Speaker1: [00:00:00] White people think that race has nothing to do with them. Hope is invented every day. If we can't do it within our NHS, there's something wrong. People believe race is real. 

Speaker3: [00:00:12] Voices of Care. The healthcare podcast.

Speaker2: [00:00:15] Professor Wilmington. Joy, welcome to Voices of Care and thank you for giving us your time today. I wanted to start because your work in equality and racism and tackling racism is so important. I think it was James Baldwin who said that we can't change everything that we face, but we'll change nothing if we don't face it. 2024 is, I think, called on all of us, health care and society to face the spectre of racism.

Speaker1: [00:00:41] Yeah, it's been it's been a bit of a rock n roll year, to put it mildly. And I think for, for many people, especially quite recently with the riots that happened towards the end of July and August, we were out with organisations and online with people who had been really traumatised by those experiences. Actually, many organisations were really proactive. They asked staff to work from home where they could. They had listening sessions for staff so that people could really talk about their concerns. But it did remind people of the 70s. It reminded people of a place that we thought we would never be again.

Speaker2: [00:01:25] Absolutely. And tell us a little bit about the work around brap because this is tackling this issue head on. You're Chief Executive, I think the mission is to think about equalities differently and do that differently. 

Speaker1: [00:01:39] Well, funny enough you're interviewing me in our 25th year, so we're 25 years old and it is a congratulatory year because for a charity that has quite an edgy mission. So our mission is to think more critically about the way that we do equality. So I think in how we've written it. It's to think about and transform the equality landscape. And that mission really came about because much of what we do in the name of equality and equity has good intentions but doesn't land well. And we wanted to really think about how we disrupt that relationship between intention and impact. So we think critically about the use of evidence. So we think about innovation. We think about organisations and how they run, how they perform, how do we deal with issues of culture. So there's lots of disciplines in terms of how we do our work that we kind of dive into them so that we can be more applicable to the organisations and the people that we partner with in the pursuit of equity, really.

Speaker2: [00:02:56] Now it's a broad mission. You work in many different sectors, but focusing on the NHS and healthcare. Just tell a little bit about your journey. I know you're a visiting professor at Middlesex University Business School, but you've worked with the NHS and many trusts. I think you were previously in Birmingham and Solihull and now, of course, with Oxford University.

Speaker1: [00:03:14] Yeah, so I mean we do work with lots of different types of organisations. So charity, large charities like Oxfam recently started working with UNICEF this year. But the NHS we've worked with for a good 15 years now, and initially that work started off quite slowly. And it has really gained traction because I think the NHS is a big system, as you know, it has a very large percentage of staff who are racialised as black or minority ethnic and also quite a lot of migrant workers. And it has challenges in terms of how does that all land to support its mission in delivering excellent patient care? And so it has internal challenges. So if you look at some of the statistics that the NHS has produced year upon year you are less likely to be appointed in some roles if you're black or minority ethnic. You're not going to have such a good time. You don't believe that your organisation provides you with the same equality of opportunities as it does with white staff. So there's lots of data that says, you know what internally in the organisation, this is not somewhere that delivers as well as it could do. And I think the NHS is recognising that, it's waking up to it.

Speaker2: [00:04:48] And I think September, this year was seminal for many different reasons. The Darzi report, Wes Streeting highlighting three shifts that need to happen. But there was also a report from the Health Services Safety Investigation Board that said that temporary workers found it hard to speak out, and that was particularly the case from people who identified as minorities. Now, this chimes with your work, and I do want to honour the fact that you've been recognised with an MBE back in 2019 for your work in this field. You produced a report, I think, with Roger Clyne back in February. "Too hot to handle". Can you just unpack that for us? Because that looked at how tackling racism when it was raised perhaps had a big impact on the workforce.

Speaker1: [00:05:36] Yeah. I mean, "Too hot to handle", it was about a year in the making, actually. And as its title suggests, what we were trying to convey was how issues of race and racism were quite routinely taken off the table or were diminished in their priority. And, I mean, one of the first things people say is, well, why race? And what about other things? But because we listen to that kind of narrative, it means that we haven't faced enough attention on race. And I mean, I often say in 2024, why is it that we find it really difficult to talk about race and racism, given the diversity not only within our organisations but within our society, and it's because we're not practiced at it. It's because we think, you know, there's lots of fear. There's lots of belief that you're going to be judged. This idea of, you know, you've got to say the right word at the right time. Lots of reasons why people think it is too hot to handle. And what the report tried to do was to bring together. It was a bit of a Bermuda Triangle moment, actually.

