, VSM)

“I was told that I take this personal. Yes, I do because I am a person. Then told, ‘We know
how this person is’. That is just how he is. He gets away with name-calling, despising
anyone who is not English, and constantly says [that] if we are not happy, to go back where
we came from. Some people seemingly laugh but afterwards talk [about] how uncomfortable
they are and what can they do or say since he openly says racist remarks in front of
managers, senior colleagues, and even consultants and no one says anything about it.”
(Black/Black British, Band 6)

Some participants suggested trusts do not have a sufficiently developed understanding of the
different forms racism can take. This can lead to them minimizing complaints raised by BME staff:

“I was made to feel like the perpetrator, the actual perpetrator who has had a number of
grievances, has been let off, I am told I need to make more of an effort, it's my problem, they
refuse to acknowledge the power differences.”
(Asian/Asian British, Band 8a)

“[I] highlighted [an] Islamophobic colleague, and [was] told he is ‘old fashioned’ rather than
racist."
(Asian/Asian British, band unknown)

"My supervisor was bullying me, she turned everyone against me, including the manager of
the service and put a complaint against me. There were two job interviews where I was
interviewed by the manager involved in the complaint. This was unfair, I had less training
than every other therapist and less opportunities, too. I was victimised. It was awful. The
complaint procedure lasted one year. I feel the trust swept it under the carpet and wanted
the issue to disappear. I had to leave.”
(Asian/Asian British, Band 7)

“Nothing happened as some managers were racist themselves and would cover up such
cases and concerns.”
(Black/Black British, Band 3)

“[there was a] very openly biase[d] investigation and appeal process. Support [was] given to
the perpetrator. I have [had] no legal help to do my witness statement, and when I submitted

24
 Why concerns about racism are not heard… or acted on

[it], they objected, saying it [was] inflammatory to the perpetrators and [much] of my
testimony was [struck] out…I tried to settle so I can move on and rebuild...I [now] have to go
on benefits.”
(Black/Black British, Band 5)

‣ The fear and reality of repercussions as a result of making a complaint

Staff expressed their apprehension regarding raising concerns, as they fear and experience
reprisal, retaliation, and victimisation. This inevitably has an adverse impact on their well-being and
mental health. These concerns are further exacerbated as staff are treated as disloyal as well as
being subjected to bullying, scapegoating, and harassment. Staff who raise concerns about racism
are often met with indifference, skepticism, or outright dismissal.

“I escalated this; the managers did nothing. I was then bullied out [of] the company.”
(Black/Black British, Band 5)

“[I was] gaslighted, victimised and excluded, given worst cases, information withheld,
scrutinised and referred to the regulator.”
(Asian/Asian British, band unknown)

“[I was] gaslit, ostracise[d], [and experienced] shifting blame and [the] formation of cliques.
[There was a] defensive response placing barriers to constructive resolution and [a] delay in
keeping me safe in the workplace. Resulting in [the] escalation of my poor experiences,
impacting on my wellbeing, mental health, and all aspects of my life.”
(Asian/Asian British, Band 6)

“[I was] told not to get involved; it wasn’t my job. Questioned if what I reported really was
racist or just a ‘misunderstanding’. [I was] made to feel [like] I was being disloyal to the
organisation as I wanted to pursue it further.”
(Multiple heritage, Band 9)

“[The] given grievance policy went against the Respect in Workplace policy…the complaint
was not upheld then lost at appeal. No one would talk to me, and I was ostracised in the
workplace. [The] gossip mill went into overdrive. Staff in CCGs also knew of my grievance
and started ignoring my emails, too. I became aware that my position was untenable.”
(Multiple heritage, Band 8a)

“I’ve been made to feel that because I spoke up…I am the bad person. I have even had
people say to me, ‘Why are you doing this to yourself?’, like the situation I am in is my entire
fault. My therapist and GP have suggested I have contracted PTSD as a result of the trust
failing to deal with the psychological impact [of] the mishandling of my case…I have tried
reaching out to management on numerous occasions in the hope of getting some support
with each of these things, only to be left with feeling gaslighted and questioning my sanity. I

25
 Too Hot to Handle?

go into this cycle of mental health deterioration, and then in the end, it becomes a disaster,
and I reach a crisis point…I am actually at the point where I feel like I am being bullied out of
my job.”
(Black/Black British, Band 6)

‣ A lack of confidence in the complaints and investigations process

Doubts about fairness, the limited impact of policies and procedures, and a seemingly rigged
investigation process all collectively hinder confidence in the NHS complaints and investigations
process:

“The Trust conducted biased investigations using their own legal team and called this
independent. They covered up and whitewashed the facts. They even promoted the
perpetrators to silence the victims.”
(Multiple heritage, Band 6)

“I was targeted and victimised further. False allegations were created. I was set up to fail.
The Trust called in their own legal team to investigate, who whitewashed and covered up
the racism. Went to tribunal and won."
(Black/Black British, Band 7)

“I raised a complaint to the CEO and Medical Director, there was an external investigation
which took a year… and [the] investigation whitewashed all the race harassment events as
‘personal issues’. They advised some policy review advice, no acknowledgement, no duty
of candour, [and] no apology. I was harassed and gaslighted to a point where I had to be
moved out of the service.”
(Asian/Asian British, Band 8a)

‣ A poor or absent institutional response to racism and discrimination

Many participants suggested institutional responses to racism are poor, with organisations often
preferring to avoid the issue. This undermines staff’s confidence in their managers ’ability to handle
race discrimination complaints:

“I reported racism experienced by myself and another colleague; [my manager] heard [it],
but no action [was] taken. In fact, I was told that there were many others who left the
organisation as they didn’t feel racism was handled or dealt with appropriately, so [the] only
option was to leave. There was no trust in the system or with senior leadership and
management to act on it.”
(Asian/Asian British, Band 8b)

26
 Why concerns about racism are not heard… or acted on

4.4 SUPPORT FROM UNIONS, HR, GUARDIANS, ETC

Participants were asked, if they were a member of a trade union, how helpful the advice they were
provided was (figure 8). A third of respondents (35.2%) said it was not helpful at all; 25.9% said it
was ‘helpful ’or ‘very helpful’.

Fig 8: If you are a member of a trade union how helpful did you find their advice?

50%
45%
38.9%
40%
35.2%
35%
30%
25%
20% 17.0%
15%
8.9%
10%
5%
0%
Very helpful Fairly helpful Not helpful at all Not applicable

NHS staff have experienced a number of issues raising race discrimination claims with HR
colleagues, unions, and, to a lesser extent, Freedom to Speak Up Guardians. Most common is a
lack of understanding regarding what racism is and how it manifests in the workplace:

“I am quite vocal about issues to do with race and will call out poor/racist behaviour. One of
the Union reps in a meeting I chaired was particularly rude asking why do we need to focus
on race - in a very derogatory manner. He subsequently gathered his mates including the
CPO and got another Union rep to raise a grievance against me.”
(Black/Black British, Band unknown)

“I really had to push for HR to potentially take staff survey results data back to the execs as
a systemic problem not just of race but also on behalf of all the protected characteristics.
We are equally failing across the board in the same areas. When previously talking about
racism experience it is just shrugged off (in a friendly way) but no material action.”
(Asian/Asian British, Band 7)

Some participants noted their trust’s HR team was not immune from the systemic racism that
pervaded other parts of the organisation. This meant they were unable to spot and respond
adequately to common indications of racism:

“The HR Director had several complaints from others but made us feel like we were the
problem especially when he got ‘white women's tears ’so basically told me I needed to
understand my boss more and be less sensitive. I chose instead to leave the NHS

27
 Too Hot to Handle?

alongside my other three colleagues who complained. It's sad as I loved my job but
couldn't continue being treated in this way, it was impacting on my mental health. HR let us
down and most times HR are racist themselves.”
(Black/Black British, Band 8b)

Other participants suggested their unions were themselves institutionally racist. As a consequence,
they are particularly ill-equipped to identify, and campaign on, organisation-wide inequalities:

"They are worse as they cover up more. They seem to ignore WRES data even though this
is poor. There seem to be no repercussions of bad WRES data. Medical Unions take no
action and like all institutions seem to be institutionally racist. I know of around 10 female
BAME doctors who have left the NHS and the unions as they feel unsupported when they
report racism in the workplace.”
(Asian/Asian British, VSM)

Some participants claimed their union advised them not to pursue race discrimination claims
because of the potential negative consequences:

“I was advised by trade union not to pursue my complaint as it would damage my

reputation.”
(Asian/Asian British, VSM)

A small group of participants relayed feeling concerned by how close their union representatives
appeared to be with their organisation’s HR and management staff:

“Colleagues complained about my work unfairly, I expressed my frustration and hurt, it was
turned into me raising that I am having issues with my work (which I didn't). This was
bullying as the whole senior team ganged up on me. I couldn't bring myself to ask my union
rep for support as they all seemed to be in a clique. I didn't want to risk making the situation
worse.”
(Black/Black British, Band 7)

Finally, a number of survey respondents questioned the power union representatives, Guardians,
and equality leads have to effect change within organisations that are committed to downplaying
race equality claims. One Guardian responded to the survey outlining the frustrations s/he
experienced when trying to get their organisation to see a pattern of racism in the complaints raised
by staff:

“I worked as a guardian at a large trust which claimed it was working hard to address
racism. It wasn't. When I highlighted cases where I perceived race to be the issue, these
were downplayed, I was told I was wrong and seeing things that weren't there. I'm white,
but could clearly see the distress and futility for staff of raising this with me. I was lucky that
they trusted me but clearly I and the trust let them down. One HR manager sat in a meeting
and said he's 'playing the race card'. I openly challenged them on this and raised with CPO
who said she would look in to it. I don't believe she really did do anything.”
(White/White British, banding withheld)

28
 Why concerns about racism are not heard… or acted on

5. LEARNING POINTS FROM KEY

TRIBUNAL CASES
The denial of racism and minimization of its impact often positions organisations into a non-
negotiable position, where defending any allegation becomes the right thing to do. There is a thin
line between recognising racism as an overt practice/behaviour and being cognizant of its impact.
Belief that racism is often over-stated (and used as an excuse for poor behaviours and non-
performance) sustains the frequent efforts to defend, minimize, or otherwise explain away
allegations of racism, at all cost. Furthermore, staff are too quickly caught up in this system to deny
racism – despite impact or evidence.

Winning often does nothing to support our understanding of racism, but it does help organisations to
recognise that there are some legal precedents which should guide our treatment of individuals and
offer them better experiences, should they wish to come forward with these types of allegations.

This section summarises the common themes found in eight recent NHS employment tribunal
decisions.

5.1 TRIBUNALS
Many Employment Tribunal cases are settled or withdrawn. Notwithstanding these cases, the
number of race discrimination cases dealt with by Employment Tribunals in England in the last year
for which data is available (2020-21) was 2,565. Despite the high profile of some NHS cases, across
all sectors just 3% of cases were successful at hearings (this the average for the last 14 years). The
median award was just £14,120.

Cases that NHS employers defend at Tribunal are those which they judge the employee will lose –
often because they are litigants in person or because of poor legal advice to the employer, or due to
reputational defensiveness by employers. Moreover, cases that might have a better chance of
success are often settled, albeit because litigants cannot face the pressures of extended cases. The
cases employers judge litigants are more likely to win are often settled, albeit with little
organisational learning.

Despite this miserable record, the outcomes of successful cases are important for three reasons.
Firstly, for a small number of people, the success of their claims is personal vindication after a
personal injustice. Second, they help establish the legal framework within which employers are
expected to conduct their employment relations, in particular in respect of race discrimination.
Thirdly, they may act as a salutary reminder to individual employers – and, in the case of the NHS,
the entire healthcare sector – of the damage to management reputation and staff morale of such
cases.