Speaker1: [00:06:49] So we did a survey to NHS staff to ask, well, what happens when you raise race and racism? And that survey was completed by over 1500 people. And overall, they said it was really difficult to raise race and racism in ways that could be heard and to be progressed proactively by their trusts. We also brought together a range of tribunal findings, including the quite high-profile Michelle Cox case, and those tribunal findings correlated with the things that people were experiencing in their organisations. And then finally, we brought together some evidence of what we think will work in terms of addressing race and racism. So there's a lot packed in to that report, and we've been really pleased how many people have taken it up. I mean, I've done presentation after presentation, I'm sure Roger has as well. But rather than it being something that's presented on and then becomes a kind of thing to prop up a bookshelf, we wanted it to be acted upon. We wanted people to take notice of the things that the report is saying that we need to do to really kind of address racism.

Speaker2: [00:08:05] No. And I think that's a fabulous distinction in terms of a report and actually doing something about it. I was shocked to see that. I think some of the stats, only 5% of the respondents said that the concerns were even taken seriously, and over 40%, nearly 42%, left their roles because of their treatment. And that's shocking when you look at the vacancies. NHS Providers, Sir Julian Hartley's been on our podcast. I think they issued an analysis of the report, and I think you referenced it in your open letter to Wes Streeting, welcoming him to his new role, but saying that actually racism needs to be faced. It's embedded.

Speaker1: [00:08:41] It is. And I think we find that really hard. We like to project a view of our society. It's over, it's done. We're never going to go back to the times that we've had previously. And of course, the murder of George Floyd and the national and worldwide concern about racism that that murder catalysed meant that many organisations were facing into this again. And I also think, unfortunately, the riots that we've had recently in August, it serves as a reminder that what we're dealing with is not as below the surface as we think. We only have to scratch it a little bit and it pops out. And I think that's really what patients have been saying. And also staff from black and minority ethnic backgrounds, have been saying that this stuff is a daily experience. It's not an exception. It's rather the norm, I think. Yeah.

Speaker2: [00:09:43] And it's been around for a very long time. I mean, the race action plan, I think was in 2004. Roger Clyne wrote the Snowy White Peaks report, I think a decade ago, if my memory is right, 2014, showing the under-representation of people from minorities at senior level. Before we talk about solutions, because I think that's going to be really important. You've done some amazing work there. I just want to tarry for a moment, one cohort, if I may. The medical profession, I think over 40% are from black minority ethnic within the NHS, but are severely under-represented. Now "Why are we still here?", as a neighbour report, I think you published back in 2022. It's quite astounding that in that cohort, I think your report found quite significant underrepresentation at senior levels. 

Speaker1: [00:10:33] Yeah, I mean, there are lots of reasons for that. And we did quite a lot of work directly with doctors to ask their opinions about what was going on. In medical careers, they're quite complex. And there are certain, what would you call them? Things that you have to gallop over, certain things that you actually have to do. And unfortunately for some doctors who are from black and minority ethnic backgrounds. If you don't get exposure to the right things at the right time, it makes for a kind of challenge in terms of moving up into the higher leadership positions within organisations and trusts. And many doctors explained to us some of the kind of things that happen routinely that they are excluded from, and also what that means in terms of the issues of self-confidence, visibility, ability to network. Unfortunately, these sorts of things still make a difference in terms of people seeing you as leadership material. And if you don't have access to that, you often don't get seen as someone who can move up into the upper echelons of the trust, really. 

Speaker2: [00:11:55] And I think, thank you for putting that into context. I mean, the NHS, I mean, the WRES data, NHS staff survey from 2024. Some positive things, but still record numbers of people from black minority ethnic backgrounds exposed to discrimination from patients, not representation at the board. I think the NHS have issued their Equalities, Diversity, and Inclusion Improvement Plan in 2023. Let's see how that pans out. I think there's an intention behind it. What I'd like to do for the rest of the podcast is you've identified these problems. They've been here for a long time and how do we solve them? So no pressure. How do we get... because you come across with a theory of change. But I thought I'd begin, because you're on record as saying we need to move from a mindset of saying we're not racist to being anti-racist, which there's a lot underneath. That concept of race is complex. So I just wanted to set the scene. Before we talk about specific actions that you've taken at brap to help address this challenge.