29
 Too Hot to Handle?

The successful claims by NHS staff considered here are therefore of importance, especially in a
sector where almost one in four staff are of BME and where every employer protests their
commitment to tackling race discrimination.

We identified a number of Employment Tribunal cases taken by NHS staff as litigants against NHS
employers. We selected three ‘landmark’ cases between 2011 and 2016 and then five of the most
prominent cases in 2023. We are confident they are reasonably representative of the employer
shortcomings tribunals have identified, not least because we, as authors, are familiar with other
cases where similar findings have been identified. We don’t claim they are comprehensive but do
believe they are sufficiently representative to identify common themes.

5.2 THE CASES

The themes in this section are drawn, in the main, from the following cases. For references, see
Appendix C.

• Eva Michalak (2011) was a hospital consultant in Mid-Yorkshire Hospitals NHS Trust who was
hounded out of her job after deciding to have a baby. She was awarded £4.5 million
compensation for the race and sex discrimination she suffered which ended her career. Remedy
decision – finding is not online.1

• Eliot Browne (2012) was a very senior scientist at Central Manchester University NHS
Foundation Trust who was awarded £1 million after an Employment Tribunal ruled he faced
“persistent discrimination” and “an intimidating environment” before the Trust suspended him
when he complained and then ended his 34-year NHS career. The Trust appealed and lost at
the Employment Appeal Tribunal.2

• Richard Hastings (2016) was an IT manager at King’s College NHS Trust who was awarded a
£1million pay-out after an Employment Tribunal found the Trust guilty of racial discrimination
and unfair dismissal. He had been (falsely) accused of assault in an incident involving a delivery
driver and a contractor and was dismissed for gross misconduct in October 2015, despite an
exemplary work record.3

• Michelle Cox (2023) was a senior nurse working for NHS England who (unanimously) won her
claims of discrimination, harassment and victimisation in a case that exposed shoddy
procedures within NHS England and prompted scathing comments from the judge about her
managers.4

• Adelaide Kweyama (2023) was an agency nurse racially abused by patients whose manager
told her to “bleach her skin” and then she would get less racist abuse. She won a race-related
harassment case against Central and North West London NHS Foundation Trust.5

• Olukemi Akinmeji (2023) was a midwife at William Harvey Hospital in Ashford, Kent who
successfully sued East Kent Hospitals University NHS Trust for discrimination and victimisation.
She faced a ‘toxic ’work environment in which her colleagues “ganged up” on her.6

30
 Why concerns about racism are not heard… or acted on

• Princess Mntonintshi and Ubah Jama (2023) were scientists at Barking, Havering and
Redbridge University Hospitals NHS Trust. They won their race discrimination claim after an
Employment Tribunal found they faced multiple incidents of discrimination over a period of two
years.7

• Samira Shaikh (2023) was an Ophthalmic Technician at Moorfields Eye Hospital NHS
Foundation Trust. She successfully claimed she had been subjected to direct race
discrimination, harassment related to race, victimisation, and constructive dismissal.8

5.3 KEY TRIBUNAL LEARNING

1. It is very unusual for individual (or collective) allegations of discrimination to be upheld by
employers or courts.

As Lord Justice Mummery explained this is because:

The legal and evidential difficulties are increased by the emotional content of the cases.
Feelings run high. The complainant alleges that he has been unfairly and unlawfully treated
in an important respect affecting his employment, his livelihood, his integrity as a person.
The person against whom an accusation of discrimination is made feels that his acts and
decisions have been misunderstood, that he has been unfairly, even falsely, accused of
serious wrongdoing.
Qureshi vs Victoria University of Manchester & Anor [2001] ICR 863.

2. Discrimination is rarely admitted and thus the function of an internal appeal is to see what
inferences could be drawn.

In Cox (a similar point was made in a number of other cases), the Employment Tribunal emphasised
that:

Under cross-examination, (the NHS England appeal hearing chair) accepted that
discrimination is rarely admitted and thus the function of the appeal was to see what
inferences could be drawn. The Tribunal found that the appeal identified a number of
instances of what it variously described as “poor” behaviour towards the claimant yet failed
to address why this poor behaviour had taken place nor was the respondent able to explain
why this was somehow unimportant. (Para 59).

3. NHS staff – including senior staff – struggle to talk about race, without becoming defensive
and falling back on stereotypes.

In Shaikh, the Employment Tribunal found:

The evidence generally points strongly towards Mr Holm stereotyping the claimant as a
‘loud ethnic female’, in particular the email sent to Ms Tinkler on 24 September 2020, the

31
 Too Hot to Handle?

fact that Mr Holm indicated the move was to allow for a ‘cooling off period ’and Mr Holm’s
evidence in cross examination that the move was because of the perceived ‘outburst’. This
conclusion is also supported by the subsequent references made by Mr Holm to the
claimant being ‘aggressive’ when she was not in fact displaying any aggressive behaviour,
coupled with the false allegation that the claimant was audible to patients after the
meeting. We also take into account that the reason for the move was that a complaint
about discrimination had been made, and only the claimant and Ms Chekar were moved
(Para 95).

We find that Mr Holm did not take well to allegations of discrimination being raised and
from that point on perpetuated a stereotype of the claimant as a ‘loud ethnic female.” (Para
106).

4. Very little direct discrimination is overt or even deliberate. Discrimination factors will, in
general, emerge not from the act in question but from the workplace environment (including
workforce and staff survey data) and previous history.

If it is established that there is an instance of negative conduct which could be assigned to race
discrimination, and the employer cannot provide a reasonable and adequate explanation that this
was not due to discrimination, then the tribunal can draw an inference that the negative conduct was
caused by discrimination (s.136 Equality Act 2010), as in the case of Cox:

Very little direct discrimination is overt or even deliberate. In Anya v University of Oxford
[2001] IRLR 377 CA guidance was given that Tribunals shall look for indicators from a time
before or after the particular act which may demonstrate that an ostensibly fair-minded
decision was or was not tainted by bias, in Anya racial bias. Discriminatory factors will, in
general, emerge not from the act in question but from the surrounding circumstances and
the previous history. (Para 72).

In Cox (Para 114) Browne, and Hastings (Para 369) workforce data was important context for the
Tribunal but something the employer failed to acknowledge.

5. Employers generally look at events individually but should consider whether there are
cumulative patterns or behaviours which required examination.

An accumulation of apparently small acts of detriment – such as microaggressions – can have a

catastrophic impact on staff which damages their health and may constitute discrimination. Failure
to consider whether such acts might cumulatively constitute race discrimination and to then fail to
investigate what might be the underlying causes, whether in an investigation or during a hearing,
might itself constitute an act of discrimination and harassment. As the Tribunal concluded in Cox:

This approach to the claimant’s grievance continued in the grievance appeal process where
the Tribunal found that the appeal outcome failed to uphold the Claimant’s grievance
despite the underlying findings made. The problem arose because the appeal looked at
events individually and did not consider cumulatively whether there was a pattern of

32
 Why concerns about racism are not heard… or acted on

behaviour which required examination. It did not consider the issue of discrimination and
or whether there might be an underlying reason for the matters complained of if those
matters were taken together. It did not ask why things happened, nor did it question or
probe what it was told. (Para 109).

6. Employers often set a high bar of needing to see ‘deliberate’ discrimination, thus failing to
consider the possibility of subconscious discrimination.

Employers often seek to show that although there were aspects of the treatment of staff which may
have led the worker to be believe they were being racially discriminated against, there was no
discriminatory intention. This is a misunderstanding of the law. Courts have made it very clear that it
is not necessary to show that the person(s) alleged to have discriminated did so consciously since
‘unconscious’ discrimination is also prohibited.

Lord Browne-Wilkinson noted that claims under discrimination legislation present special problems
of proof as those who discriminate…

…do not in general advertise their prejudices: indeed, they may not even be aware of
them.
Glasgow City Council v Zatar 1998 ICR 120, HL

In another significant case, the House of Lords similarly stated:

Many people are unable, or unwilling, to admit even to themselves that actions of theirs
may be racially motivated.
Nagarajan v London Regional Transport and others [1999] IRLR 572 (HL)

A tribunal will not assume that a person’s actions are free of subconscious bias even if the person is
an honest and reliable witness, and one who genuinely believed they were acting for non-
discriminatory reasons. In Cox, NHS England failed to act accordingly:

Despite the claimant’s grievance about (her line manager’s) conduct, the Tribunal
considered that the respondent’s grievance outcome and appeal outcome avoided
addressing the reasons for (her) behaviour towards the claimant. They did not draw
inferences from the evidence gathered despite, as the Tribunal found there, were many
aspects from which inferences could be drawn. In addition, by setting a high bar of
needing to see ‘deliberate ’discrimination, the respondent failed to consider the possibility
of subconscious discrimination at all. (Para 117).

When presented with such a pattern of events, HR are expected to be curious and understand what
might lie behind them and to consider the possibility that they might constitute direct discrimination.
They should never try to deter staff raising concerns by claiming that to be successful they must first
prove that those responsible were motivated by racism (or sexism, homophobia, etc.).

33
 Too Hot to Handle?

7. Employers repeatedly seem insufficiently aware of the legal framework of burden of proof in
discrimination cases.

Once it has been established that a claimant has been treated less favourably, the burden of proof
shifts to the respondent to disprove that this was on the grounds of race. In Hastings, the Court
summarised this as follows:

We conclude that the Claimant has shown sufficient facts from which the Tribunal could
conclude that he has been treated less favourably because of race. The burden of proof
shifts to the Respondent to show that the treatment was in no sense whatsoever on the
grounds of race. Ms Casseatari (Appeal panel chair) has provided no credible reason for
failing to comply with policies, failing to investigate the Claimant’s evidence of race
discrimination and failing to conduct a fair and non-discriminatory process. The claim for
race discrimination by summarily dismissing him is well founded. (Para 385).

In their internal processes NHS organisations often appear to not recognise this approach. The
onus is on employers, and indeed, the HR professionals within large NHS organisations, to be alive
to the fact that once it has been established that the claimant has been treated less favourably, it is
for the respondent to disprove that this was on the grounds of their race. Educating employers and
being aware of the nuances of this area is vital if they are to properly support an employee who
raises concerns about race discrimination.

8. Discrimination (including race discrimination) need not be the main reason for an act or
omission to have been discriminatory.

Case law (referred to in a number of these cases) has determined discrimination simply needs to
have a ‘significant influence’. Thus:

the discriminatory reason for the conduct need not be the sole or even the principal reason
of the discrimination; it is enough that it is a contributing cause in the sense of a ‘significant
influence'.
Law Society v Bahl [2003] IRLR 640, at 83

9. Employers should ensure that they are signposting staff to the appropriate policies. Not to
do so can derail an investigation.

In Cox, the Tribunal noted:

The claimant emailed (the appeal hearing chair and the senior HR adviser) with additional
information, pointing out the fact that her grievance was about discrimination and that she
had asked for the respondent’s Equality Diversity and Inclusion in the Workplace policy to
be used, whereas the respondent had decided to investigate it under the Respect at Work
policy despite that the claimant had been clear that race discrimination was a factor in her
complaint. (Para 57).

Anecdotally, this is a common shortcoming, and one which can easily derail an investigation.

34
 Why concerns about racism are not heard… or acted on

10. Employers (and external consultants) may be reluctant to conclude that race discrimination
has occurred even when it is clear it has.

Employers, and those resisting allegations, may confuse being a racist with the existence of race
discrimination. Thus, when a selection or disciplinary process results in an outcome that is
discriminatory, employers will generally resist reaching such a conclusion because of the stigma
attached to a finding of race discrimination. The lack of accountability for systemic or institutional
racism enables individuals to be scapegoated.

The Macpherson Inquiry definition of institutional racism is regularly referenced in employment

tribunals and captures much of the experience of race discrimination in the NHS:

the collective failure of an organisation to provide an appropriate and professional service

to people because of their colour, culture or ethnic origin. It can be seen or detected in
processes, attitudes and behaviour which amount to discrimination through unwitting
prejudice, ignorance, thoughtlessness and racial stereotyping.

All manner of euphemisms are used to avoid naming racism in many of the cases considered,
notably in Kweyama (Para 382), Akinmeji (Para 143), Shaikh (Para 77), and Browne. In Cox, NHS
England agreed that Michelle Cox was subjected to ‘poor behaviours’ but the appeal hearing could
not bring itself to name these as race discrimination:

The grievance conclusions recorded that it was “evident that the relationship between Gill
Paxton and the claimant had broken down significantly” and that the claimant “feels greatly
impacted by this and she does feel undermined, excluded, unappreciated and
disenfranchised” whilst finding that it was reasonable for the claimant to feel like that in the
circumstances. Nevertheless, it was not prepared to examine the conduct in terms of
possible discrimination nor to even state in clear terms that the grievance appeal had been
upheld in part. In those circumstances, the Tribunal considered that the outcome served as
a way of placating the claimant whilst failing to deal with the issue of discrimination. (Para
133).

In Browne, the Trust did not deny that Mr Browne had been wrongfully dismissed but disputed the
claims of race discrimination and victimisation arising from his claims of race discrimination. The
Employment Appeal Tribunal dismissed the appeal.

11. Simply because race discrimination has not been alleged does not mean it has not taken
place.

Many organisations in the NHS have parts of their workplaces where racism is normalised and not
challenged and where staff fear challenging it because they believe it is either pointless or will make
things worse. Racism will go unchallenged without a continual proactive process of review of
employer data on patterns of treatment (such as disproportionately poor outcomes in recruitment, or
disciplinary cases, or turnover by BME staff) as well as staff survey data, analyzed by ethnicity, and
of lived experience, accompanied by challenge and improvement. And most importantly,
organisations having the moral courage to name racism as the cause.

35
 Too Hot to Handle?

In Mntonintshi the Tribunal notes:

Although we have found (para 176 onwards) that Ms Mntonintshi did not mention race
discrimination, either in this email or orally, we have found (para 186) that Ms Valera-Larios
believed that Ms Mntonintshi was complaining about race discrimination and supporting
Ms Jama’s complaints of race discrimination. (Para 459).

In Akinmeji:

Finally we note the following. This was an unusual case, with the claimant relying on
matters which she did not believe were race discrimination at the time, but only with
hindsight. The evidence we heard reflected a toxic and difficult working environment
generally where the claimant and colleagues were shouted and sworn at over differences
of professional opinion. There was some evidence before us that there were wider issues
beyond the specific allegations before us and which were possibly related to race. There
were references to further issues related to the claimant’s reasons for leaving. (Para 148
and 149).

12. Investigations in general are prone to bias but, where race may be a factor, they are
notoriously poor in quality and especially prone to bias.

In Hastings, the Tribunal was scathing, concluding that one of the respondent’s “evidence was not
credible on a number of occasions” (para 365). It went on to say:

Turning to the next issue of whether the investigation conducted and the conclusions
reached by Mr Yousuf were less favourable treatment because of race, we conclude that
they were. Mr Yousuf impressed upon the Tribunal his 17 years ’experience as a police
officer in conducting investigations and with evidence handling but the conduct of the
investigation showed unconscious bias. There were a number of examples that the Tribunal
refer to in support of this conclusion, the first being that he referred to the white
complainants as victims. (Para 373).

He (the Trust’s investigator) professed to be sceptical about the Claimant’s evidence that
he was subjected to race discrimination and did not investigate. His failure to investigate
was in breach of the Respondent’s policies as referred to above and in breach of the EHRC
Code of Practice. There has been no explanation from any of the Respondent’s witnesses
as to why they failed to comply with their policies despite three HR managers
having involvement throughout. (Para 374).

13. That the commissioning manager, investigator, panel members, or their HR advisers are
themselves BME is no assurance that investigations in such matters will be robust and
unbiased.

Investigators, advisers and panel members who are of BME heritage may indeed have additional
insights, but unless they are effectively trained, held to account, are expected to speak truth to

36
 Why concerns about racism are not heard… or acted on

power, and feel safe in doing so, there can be no assurance that their involvement necessarily
mitigates the likelihood of bias. In Hastings, (Para 378) it was a former BME police officer who
carried out the investigation so heavily criticised by the Tribunal. In Cox, the initial investigator was a
BME senior manager, whilst the senior HR adviser to the panel (which concluded racism was not
proved) was of BME heritage.

In Kweyama, the Trust’s claim that the ethnicity of the manager would mitigate any bias was not
accepted by the Tribunal:

It is argued by the respondent that since KM’s husband is West Indian, she is more likely
than most to be well acquainted with the effect of racial abuse in the workplace and in
wider society. However, this was not the evidence she gave about the relevance she
attaches to her family circumstances. She did not say that she went to see the claimant
because she had an understanding about what the claimant had gone through. (Para 105)

14. Employers should be proactive and preventative when seeking to address race
discrimination rather than waiting for individuals to raise concerns formally.

The primary reliance on policies, procedures, and training in employment relations frequently gives
employers false assurance of fairness when handling cases of race discrimination. An employer
who relies on individual staff raising concerns about race discrimination, rather than using data and
soft intelligence to be proactive and preventative, will inevitably be faced with staff who leave, keep
their heads down, or eventually raise concerns but only after relations have become embittered and
formalised.

Employment Tribunals expect employers to be curious and apply the Equality Act 2010 which
requires that public bodies have due regard to the need to:
• eliminate discrimination
• advance equality of opportunity
• foster good relations between different people when carrying out their activities

In Shaikh, not only had management failed to address concerns raised by staff but the Employment
Tribunal concluded that:

We find that the respondent did not take action or make any real attempt to understand
what the issues were. Management was by this point so sensitive about allegations that
discrimination had occurred that rather than dealing with such allegations head on they did
not touch on the issues at all. (Para 114).

15. Tribunals regularly criticise Human Resources staff for falling short of the expected
standard in race discrimination cases and that may itself be an act of discrimination.

The judgements in Browne (2012) and Hastings (2016) should have been a core part of subsequent
HR training across the NHS but clearly have not been – many of the shortcomings identified there
were repeated in subsequent cases, including that of Michelle Cox. Repeatedly, there appears to be

37
 Too Hot to Handle?

no HR oversight of the credibility of the case being defended. In Hastings, for example, the Tribunal
found a number of shortcomings with the HR responses:

None of the Respondent’s witnesses made reference to their own Dignity at Work Policy
and Equal Opportunities Policy which was not produced until the fourth day of the hearing
after the Tribunal had requested sight of it. (Para 365).

It appears to be an unfortunate coincidence that all the minutes of the hearing and appeal
are missing and neither manager chairing the hearings took minutes during the hearing, we
raise an adverse inference from this. (Para 367).

The Respondent failed to carry out any investigation into the Claimant’s complaints of
racist abuse, despite this being a breach of their own policies and procedures. (Para 368).

16. Tribunals regularly find that key management witnesses, including investigators and panel
members, are not credible. Yet there do not appear to be any consequences for those
responsible even when it is clear they lied or were complicit in a coverup.

In every single one of these eight cases we are exploring, key management witnesses were simply
not believed by the Tribunal. That raises the question as to what level of prior scrutiny existed within
each organisation which allowed key witnesses’ lies to go undetected. Thus, in Cox, the main
employer witness was described thus:

The Tribunal found that the evidence of the claimant’s line manager, Ms Paxton, was less
than credible. Her responses to cross-examination were often unhelpful, evasive or
defensive. At times, she sought to avoid answering questions from Counsel for the
claimant, or did not explain her evidence despite it being probed. A number of explanations
were given with the benefit of hindsight and differed from contemporaneous evidence or
conflicted with it. The Tribunal considered that Ms Paxton’s continued evasion
when challenged, and her failure to explain her conduct at the material time, on occasion
providing new excuses not mentioned before or to the grievance appeal, led the Tribunal to
view her as an unreliable witness. (Para 97).

The evidence from these tribunals (with one exception, Michalak) is that those who lied and thereby
contributed to the injustice were not held to account by their employer. Indeed, where career paths
after the acts of race discrimination are known, they generally show that key witnesses were
promoted.

17. Tribunals may make a damaging note of events even when they are not upheld or were
only part of a claim.

In Akinmeji, for example, the Tribunal noted there was evidence of race discrimination even though
the claim was ruled out as being made out of time, e.g.:
• a colleague asking the claimant not to go near her patients
• a colleague saying to the claimant: “nobody likes you or wants you here” and “go back to where
you came from”
• a colleague telling the claimant that her help was not needed when they worked together

38
 Why concerns about racism are not heard… or acted on

Though the majority of complaints were not upheld, the Tribunal found, compounded by the multiple
documented failings of the senior HR person involved, that the evidence:

reflected a toxic and difficult working environment generally where the claimant and
colleagues were shouted and sworn at over differences of professional opinion. (Para 148).

18. Administrative and policy incompetence and delayed timescales may contribute to the
finding that discrimination occurred.

Incompetence and delay appear normal in the cases examined but, of course, are no defence for an
employer. In Hastings, the Tribunal said:

Although unreasonable and incompetent handling of a process cannot be equated to

discrimination, the catalogue of failings in the disciplinary process showed a correlation
between the less favourable treatment of the evidence provided by the white complainants
as compared to the disbelief and the distrust shown by Ms Cassetari (appeal hearing chair)
when considering the Claimant’s evidence. (Para 385).

19. HR do not always acknowledge the possibility that complaints about staff subjected to
discrimination may be manufactured either to justify discrimination or as acts of retaliation.

When staff raise concerns of any kind there is always a risk that retaliatory steps may be taken by
colleagues or managers. This was recognised by Robert Francis’s Freedom to Speak Up report. If
concerns about performance or behaviour that had not been mentioned previously suddenly surface
when discrimination is an issue, alarm bells should ring – it was a feature in every one of the cases
we’re exploring here.

In Michalak, where sex and race discrimination were found proved, senior doctors conspired to
make complaints about her based on her having trained in Poland, after she became pregnant. She
was subjected to a “lengthy and wholly unauthorised period of suspension” and then dismissed
following complaints and criticism which were without foundation. The Employment Tribunal
described the Trust’s disciplinary process as “bogus”. In other cases, the tribunals identified
retaliation such as:
• in Shaikh, “the Respondent moved the Claimant out of the adult department and into paediatrics
following her querying management’s plan of action following discrimination claims from four
other members of staff”
• in Mntonintshi, extending probation was “a cynical act of victimisation”
• in Browne the Tribunal found that “Once the race discrimination grievance was put in […] the
Trust closed ranks around [the deputy CEO] and commenced disciplinary action against the
claimant to secure his removal from office”

39
 Too Hot to Handle?

20. The NHS employer should not assume that it has no responsibility for the behaviour of
contract staff.

In Kweyama, the claimant had been regularly carrying out shifts as an agency nurse at band 5 and
the Tribunal noted that:

it is equally absolutely clear that the Dignity at Work policy does apply to agency workers
since they would fall within the category “employees of other organisations who are on
site” within the scope definition on page 250. (Para 45).

In Hastings, the racist abuse came from two contract workers. The Tribunal had no hesitation in
holding the Trust responsible for what happened.

21. Tribunals have repeatedly found that NHS employers fail to action their own internal
decisions, to the detriment of the employee concerned.

In Akinmeji, in the Tribunal noted:

[A] was given a false explanation of what the respondent had done in consequence of her
complaint. She was told [KC] had done unconscious bias training and reflected on her
actions and had been warned about the possibility of disciplinary action if she repeated
such conduct. The only unconscious bias training organised had been in response to an
earlier grievance by another colleague. [KC] had not even attended it. She was not warned
about any possible disciplinary action. She had been spoken to in order to get her account
and that was all. (Para 142.5).

22. Employers tend to disproportionately focus on the distress of those who may be causing
discrimination rather than that of those experiencing it.

In Shaikh, for example, a manager wrote of the claimant’s line manager:

The increased levels of stress and aggression she is having to endure since the first
Medical Imaging meeting from Samira Shaikh have had some very distressing
consequences to her physical and mental health… Following a meeting with Katie this
morning with her blessing as from today I wish Katie to be removed from any further
telephone/email or video conference interaction with Samira Shaikh.

Perpetrators, and alleged perpetrators of race discrimination, may be distressed when challenged.
But their distress is nothing compared to the distress experienced by BME staff who have often
experienced racism for a very long time and only challenged it when a last straw triggered their
raising a concern. BME staff distress may be increased by the process they experience when
raising their concern.

40
 Why concerns about racism are not heard… or acted on

23. NHS employers frequently allow cases to reach the courts, despite the evidence appearing
to straight forwardly benefit the litigant.

In all the cases considered, it is difficult to understand why early decisive action was not taken to
address the concerns raised. The corporate decision to fight each case – sometimes using
barristers who behaved brutally towards already traumatised staff – raises serious issues of
governance and a shoddy corporate attitude towards race discrimination. It is unclear what scrutiny
or peer review took place to check why the employer was defending each case at tribunal with the
risk of substantial financial cost, reputational damage, and undermining of relations with BME staff.

In Kweyama, for example, the Tribunal found:

The respondent subjected the claimant to race-related harassment by the following

unwanted conduct:

• On 9 February 2019 by a nurse saying to the claimant. "You need to get a pool of bleach
and bleach your skin so that you come back tomorrow white and the patients will be nice
to you";
• On 10 February 2019 by the same nurse who was overheard saying "I do not care let her
go into bleach her skin, I am sick and tired of people coming to work and said they are
not well”;
• On 22 February 2019 by the deputy lead nurse for offender care saying that she was
concerned about the claimant's mental health because some of the words used in her
statement to complain of the above race related harassment were worrying

The same Tribunal was presented with evidence that:

they (the detainees) “started calling me nigger, monkey, and started making monkey noises
and dog noises, demanding to come in at the same time.” (Para 36).

We have been told by some employers that they did try to settle cases before a tribunal, but a
serious obstacle was the refusal of the DHSC/Treasury to contemplate settlement in many cases.
That ought to act as an incentive to avoid ever being in a position when a Trust wants to settle but
cannot because of the Treasury.

Moreover, given that the average award for race discrimination cases currently stands at around
£6,000, the claimant’s legal costs, should they be represented, will often far outweigh their award for
damages. In turn, this essentially nullifies the award to the claimant beyond the personal vindication
they may receive for winning all or part of their claim.

Finally, and crucially, when cases are settled without the need for legal proceedings it is absolutely
crucial that what emerges is not covered up by a Compromise Agreement whose prime aim in
general is to protect the employer’s reputation, not ensure learning from the distress caused to the
person with whom the employer is settling.

41
 Too Hot to Handle?

6. WHAT DOES ALL THIS MEAN?

6.1 WHAT WE HAVE HEARD

As sections 4 and 5 show, racially minoritised staff face common responses when raising concerns
about race equality. These include:
• denial: in many of the cases outlined above, staff were subjected to ‘poor behaviours’ but
neither managers nor subsequent investigations felt they could name the race discrimination
that lay behind these behaviours
• reluctance or refusal to acknowledge race as an issue: connected with the above, when a
process or series of behaviours cause distress to a BME member of staff, employers tend to
resist acknowledging such treatment as race discrimination often, it seems, because of the
stigma attached. Employers, and those resisting allegations, may further confuse being a racist
with the existence of race discrimination
• minimising of harm: organisations go to great lengths to downplay the impact of racist
behaviours. As we note in section 5, the accumulation of apparently small acts of detriment –
such as microaggressions – can have a devasting impact on staff wellbeing. Yet many
organisations seem intent on viewing, and responding to, specific incidents as individual
allegations rather than a potential pattern of exclusion and discrimination
• a lack of empathy: an outcome of the above responses is that minoritised staff do not always
receive compassion and understanding when raising concerns. Indeed, it is more common they
are met with frustration, defensiveness, and exasperation (particularly, it seems, that they are
playing the race card ‘again’). Common to these responses is the focus on how the managers
feel at having to respond to race concerns, rather than a consideration of the emotions the
complainant may be experiencing

In addition to the above responses, there are some very common features of race-related
investigations:
• many employers set an unnecessarily high bar requiring staff to prove any allegation of
race discrimination was ‘racially motivated’: employers may accept there were aspects of
the treatment of staff which may have led the worker to be believe they were being racially
discriminated against, but then proceed to reject the claim because the complainant cannot
prove there was racially discriminatory intention
• tackling racism is seen as too difficult and so is avoided: White managers may be less
comfortable speaking with, or listening to, an individual of a different ‘race’ or background. This
can lead to a lack of rapport that, in turn, may impede the ability of investigators to obtain
information
• the process of raising a concern and the time an investigation takes deters staff from
raising a concern: concerns about the length of the process prompted by staff raising a race
discrimination concern is a common theme arising from the survey results in section 4 and the
review of tribunal cases in section 5. There is a widespread belief amongst staff raising

42
 Why concerns about racism are not heard… or acted on

concerns about racism that such delays may often be deliberate, sometimes to ‘time out’ tribunal
claims and sometimes to simply wear staff down
• staff lack confidence investigatory processes and other responses will be fair: this may be
prompted by a view that HR are not independent upholders of NHS values but are an arm of
management, that investigations are likely to be biased, and that senior managers who sit on
panel hearings (and appeals) may themselves be biased

As section 1.3 suggests, some of the above analysis is already known to the sector. As such, in the
next section we want to address a connected, but harder-to-answer, question: why do these
behaviours persist? What follows is an atypical form of analysis but one that we hope will stimulate
the curiosity of leaders in the NHS.

6.2 WHY DOES RACISM PERSIST?

An uncomfortable truth
It’s still common for people today to define racism exclusively as a deliberate act of discrimination
motivated by prejudice. This is misguided. Racism (also) operates through formal and informal
habits and norms that subtly and consistently disparage, limit, and dehumanise individuals who are
racialised as ‘not white’. In other words, racism is systemic. It operates as a system of
marginalisation and discrimination. Its effects can be seen in differential employment rates, ethnic
disparities in stop and search statistics, housing inequalities, and a range of other fields.

Central to the maintenance of racism as a system of marginalisation is the way particular people
(and their experiences) are racialised. Because white people are positioned outside of race (that is,
they very rarely have to think about their race), their experiences and outlooks are considered the
default. Mention of someone being white or of ‘whiteness’ as a concept is often seen as ‘woke’ or
politically incorrect, which tends to curtail the discussion. Other cultural norms, beliefs, and ways of
being are considered ‘different’, and an expectation is made that these individuals will adapt to a
system that privileges the status quo.

If this concept seems odd to you, consider whether you have ever heard of a white person having
‘lived experience’, or if colleagues have ever discussed the need to recruit a white person to a board
for the ‘unique’ perspective they might bring. Even in circumstances where a White British person
may be in a minority, there is rarely a need to find a White community representative because a
presumption of whiteness is built into the system.

Understanding the structural nature of racism allows us to move beyond simplistic notions, such as
the idea only ‘bad’ people can be racist or that racism is conscious dislike. But this does not make
dealing with allegations of racism any more palatable. Engaging with racism can invoke a range of
emotions – anger, resentment, fear, shame, sadness – which, together, can help explain why
concerns about race equality are evaded more often that they are confronted:
• exposing views of normality: we have a very narrowly defined view of who is normal. Issues
such as class, religion, disability, gender, and sexual orientation can all have an impact on who
fits in and who belongs. When we think of this in racial terms, not being seen as white often
means people are classified as ‘different’ or the ‘other’. This means it can be challenging for

43
 Too Hot to Handle?

majority white groups to understand the impact of racism or even ‘see’ racist behaviours.
Because racism is outside of the experience of these groups, allegations of racism can feel like
a personal attack when, in reality, they are actually a statement of how the system operates.
Often, responses from the system defend the hurt that people feel and seek to explain away
behaviours which they are uncomfortable with
• assumption of system fairness: not being able to see how bias operates is muddied by a
strong belief that the existing system is fair. When considering our success, we tend to focus on
the things we had control over (such as hard work and long hours of study) and assume this
experience is the same for other people. As a result, when managers are confronted with
concerns that, for example, a particular individual is not progressing at the same rate as their
colleagues, a natural response is to question the individual’s competence rather than face the
possibility the playing field is not fair. Acknowledging there are other factors that contribute to
success (a pushy mentor, access to secondments, supportive managers) and that the allocation
of these goods is not always equitable can be disorientating to those who have received those
benefits in the past
• operationalisation of stereotypes: challenging prevailing assumptions about BME staff
requires a shift in mindset. Note that the assumptions in question do not necessarily relate to
cultural or ethnic practices (although this can still be the case). Rather, they relate to the
expectations leaders have of BME staff. For example, it is not uncommon for BME senior
leaders to be undermined, unsupported, and over-scrutinized. Trusts’ lack of response to these
pressures can stem from assumptions that BME people are not a good fit for leadership: as
BME leaders’ pleas that they are being undermined and unsupported are dismissed as
incompetence, the assumption becomes a self-fulfilling prophecy. Many of the respondents to
this survey are BME leaders in bands 8 and above, and it is striking how many feel undermined
in their role
• fear of talking about race: people are still reluctant to talk about racism. Not only are leaders
within the health system fearful of saying the ‘wrong’ thing, they are, quite naturally, keen to
avoid the emotions discussion of racism generates: uncertainty, guilt, defensiveness, cognitive
dissonance. Holding on to this fear avoids discussion about our role in maintaining the status
quo and colludes with our feelings of incompetence. This silence hinders the early identification
of problems and inhibits collective efforts toward change

Outlining the aspects of people’s thinking that maintains structural racism is crucial to understanding
why it persists. This thinking has become part of our response mechanism. It also helps us
understand some of the limitations of past approaches to promoting race equality. Toolkits and
policies can only go so far. As this section hopefully shows, what is required is more concerted effort
on challenging mindsets and ways of thinking. What would such an approach look like? Well, first of
all, let us consider the story of the emperor’s new clothes…

The emperor’s new clothes

Some of us will know the story of the emperor’s new clothes. A couple of conmen are presented
before an emperor who has a taste for magnificent clothes. In an attempt to convince the emperor
that he will be purchasing the most magnificent set of clothes, the conmen convince him that they
will create an invisible suit that only those who are wise will be able to see. The emperor sets off in
his new invisible clothes in a procession through the city. Those who see the emperor go along with
the pretense because he is in power and because they do not want to appear to be inept or stupid.

44
 Why concerns about racism are not heard… or acted on

It is only when child blurts out that the emperor is wearing nothing at all that the emperor realises he
has been fooled and others begin to laugh.

What is the relationship between this story and work on race equality? Well, we are unfortunately
tied into a system which convinces itself and us that it is doing exactly what needs to be done on
issues of racism and that we can be satisfied that there is progress. Because we haven’t developed
enough understanding of the causes of racism and are not good at using evidence in our solutions
to address it, we are tied into a process that rewards our efforts that we enjoy and silences the
voices of those who counter these views.

Our interventions to address racism are often transactional in their nature; that is, their impact is
limited to surface-level change. The underlying causes of race discrimination – the unthinking norms
and assumptions by which we categorise people – remain untouched. Transactional activities are
interventions like celebrating Black History Month, hosting award ceremonies for diversity initiatives,
or providing mentoring programmes for BME staff. Many reasons are given for pursuing
transactional approaches, including a lack of time and resources. Most often, however, this
approach is tied into existing belief systems, and a tendency to rehearse the activities and
interventions which provide comfort by not upsetting the status quo. Activities such as these may
have individual benefit, but tend not to move the dial on the experience of BME staff as a whole.
And even if they provide an individual staff member with an initial boost, this tends to be short-lived.
The minoritised member of staff still has to navigate a system that is unchanged in its unfairness. In
the face of this, the sheen of the support that has been offered soon wears off.

Opposed to transactional activities is transformational work. Transformational activities aim to

change the culture of organisations by focusing on the way people interact with others.
Fundamental to this is engaging leaders so they are better able to identify and address systemic
racism within their organisation and leadership practice. But transformational change doesn’t stop
with leadership: the whole organisation becomes responsible for engaging in change.
Transformational practices deliberatively intend to engage white staff in exploring their beliefs and
behaviours. Crucially, the job of creating a more inclusive culture is not left solely to those who
experience racism.

Figure 9 over the page shows some of the differences between transactional and transformational
approaches. In the next section, we consider what this means in terms of organisations’ responses
to race equality claims.

6.3 SOME THOUGHTS ON WHAT ORGANISATIONS SHOULD DO NEXT

Organisations employ a range a techniques and tools to influence their culture (the behaviours and
ideology of ‘just’ cultures, for example, or values-based work, strategies on kindness, and inclusive
management). What is often not thought through, however, is how organisations should reinforce
adherence to the behaviours these initiatives are designed to promote. This is particularly important
given these strategies are often the primary means by which organisations choose to foster
inclusion (despite the equalities monitoring data they then receive).

45
 Too Hot to Handle?

Fig 9: Transactional vs transformational approaches

What success looks like

Transactional activities Limitations of this approach for transactional
activities

▪ increased
▪ collecting data
representation of
▪ increasing representation ▪ not intended to affect
racialised individuals
▪ revamping policies and procedures organisational culture
▪ the progress of
▪ increasing diverse representation in ▪ not intended to change
particular racialised
publications behaviours or relationships
individuals
▪ diverse representatives on panels or in between majority/minority
▪ assigning resources
advisory roles experiences.
based on
▪ changing menus, celebrating diverse ▪ responsibility for engagement
background/identity to
events lies mostly with groups who
fulfil particular gaps and
▪ information giving and outreach are racialised or those who
needs
▪ establishing support processes (e.g. already have power within the
▪ celebratory events
staff networks/mentoring) organisation
▪ awards/public
▪ putting in place board champions
recognition

What success looks like

Transformational activities Limitations of this approach for transformational
activities

▪ acknowledgement of systemic racism

within the system and organisation and ▪ how people experience
willingness to address it work and feel about
▪ leadership engagement so that leaders ▪ more disruptive and coming to work
are better able to sponsor and support challenging to the status quo ▪ increases people’s
this way of working ▪ ‘white’ people can feel understanding of the
▪ learning and self-reflection and attacked or made to feel more root causes of racism
assertive interrogation – especially by responsible and their ability to face
those who are not racialised – ‘white’ ▪ interventions can be criticised into systemic
people as promoting one group over challenges.
▪ understanding and responding to the another ▪ less ‘fear’ and improved
various forms racism, prejudices and ▪ it requires viewing success as confidence about how
biases learning, development, and we work with difference
▪ moving away from stereotypes behavioural change – and not ▪ can break down barriers
▪ relationship building just how an organisation looks and cliques within
▪ support to form new alliances and to ▪ it can take different types of organisations
have challenging conversations skills and resources ▪ reduction in
▪ support to work on hierarchies, ▪ it is a longer term strategy and discriminatory
behavioural norms and cultural requires commitment from behaviours and biases
practices which stifle authentic/ diverse leadership ▪ more likely to bring
contributions about sustainable
▪ reflection on leadership behaviours/ change
style and the consequences of these
© brap 2019

46
 Why concerns about racism are not heard… or acted on

As this survey has shown, everyday racism is too often accepted within NHS organisations.
Organisations will minimize, explain away, or outright deny the existence of behaviours that exclude
people. This means BME staff have to accept poor treatment for much longer than necessary and
action is only taken when the situation escalates. In these cases, the effectiveness of a behavioural
standard is constrained by an organisation’s unwillingness to uphold it. This is not to say that
regulating behaviour is easy, of course. Below, we offer some thoughts on how to go about this
tricky task.

6.3.1 ALL ABOUT CULTURE

‣ Talking about race

Time and time again people have said that they fear discussing race. They fear offending someone
and saying the wrong thing. There is a lack of competence (in understanding racism, how it plays
out, and how it is maintained) that which means we don’t believe we can confront it unless it is
staring us in the face – until we are ‘forced’ to confront it. Being able to talk about ‘race’ and in
particular covert racism (‘everyday racism’) helps people get past the belief that racism is an
unusual occurrence. It works the muscle of understanding, lessens the fear of discussing it, and
helps create conditions where racism is spotted, believed, and referred to more routinely.

Once organisations adopt a culture where racism is spoken about routinely and understood as
being maintained by organisational culture, they can create an early reporting system that can flag-
up opportunities for intervention. We already know that data on attrition, complaints, disciplinary,
and absenteeism and presentism rates are indicators that there is something that is amiss with
culture: the crucial step is acting on what this data is saying.

‣ Setting standards
NHS organisations are increasingly developing behavioural standards. These are not primarily
focused on racism but will include standards relevant to how we treat one another. As such, there is
an opportunity for behavioural standards to establish expectations of behaviours with regards to
‘race ’and the consequences of breaching them. Depending on the nature of the behaviour,
interventions should be improvement-focused, taking for example, the form of coaching for
individuals so they understand more about the impact of their behaviours or the use of nudge theory
as a means of improving performance and recognising how non-inclusive behaviours are
experienced. However, compliance-focused measures will be essential when responding to:
• overt racism whether by staff, contractors, visitors and patients
• discriminatory practices where there is a refusal to learn and change behaviours
• any action intended to victimise a staff member for raising concerns about racism

‣ Getting comfortable with staff speaking up

Employers, despite ongoing evidence to the contrary, must recognise organisations are
experienced very differently depending an individual’s role, position, and identity. The result of this
is that staff hesitate to make allegations of racial discrimination because there is good evidence that

47
 Too Hot to Handle?

they won’t be believed, and raising a complaint will make things worse or will be a waste of their
time. As such:
• Employers should appreciate that individual efforts to raise race discrimination are often costly
(psychologically, relationally, financially, and timewise) and therefore should be keen to employ
preventative measures, rather than waiting for individual members of staff to raise concerns
formally. (There is a particular irony in employers assuming raising complaints about racism is
easily done when the fear of talking about racism is so abundant.)
• When allegations of race discrimination are made, it prompts an intense level of defensiveness:
• complaints are often not taken seriously. The concern may be dismissed as a
‘communication problem’ or a ‘misunderstanding’ or the complainant is told the person who
they believe is responsible ‘didn’t mean it ’or it was ‘completely out of character’. Worse still,
they themselves may be regarded as ‘playing the race card, raising racism as a defence
• even when detriment is shown to have taken place there is a great reluctance to accept race
discrimination has occurred and instead it is often categorised as ‘poor behaviour’ or ‘poor
management practice’

‣ Adopting a coherent anti-racist strategy

Anti-racism is about proactively intervening in the system of racism, which means boards and senior
leadership teams need to acquire an understanding of systemic discrimination and racism. This will
enable them be more curious about the organisations they lead and the impact of systemic racism
on staff and patients. Anti-racist practice is deliberate in its involvement of all people whatever their
ethnic background. It will also enable the board to understand how organisational culture can help
maintain discriminatory practices (and allow white people to opt out) and why BME staff may be
reluctant to raise concerns.
• The board should be able to model discussions on race discrimination and openly acknowledge
and discuss their collective and personal responsibilities to tackle race discrimination.
• Leaders at all levels must recognise how their behaviours may contribute to creating a culture
where race discrimination is minimised or dismissed and where their own lack of understanding
about racism can lead them to be overly defensive.
• Boards should above all create environments that support an anti-racist approach by both
stressing its benefits and also the consequences of discriminatory behaviours.

In addition, boards, in their role in establishing a culture freer from racism, must ensure there is
learning from all cases including:
• noticing whether there is a greater level of ease in discussing race and racism
• reviewing all investigations and hearings for learning – including recognising whether issues
could have been addressed more informally
• reviewing investigations to ensure they are in line with an anti-racism policy
• gaining feedback on the process from the staff who raised concerns
• sharing learning from the case reviews across the whole organisation, but in particular HR staff
and managers

48
 Why concerns about racism are not heard… or acted on

‣ Being proactive
Employers should think more critically about the environment they create and foster – including their
own inability to speak confidently and directly about racism within their culture. As part of their
adherence to the Equality Act 2010, organisations should also take seriously their obligation to
prevent discrimination from happening in the first place.

Leaders should be supported to proactively address race discrimination. This means more than
reviewing data and listening to the ‘lived experience’ of staff: It also means understanding how their
organisation’s normative culture can make it unsafe for minoritised staff (and patients) to speak up.
The board and senior leaders need to be to be seen to praise anti-racist behaviour and reward
standers (allies) who intervene and stand up for others.
• Organisations must use evidence to inform the strategies they devise to tackle disparities in
disciplinary, appraisal, recruitment, complaint, and bullying rates. If an organisation doesn’t
know why what it plans to do has a reasonable likelihood of achieving what it wants, it should
ask itself why it is adopting that particular course of action. This is, after all, what we would do in
other aspects of healthcare.
• Organisations should use hard and soft intelligence to address concerns at the earliest possible
stage (rather than wait until a beleaguered member of staff plucks up the courage to raise a
concern)
• All staff, especially leaders, should be encouraged to intervene early so that when issues arise,
they are taken seriously, acted upon promptly, and in a way that builds confidence that racism is
seen as a serious issue. Organisations should recognise that toolkits have limited value here
and that staff need practical support /modelling to effectively intervene.
• HR and managers must be immersed in development opportunities which help them hold
conversations about recognising and responding to racism – recognising that trust is a
precondition of effective conversations.

‣ Commissioning the right development

Training may help understand bias and discrimination but in isolation won’t prevent discrimination or
flawed responses to discrimination concerns. Bias is often positioned as a term to disguise racism
and racist behaviours, and can normalise and minimise its impact. An understanding of racism and
how it impacts our beliefs and behaviours is essential to sustainable progress. But whilst good
development can improve cognitive understanding and create a willingness and determination to
act, accountability and debiasing of processes will also then be essential to ensure leaders can act
on their understanding.

Employers need to think about commissioning ‘development’ and not ‘training’ (and be clear about
the distinction and about what they have commissioned). Common flaws with training opportunities
are: they are often not lengthy enough; they are not engaging; and they do not support staff to gain
a more critical understanding of race and racism. Organisations should be prepared for staff to feel
disrupted as a consequence of any development. Simply having training that endorses beliefs about
those who are 'different’ and peculiarising their behaviours will not create the conditions that enable
staff to challenge systemic racism, especially within themselves. Even when good quality

49
 Too Hot to Handle?

development is commissioned, employers must be aware that there is a limit to what can be
achieved through programmes of this type.

Cultures that don’t permit racism to be discussed and challenged often limit the ability of individuals
to put in place what they have learnt. With this in mind we recommend:
• Development should help participants understand what types of behaviour are discriminatory
and by implication the types of behaviours which are not.
• Organisations should encourage staff to put in practice what they have learnt.
• The most effective development opportunities will be tailored to specific roles (e.g. for boards,
leadership, HR, investigators, panel members); designed to develop skill and confidence; and,
most importantly, able to provide clarity about what racist behaviours are and how they are
maintained.
• Organisations should have a range of measures in place to sanction staff who exhibit racist
behaviours. If not, development opportunities to identify and call out racism will be wasted.
• Organisations should be clear about what racist behaviours are – and not confuse intent with
impact. An act or omission can be an act of race discrimination whether or not it was intended to
be.

6.3.2 HR RESPONSIBILITY
HR teams have specific responsibilities to prevent race discrimination and address specific
concerns raised. The role of HR, OD, and EDI staff should not simply be to manage risks as they
arise but to seek to improve culture to prevent discrimination and promote equity, diversity, and
inclusion. Here are as several key recommendations for the HR community.

‣ Developing the right individual and collective capabilities

HR, OD, and EDI staff must be enabled to develop a professionally based expertise, which draws
on an understanding of the evidence-base of EDI initiatives and specifically on race discrimination.
That expertise must include an understanding of institutional racism and how it is maintained, the
dynamics of power, what is normalised and ‘othered’, how biases are enacted and the role of racism
in institutional decision making. They should also recognise not only ‘what works’, but also how
when positioning interventions, the burden of change is often placed onto those who experience
discrimination in the first place.

All managers, but especially HR colleagues, must become problem-sensing and not comfort-
seeking. This means being curious about what lies behind patterns of detriment even where
individual detriments may not be obviously driven by race discrimination.
• Every HR, OD and EDI staff member should be expected to flag potential concerns about
racism without waiting for individual staff to do so.
• There should be peer review of race cases before, during, and after informal and formal
processes with HR staff involved. If possible, reviews should include staff who have
investigation training and/or training on racism and anti-racism. This should be consistently
applied, whatever the ethnicity of the individuals involved.

50
 Why concerns about racism are not heard… or acted on

• Ensure that case investigators are appropriately competent to undertake any investigation
concerning race (competence is not automatically linked with the background of the
investigator!).

‣ Consider carefully the motivation for complaints

HR do not always acknowledge the possibility that complaints about staff subjected to discrimination
may be manufactured either to justify discrimination or as acts of retaliation. Unfortunately, NHS
staff raising concerns of race discrimination are commonly subjected to detriment as a result of
doing so.

HR staff and senior managers should assume that detriment is a possibility, take it seriously, and
make it clear to all those who might be responsible that causing such detriment will be grounds for
gross misconduct proceedings.

‣ Better use of Freedom to Speak Up Guardians

Organisations should recognise that complaints raised through a Guardian are a reflection of the
(lack of) trust in, and the credibility of, other existing arrangements. As such boards should actively
discuss how information from Freedom to Speak Up Guardians, in combination with other
information the trust collects, tells a story about its culture and is acted on in a timely and effective
manner.

Relying on a network of Freedom to Speak Up Guardians will not, in itself, be an effective means of
encouraging staff to raise concerns: Trusts must ensure Guardians are supported and have
credibility with staff on issues of equality, especially on race.
• Guardians should have training in understanding systemic racism and in noticing how patterns
of discrimination are often overlooked and reproduced. This might not just be helpful in cases of
‘race’, but also in recognising how power is distributed and maintained and its impact on those
who voices are marginalised within cultural practices.
• The Guardian could be an active part of the organisation’s strategy to win the trust of BME staff.
• The Board must make it clear that managers who seek to dissuade staff from raising concerns
about race or impede Guardians from doing so, or who seek to victimise staff as a result of
raising concerns will face gross misconduct proceedings.

‣ Assuring policies and procedures

Every employer has a range of policies that are relevant to considerations of race discrimination.
Most will have been equality impact assessed, but these assessments have frequently been tick-
box exercises.

Employers should ensure relevant policies, procedures and reporting structures have been
reviewed to understand how they are used and whether they can be triangulated to deliver

51
 Too Hot to Handle?

assurance. In many cases, there is little evidence that policies offer this level of assurance.
Expertise in this area should be sought.

‣ Take notice of the warning signs

We have proposed that organisations should be proactive in their promotion of interventions that
support dialogue and increase understanding of race and racism. There is a growing evidence
based to suggest that more fluency will create less fear and that improving understanding and
recognition of racism will create competence in being able to deal with racist behaviours more
informally. What does this look like in practice?

Even if there is an organisational determination to tackle racism, there can still be a tension
between staff and organisations on the most appropriate approach. Informal approaches may seem
more attractive but may be ineffective and undermine taking matters further. Formal approaches
may be necessary but can become entrenched, lengthy, and ineffective. In light of this, employers
should explore how they can intervene without waiting for an individual to raise a concern, perhaps
by asking whether there is sufficient evidence that there is a problem that needs to be addressed.
This is how organisations approach patient safety concerns.

Responding informally may often (but not always) be best. Mediation can be useful, but only if
parties are willing – and it is important to note that the outcomes of mediation do not always require
individuals to acknowledge racist behaviours that may have been at play. In fact, the result can
sometimes create conditions where racist behaviours are masked as ‘misunderstandings’; giving the
impression that there was smoke without fire. In addition, mediation can often be ineffective when
there is a power imbalance between the parties involved. For these reasons, mediation should not
be mandated in policy and should be considered carefully as a response to race discrimination
claims, and if it is used the meditators deployed should have skill and experience of dealing with this
issue.

If informal approaches are to be utilized organisations will need:

• people who have an excellent understanding of racism especially in its covert form
• people who are supportive, but are also good at handling challenging conversations – about
‘race’
• clear anti-racist commitments in place which specify behaviours required of their staff (including
recognition of covert behaviours/microaggressions) in line with the explicit values of anti-racism

Organisations that are clear about the existence of systemic racism and their commitment to
tackling it won’t be taken by surprise when it crops up in the workplace. They can begin to hold
themselves and their staff accountable for behaviours which contravene their expectations. And
they will be more willing to explore a lack of reluctance in naming racism as a cause for poor
behaviours.

Based on the above, organisations should consider:

• Informal approaches may work but only if they are used at an early stage and within an
organisation that makes absolutely clear its commitment to anti-racism. (a commitment to anti-
racism means that we recognise that racism is inculcated into our society).

52
 Why concerns about racism are not heard… or acted on

• Informal approaches mean coaching staff in behaviours which are in line with anti-racist
commitments – not waiting for infringes to occur.
• Informal approaches require therefore, staff who understand their own positionality, are skilled in
their communication and understand of racism, and are serious about tackling racism.
• Staff may lack confidence in informal processes, if difficult issues are not discussed and
addressed. They should not be expected to engage in mediation any more than we would
expect someone to sit down with a sexual harasser for mediation. Staff may also be reluctant to
raise matters formally for fear the process will drag on, will not be effective, and may make
things worse. They may also fear that an informal ‘resolution’ may be a fudge that does not
addressed the underlying issues and prevent recurrence.
• On the other hand, staff may well be reluctant to lodge formal complaints since their experience
will be that such process are frequently drawn out, and may make matters worse (as this survey
has shown, the risk of retaliation is real). However, staff who wish to keep open the possibility of
recourse to Tribunals will need to lodge their concerns more formally or risk being unable to
access legal recourse.
• Staff could be offered the option of placing their concerns formally on the record as a prompt to
management action without being expected to necessarily lodge a formal grievance. The
organisation could then use the available evidence to intervene e.g. to prevent discriminatory job
appointments and development opportunities, or intervening whether there is evidence of
sustained micro-aggressions.
• Organisations should always start by assuming concerns about racism are raised in good faith
and then decide (after discussion) how to address them.
• Beware the temptation to reclassify such concerns under other headings (e.g., bullying) as an
alternative.
• If the complainant is a contract worker of any kind, or is leaving employment, they are entitled to
have their complaint addressed.
• Make clear to relevant managers and staff that any attempt to impede or victimise a complainant
will be regarded as potential gross misconduct.
• Staff considering raising concerns will be hesitant as they fear victimisation, ostracism, or are
skeptical of being heard fairly and effectively. The employer should have a dedicated trained
member of staff to offer support to complainants.

There is a wider challenge for the NHS. There is no national framework for addressing these issues,
where an individual trust is self-evidently not capable of addressing racism. Though ICBs for
example, have been alerted to the EHRC inspecting them, and though the CQC have improved
their framework for inspecting on discrimination, and though NHS England has a series of standards
on equality, there remains no coherent framework of accountability that enables or requires ICBs,
the CQC or NHJS England to intervene.

Where this does currently happen (and it does sometimes) it relies heavily on senior individuals
being prepared to intervene. When that happens that are few options for effective specialist support
available, nor is there any coherent system for sharing evidenced good practice in this field. Both
shortcomings need to be addressed.

53
 Too Hot to Handle?

‣ Improving the case management and administration of concerns

Both employment tribunals and this survey have identified sustained shortcomings in the
administration and management of concerns raised about race discrimination. The administrative
and managerial shortcomings identified in race discrimination cases are likely to apply to other
employment issues, notably whistleblowing and other discrimination cases, and so some
recommended actions include:
• HR need to review the administrative staff and IT/case management systems to give confidence
that administrative mistakes are minimised including whether outcomes from investigations or
hearings are acted on in a timely manner.
• When local management deny allegations of racism, the triangulation of available evidence
should enable an organisation to determine whether to consider taking take the matter further
This would include granular data from staff surveys, WRES data and other relevant data
analyzed by ethnicity e.g. turnover, sickness, exit interviews.
• HR should beware of allocating race cases to BME staff in the belief that this will impress
tribunals or in the belief that such staff are necessarily the appropriate person – whether as
adviser, investigator or panel member unless those staff have the appropriate level of
competence.
• When BME HR staff are allocated to race cases, peer support may be necessary to ensure
there is psychological safety for that HR staff member to reach the appropriate decisions.
• HR teams should ensure they model the behaviours on racial equity they expect of other teams

‣ Understanding what the case law says

Employment tribunals have repeatedly identified misunderstandings of race discrimination case law
by NHS employers, so a key and self-evident recommendation points to organisations
understanding these lessons.
• Employers and staff need to be confident that HR staff understand the key principles of case law
in discrimination with specific reference to race discrimination and how to apply them.
• HR staff must be competent and confident is sharing their knowledge with managers they advise
including with managers at an equivalent or higher grade who may disagree with the advice
being given and may seek to pull rank. HR staff should receive explicit senior management
support if line managers seek to ignore their advice and should be equipped and supported to
deal with any detriment that arise as a result of escalating their concern.
• Those who respond initially (formally or informally) at an early stage to allegations of race
discrimination must be trained to identify relevant contextual factors and/or be required to
access advice from those who are. This should be incorporated into all management training.
• Systematic analysis of internal processes should be initiated to identify possible triggers for
racial bias (e.g., in recruitment, career progression, appraisal, disciplinary processes, and so on)

54
 Why concerns about racism are not heard… or acted on

‣ Fulfilling your duty of care

Staff subject to any form of race discrimination are likely to be distressed. Their employer has a duty
of care to both offer support and ensure the processes do not unduly impact their health and
wellbeing. That should include offering wellbeing support.

Staff alleged to be responsible in some way for alleged racism may be very upset. An employer also
has a duty of care to these staff but should not disproportionately focus on the distress of those who
may be causing discrimination rather than that of those experiencing it. Some specific
recommendations here include:
• Staff alleged to have been party to direct or indirect discrimination or victimisation may be
distressed when this is called out. Any support offered, wherever possible, should be focused on
them owning responsibility for their acts and omissions.
• Staff making allegations should be cautioned about confusing direct racism with covert (indirect)
racism. These distinctions are important and can help to clarify the process going forward.
• Research shows conclusively that staff subjected to race discrimination – whether direct or
indirect – experience significant adverse health impact, both physically and mentally. They
should be offered support both in respect of such health impact arising from the original alleged
detriment and support during whatever process follows.

‣ Don’t litigate when the evidence is clear

It is difficult to understand why an NHS employer would ever allow cases in which the evidence
seems so straightforwardly to the benefit of the litigant to reach the Courts. Wherever possible race
discrimination should be dealt with as early as possibly, proactively and with clear outcomes to
tackle root causes and present repetition.

Employer decision-making where litigation is considered should consider the following questions:
• do you understand racism?
• have the correct tests/understanding of racism applied in reaching a decision?
• in whose interest is it to proceed to an employment tribunal hearing?
• if there is a need for further evidence – including recalling witnesses – has that been done?
• does the panel outcome not only address any discrimination that occurred but how to prevent
any recurrence of the specific issue?
• are there clear criteria for checking the process and outcomes at each stage (pre-investigation
(if one needed), investigation, initial hearing, appeal, decisions post appeal)?

For staff, a failure to seriously resolve the issues raised, to address possible repetition and prevent
retaliation will be crucial. Fudged settlements are not acceptable.

‣ Accountability
Employers need to have more in the tank than believing that transactional measures demonstrate
an understanding of racism. Measures of numbers of BME staff on boards and at ‘higher levels’ in
the organisation can be false positives.

55
 Too Hot to Handle?

‣ Engaging external consultants

NHS employers should not employ external consultants to undertake reviews of culture or carry out
investigations unless they have a proven track record of understanding race discrimination and how
to challenge it. Our recommendations here include:
• Be especially cautious about using lawyers who may understand the law but have little
understanding of the culture – and focus on individual cases at the expense of wider contextual
and cultural considerations.
• There will be a temptation to expect external consultants of any kind to ‘find’ what an employer
wanted them to find and that may be both picked up by and influence how some external
consultants and lawyers work.
• Wherever possible employers should develop internal expertise and capacity and possibly
partner with other organisations to “loan” independent investigators where possible.
• Where external support is required insist on scrutiny of the consultants track record and
knowledge of race discrimination and how to tackle it.

6.4 A FINAL WORD

In producing this report, we hope to have created a persuasive argument for organisations and
leaders to think critically and act in line with the evidence of what will create more impact in
addressing racial discrimination. The confusion about what to do and how progress is judged and
supported remains real, with many organisations treading water in relation to their progress.

The NHS is a microcosm of our society – and a really important one. If we can create the conditions
of change within this beloved institution, we can possibly lead a way through the quagmire of
approaches that exist to manage our emotional response to racism but which do very little to
address the racist experiences of staff and patients.

56
 Why concerns about racism are not heard… or acted on

APPENDIX A: SURVEY RESPONDENT

PROFILE
In total, 1,327 people responded to the to the survey between May and July 2023.

‣ Employment status
93.3% of respondents are employed by the NHS. 3.4% are contract workers, and the remaining
3.3% work as bank or agency workers.

‣ Agenda for Change Banding

23.8% of respondents work in bands 5 and below. 44.1% are in bands 8a and above. 15.6% are in
band 6, with a further 16.6% in band 7 (figure 10).

Fig 10: Survey respondents by AfC band

20%
18% 16.6%
15.6%
16%
14.3%
14% 13.4%

12%
10% 9.2%
8.0%
8%
5.8%
6% 4.7%
3.9%
4% 2.5% 2.8% 3.1%

2%
0.2%
0%
1 2 3 4 5 6 7 8a 8b 8c 8d 9 VSM

‣ Training location
70.4% of respondents received their training in the UK; 25.4% abroad. (For 4.3% of respondents the
question was not a binary choice, either because they had not received training or were trained in
multiple locations)

‣ Occupational group
A quarter (25.6%) of respondents are nurses or midwives. 20.6% are AHPs/Healthcare Scientists;
15.6% in general management; and 12.5% nursing or healthcare assistants (figure 11).

57
 Too Hot to Handle?

Fig 11: Survey respondents by occupational grouping

Registered Nurses and Midwives 25.6%

Allied Health Professionals/ Healthcare Scientists/ Scientific and Technical 20.6%

General Management 15.6%

Nursing or Healthcare Assistants 12.5%

Other 11.9%

Medical and Dental 11.5%

Commissioning 2.7%

Public Health 1.7%

Wider Healthcare Team 1.2%

Social Care 0.8%

‣ Ethnicity
In our analysis, we have organised data in broad ethnic categories based on commonly used ethnic
categorisations found in, for example, the 2021 Census and the Workforce Race Equality Standard
(WRES). We acknowledge that these categories have limitations and do not fully capture individual
experiences. However, they provide a means of comparison with existing data.

Over a third (37.9%) of respondents are from Asian/Asian British backgrounds. 37.2% are from
Black/Black British backgrounds (fig 12).

Fig 12: Survey respondents by ethnic category (broad)

40% 37.9% 37.2%

35%

30%

25%

20%

15%
10.5%
10%
4.1% 5.3% 5.1%
5%

0%
Asian or Black or Multiple Other ethnic White British White Other
Asian British Black British heritage group

58
 Why concerns about racism are not heard… or acted on

APPENDIX B: LESSONS FOR TRADE

UNIONS
This report has been written to support NHS organisations to better understand and respond to
instances of race discrimination. However, there are also important lessons for trade unions.

Some trade union officials and local representatives are exemplary in their understanding, advice,
and representation of BME staff who raise allegations of racism. However, as responses to this
survey show, it is important not to assume someone raising concerns is receiving good advice from
their trade union representative. It was clear from our survey that many staff lack confidence in trade
unions when tackling racism. Common failings included:
• misunderstanding the law – especially in respect of whether it was necessary to show the
person discriminating was ‘motivated’ by racism
• failing to consider methodically the context in which the alleged racism took place, including the
extent to which other members might have similar concerns
• advising members to reach a compromise that fails to address the causes of what is alleged to
have occurred
• poor preparation, a lack of attention to detail, and a lack of preparation for any meeting or
hearing – often (but certainly not always) driven by a heavy workload
• referring a member to a member of the BME network rather than a local representative initially
• seeking to address a potentially complex issue via a volunteer local representative rather than a
paid official
• possibly most crucially, failing to be curious about the root causes behind an individual case and
whether it is the tip of a much wider problem

Whilst in some cases (Michalek and Browne, for example) representation was clear and effective, in
other instances the advice given was clearly wrong (including initially on Cox).

One concern is the application of what trade unions call the 51% rule applied by almost all unions to
any case before it can be supported in legal proceedings. This is based upon a judgement as to
whether the member has a 51% chance or better of succeeding in court. This criterion is open to
subjective judgements and may be influenced by the poor preparation and representation at
employer level.

Our recommendations for trade unions include:

• Trade unions should consider how they can be more effective in tackling racism at source rather
than primarily responding to individual cases, where possible working with HR, OD, and EDI
staff. They need to become more preventative and proactive beyond media campaigns.
• Trade union-employed officials need to ensure they have at least the same level of legal and
cultural knowledge as the HR staff they are dealing with. Trade unions should work jointly with

59
 Too Hot to Handle?

employers to encourage informal resolution of allegations but not at the expense of cases where
the allegations are exceptionally serious, where there is a pattern of discrimination, or where
there is a refusal by those responsible to accept responsibly and work to improve the culture.
• Trade unions should ensure they engage properly with BME staff within their local branches or
networks.
• Trade unions might consider whether a better test than the standard 51% test might be whether
the member has demonstrated there is a case to answer. If so, the member can reasonably
expect representation where needed.

60
 Why concerns about racism are not heard… or acted on

APPENDIX C: LIST OF EMPLOYMENT

TRIBUNAL CASES REFERENCED
1. ‘Michalak v Mid-Yorkshire Hospitals NHS Trust and others’ (2011) Leeds Employment Tribunal,
case 1810815/2008. Practical Law. Available from:
https://uk.practicallaw.thomsonreuters.com/Link/Document/Blob/Idf0a8e7d59b911e498db8b09b4f043e0.pdf?targetType=
PLC-multimedia&originationContext=document&transitionType=DocumentImage&uniqueId=30e402b2-35d8-4c1a-936f-
402e37540019&ppcid=c3bfbd1051f84fa18980f4415f2de93a&contextData=(sc.DocLink)&comp=pluk.

2. ‘Central Manchester University Hospitals NHS Foundation Trust v Browne’ (2012) Employment
Appeal Tribunal, case UKEAT/0294/11/CEA. Employment Cases Update. Available from:
https://employmentcasesupdate.co.uk/content/central-manchester-university-hospitals-nhs-foundation-trust-v-browne-
ukeat-0294-11-cea.a31eb7787ea04783abe690687151a2c8.htm.

3. ‘Mr R Hastings v Kings College Hospital NHS Foundation Trust’ (2016) Employment Tribunal
Services, case 2300394/2016. GOV.UK. Available from:
https://www.gov.uk/employment-tribunal-decisions/mr-r-hastings-v-kings-college-hospital-nhs-foundation-trust-2300394-
2016.

4. ‘Ms A Cox v NHS Commissioning Board’ (2023) Manchester Employment Tribunal, cases
2415350/2020 and 2401365/2021. GOV.UK. Available from:
www.gov.uk/employment-tribunal-decisions/ms-a-cox-v-nhs-commissioning-board-operating-as-nhs-england-slash-nhs-
improvement-2415350-slash-2020-and-2401365-slash-2021.

5. ‘Ms A Z Kweyama v Central and North West London NHS Foundation Trust’ (2023) Watford
Tribunal Hearing Centre, case 3319570/2019. GOV.UK. Available from:
www.gov.uk/employment-tribunal-decisions/ms-a-z-kweyama-v-central-and-north-west-london-nhs-foundation-trust-
3319570-slash-2019.

6. ‘Ms O Akinmeji v East Kent University NHS Trust’ (2023) Ashford Tribunal Hearing Centre, case
2303204/2020. GOV.UK. Available from:
www.gov.uk/employment-tribunal-decisions/ms-o-akinmeji-v-east-kent-university-nhs-trust-2303204-slash-2020.

7. ‘Ms P Mntonintshi and Ms U Jama v Barking Havering and Redbridge University Hospital NHS Trust
and Ms C Beck’ (2023) East London Tribunal Hearing Centre, cases 3202401/2020 and others.
Available from:
www.gov.uk/employment-tribunal-decisions/ms-p-mntonintshi-and-ms-u-jama-v-barking-havering-and-redbridge-
university-hospital-nhs-trust-and-ms-c-beck-3202401-slash-2020-and-others.

8. ‘Ms S Shaikh v Moorfields Eye Hospital NHS Foundation Trust’ (2023) Central London Employment
Tribunal, case 2200854/2021. GOV.UK. Available from:
www.gov.uk/employment-tribunal-decisions/ms-s-shaikh-v-moorfields-eye-hospital-nhs-foundation-trust-2200854-slash-
2021

61
 Too Hot to Handle?

REFERENCES

Adebowale, V. and Rao, M. (2020). It’s time to act on racism in the NHS. British Medical
Journal,368(m568). Available from: https://doi.org/10.1136/bmj.m568.

Ahlberg, B. M., Hamed, S., Thapar-Björkert, S. and Bradby, H. (2019). Invisibility of racism in
the global neoliberal era: implications for researching racism in healthcare. Frontiers in
Sociology, 4(61). Available from: https://doi.org/10.3389/fsoc.2019.00061.

Alexis, O., Vydelingum, V. and Robbins, I. (2007). Engaging with a new reality: experiences of
overseas minority ethnic nurses in the NHS. Journal of Clinical Nursing, 16, pp.2221-
2228.

Atewologun, D. and Kline, R. (2019). Fair to refer? Reducing disproportionality in fitness to

practise concerns reported to the GMC, General Medical Council. Available from:
https://www.gmc-uk.org/-/media/documents/fair-to-refer-report_pdf-79011677.pdf
[accessed 19 December 2023].

Bonilla-Silva, E. (2013). Racism without racists: color-blind racism and the persistence of racial
inequality in America. 4th ed. Lanham, MD: Rowman and Littlefield.

Brathwaite, B. (2018). Black, Asian and minority ethnic female nurses: colonialism, power and
racism. British Journal of Nursing, 27(5), pp.254-258. Available from:
https://doi.org/10.12968/bjon.2018.27.5.254.

Braveman, P. A., Arkin, E., Proctor, D., Kauh, T. and Holm, N. (2022). Systemic and structural
racism: definitions, examples, health damages, and approaches to dismantling. Health
affairs, 41(2), pp.171-178. Available from: https://doi.org/10.1377/hlthaff.2021.01394.

British Medical Association (2022). Racism in medicine. Available from:

https://www.bma.org.uk/media/5746/bma-racism-in-medicine-survey-report-15-june-
2022.pdf.

Carter, M., Thompson, N., Crampton, P., Morrow, G., Burford, B., Gray, C., & Illing, J. (2013).
Workplace bullying in the UK NHS: a questionnaire and interview study on prevalence,
impact and barriers to reporting. BMJ Open, 3(6), Article
e002628. https://doi.org/10.1136/bmjopen-2013-002628

Crenshaw, K. (1989). Demarginalizing the intersection of race and sex: a black feminist critique of
antidiscrimination doctrine, feminist theory and antiracist politics. University of Chicago
Legal Forum, 1989(1), pp.139-167. Available from:
https://chicagounbound.uchicago.edu/uclf/vol1989/iss1/8.

62
 Why concerns about racism are not heard… or acted on

Danso, A. and Danso, Y. (2021). The complexities of race and health. Future Healthcare Journal,
8(1), pp.22-27. Available from: https://doi.org/10.7861/fhj.2020-0225.

Devakumar, D., Selvarajah, S., Shannon, G., Muraya, K., Lasoye, S., Corona, S., Paradies, Y.,
Abubakar, I. and Achiume, E. T. (2020). Racism, the public health crisis we can no
longer ignore. Lancet, 395(10242), pp. e112-e113. Available from:
https://doi.org/10.1016/S0140-6736(20)31371-4.

Dhaliwal, S. and McKay, S. (2008). The work-life experiences of black nurses in the UK: a report
for the Royal College of Nursing. Working Lives Research Institute. Available from:
http://dx.doi.org/10.13140/RG.2.2.29910.45123.

Estacio, E. V. and Saidy-Khan, S. (2014). Experiences of racial microaggression among migrant

nurses in the United Kingdom. Global Qualitative Nursing Research, 1. Available from:
https://doi.org/10.1177/2333393614532618.

Francis, Robert (2015) Report on the Freedom to Speak Up review [online]. Available from:
https://webarchive.nationalarchives.gov.uk/ukgwa/20150218150512/http://freedomtospea
kup.org.uk/the-report/

Fricker, Miranda (2007). Epistemic injustice: power and the ethics of knowing. New York: Oxford
University Press.

Hassen, N., Lofters, A., Michael, S., Mall, A., Pinto, A.D. and Rackal, J. (2021). Implementing
anti-racism interventions in healthcare settings: a scoping review. International Journal of
Environmental Research and Public Health, 18(6), 2993. Available from:
https://doi.org/10.3390/ijerph18062993.

House of Commons Health Committee (2013) After Francis: making a difference Third Report of
Session 2013–14 [online]. Available at:
https://publications.parliament.uk/pa/cm201314/cmselect/cmhealth/657/657.pdf [

Khan, K. S. (2022). Racial discrimination against minority healthcare workers in women’s health.
Women, 2(2), pp.88-92. Available from: https://doi.org/10.3390/women2020010.

Kline R. (2022) Paradigm lost? Reflections on the effectiveness of NHS approaches to improving
employment relations. BMJ Leader. Available from: doi:10.1136/ leader-2022-000729

Kline, R. and Somra, G. (2021). Difference matters: the impact of ethnicity on speaking up.
National Guardian’s Office. Available from: https://nationalguardian.org.uk/wp-
content/uploads/2021/09/Difference_Matters.pdf.

Kmietowicz, Z. (2020). Are medical schools turning a blind eye to racism? British Medical Journal,
368(m420). Available from: https://doi.org/10.1136/bmj.m420.

63
 Too Hot to Handle?

Levy, N. (2017). Am I a racist? Implicit bias and the ascription of racism. The Philosophical
Quarterly, 67(268), pp.534-551. Available from: https://doi.org/10.1093/pq/pqw070.

Lewis, D. (2013) Resolving Whistleblowing Disputes in the Public Interest: Is Tribunal Adjudication
the Best that Can be Offered?, Industrial Law Journal, Volume 42, Issue 1, March 2013,
Pages 35–53. Available from: https://doi.org/10.1093/indlaw/dwt001

Likupe, G. (2013). The skills and brain drain: what nurses say. Journal of Clinical Nursing, 22(9-10),
pp.1372-1381. Available from: https://doi.org/10.1111/j.1365-2702.2012.04242.x.

Moore, W. L. (2020). The mechanisms of white space(s). American Behavioral Scientist, 64(14),
pp. 1946-1960. Available from: https://doi.org/10.1177/0002764220975080.

Nguyen, T. T., Criss, S., Michaels, E. K., Cross, R. I., Michaels, J. S., Dwivedi, P., Huang, D.,
Hsu, E., Mukhija, K., Nguyen, L. H., Yardi, I., Allen, A. M., Nguyen, Q. C. and Gee, G.
C. (2021). Progress and push-back: how the killings of Ahmaud Arbery, Breonna Taylor,
and George Floyd impacted public discourse on race and racism on Twitter. SSM -
Population Health, 15(100922). Available from:
https://doi.org/10.1016%2Fj.ssmph.2021.100922.

National Guardians Office (2023) Fear and futility: what does the staff survey tell us about
speaking up in the NHS? [online]. Available from:
https://nationalguardian.org.uk/2023/06/08/fear-and-futility/

NHS England (2023). NHS equality, diversity, and inclusion improvement plan [online]. Available
from: https://www.england.nhs.uk/long-read/nhs-equality-diversity-and-inclusion-
improvement-plan/#_High_Impact_Actions.

NHS England (2022). The guide for the NHS on freedom to speak up [online]. Available from:
https://www.england.nhs.uk/publication/the-guide-for-the-nhs-on-freedom-to-speak-up/

NHS Workforce Race Equality Standard (WRES). (2023). 2022 Data analysis report for NHS
trusts [online]. Available from: https://www.england.nhs.uk/publication/nhs-workforce-race-
equality-standard-2022/.

Nursing Standard (2020) Is a ‘culture of keeping quiet and working hard’ costing Filipino nurses
their lives? 21 April 2020. Available from: https://rcni.com/nursing-
standard/newsroom/news/a-culture-of-keeping-quiet-and-working-hard-costing-filipino-
nurses-their-lives-160221

Priest, N., Esmail, A., Kline, R., Rao, M., Coghill, Y. and Williams, D.R. (2015). Promoting
equality for ethnic minority NHS staff—what works? British Medical Journal, 351(h3297).
Available from: https://doi.org/10.1136/bmj.h3297.

64
 Why concerns about racism are not heard… or acted on

Reitz, M and Higgins, J (2020) Speaking truth to power: why leaders cannot hear what they need
to hear. BMJ Leader 2021;5:270-273. Available from: https://doi.org/10.1136/leader-2020-
000394

Rimmer, A. (2020). NHS trusts are given new powers to bar racist patients. British Medical Journal,
368(m644). Available from: https://doi.org/10.1136/bmj.m644.

Roberson, Q. (2023). Understanding racism in the workplace. Journal of Applied Psychology,

108(2), pp.179-182. Available from: https://doi.org/10.1037/apl0001079.

Smart, A. (2021). Protecting UK healthcare workers from patient racism. Sociology of Health &
Illness, 43(8), pp.1826-1830. Available from: https://doi.org/10.1111/1467-9566.13279.

Smith, P., Allan, H., Henry, L., Larsen, J. and Mackintosh, M. (2006). Valuing and recognising
the talents of a diverse healthcare workforce: report from the REOH study: researching
equal opportunities for overseas-trained nurses and other healthcare professionals.
European Institute of Health and Medical Sciences, University of Surrey, the Open
University and the Royal College of Nursing.

Wim, V; Cathy, J; and West, F (2013) Whistleblowing: the inside story - a study of the experiences
of 1,000 whistleblowers. Project Report. Public Concern at Work, London, UK

West, E., Nayar, S. and Taskila, T. (2017). The progress and outcomes of Black and Minority
Ethnic (BME) nurses and midwives through the Nursing and Midwifery Council's “Fitness
to Practise” process: final report. Nursing and Midwifery Council.
https://www.nmc.org.uk/globalassets/sitedocuments/other-publications/bme-nurses--
midwives-ftp-research-report.pdf.

Woodhead, C., Stoll, N., Harwood, H., TIDES Study Team, Alexis, O. and Hatch, S. L. (2022).
“They created a team of almost entirely the people who work and are like them": a
qualitative study of organisational culture and racialized inequalities among healthcare
staff. Sociology of Health & Illness, 44(2), pp. 267-289. Available from:
https://doi.org/10.1111/1467-9566.13414.

Wu, F; Dixon-Woods, M; Aveling, E; Campbell, A; Willars, J; Tarrant, C; Bates, D; Dankers, C;

Mitchell, I; Pronovost, P; Martin, G (2021) The role of the informal and formal
organisation in voice about concerns in healthcare: A qualitative interview study. Social
Science & Medicine, Volume 280. Available from:
https://doi.org/10.1016/j.socscimed.2021.114050.

65
AND

ROGER KLINE

© brap and Kline 2024

Roger Kline is Research Fellow at Middlesex University Business School. www.rogerkline.co.uk

brap is a charity transforming the way we think and do equality. brap have been changing organisations,
communities, and places for 25 years.
www.brap.org.uk

Registered Charity Number: 1115990 | UK Registered Company Number: 03693499