Speaker1: [00:12:57] I think it's really difficult for this organisation and for this society actually in larger terms, to recognise the difference between not racist and anti-racist. So racism, as you have so rightly kind of said and alluded to, is a made-up thing really based on this idea that there are different races. And it's really challenging sometimes for people to hear this. But we invented race and we invented race so we could exploit groups of people. And part of the invention led to the exploitation, because if we could say that there were groups of humans who were inferior, and in this case inferior to those people who were white, then it justified us being able to enslave them, to be able to take them away from their lands and their properties and their families, to be able to take things... 

Speaker2: [00:13:58] In the name of eugenics.

Speaker1: [00:13:59] Yeah, absolutely. And to put together false scientific data to enable us to do all of that. And that feels such a long time ago, and it feels so long in our past that what we tend not to realise is that we're still operating on the basis is that we do have different races. And because of that, we believe the trope that goes with it. So we believe that there are different sets of abilities based on how you look physically. Now, all of that is well documented. It's well evidenced, but what does it mean in the here and now. And in the here and now, it means that we're still acting on those stereotypes and biases. So one of the things that we talk about when we talk about being anti-racist is really recognising some of the false, recognising that race is nothing more than a social construct.

Speaker2: [00:14:54] Operating from a predicate which isn't valid.

Speaker1: [00:14:55] It's an idea. Race is an idea, and we've given that idea meaning. So you've got to dial back from that idea. And quite often the thing that I find interesting is when I go into organisations and I talk about anti-racism, people believe race is real.

Speaker2: [00:15:10] Right.

Speaker1: [00:15:11] Now, if you believe race is real, when you look at your stats, when you look at the evidence base, you kind of think, oh, there's nothing really that wrong with it,

Speaker2: [00:15:20] Because you're the lens through which you're looking at life is what you're saying. We need to unpack that and take those myopic glasses off. 

Speaker1: [00:15:28] Absolutely. Because you're looking at things in a way that you have been taught and socialised is right and true.

Speaker2: [00:15:36] The shift in language is going to be really important.

Speaker1: [00:15:40] The shift in language, the shift in belief, really.

Speaker2: [00:15:43] And that makes for uncomfortable work, doesn't it?

Speaker1: [00:15:45] It makes for very uncomfortable work. I mean, I did a bit of a piece with a colleague of mine, Simon Hewitt from The King's Fund, looking at some of the six principles of anti-racism. And I think the first one is race is a social construct. If you then believe that race is a social construct, then you have to look seriously at how you use race. How do you racialise groups of people? How do you continue to make it? How do you use your power to unmake it? What's the role of white people in this work? Because often white people feel that they're excluded from race because they don't see themselves as being a race. They see themselves as being normal. So there's lots of work. I won't go through the six principles, actually, but there's lots of work to do to be anti-racist. It's hard work.

Speaker2: [00:16:37] To bring everyone under the tent as it were.

Speaker1: [00:16:37] Yeah. It's different. Anti-racism is different from racial equity work. 

Speaker2: [00:16:42] Right, that's interesting.

Speaker1: [00:16:44] People don't understand that. So people think that when they say they're being anti-racist, it just means doing what they've done or harder.

Speaker2: [00:16:50] An action plan that's been now issued.

Speaker1: [00:16:52] What we're saying is anti-racism is a different set of thinking, a different set of activities.

Speaker2: [00:16:58] Taking race off the table.

Speaker1: [00:16:59] Yes.

Speaker2: [00:17:00] Effectively. And that's a big shift.

Speaker1: [00:17:02] It is.

Speaker2: [00:17:02] And I wanted just to unpack just a bit more around that, because I think some of the work that you've done talks about moving, the change that we want to see. And let's be clear about the benefits. I mean, the evidence, as I understand it and you're the expert, is that when you have a diverse group of people working in an organisation in healthcare, the more they are valued, that will lead to better patient outcomes. I think that's been established. So we have to move the dial you said from individuals to looking at things systemically. What does that mean? Because systemic can sometimes throw people off as quite a complex set of factors.

Speaker1: [00:17:41] I think systemically, if I was going to explain this as simply as I can, it would mean a set of beliefs that we tend not to question at an organisational or societal level. So we tend not to question the belief in different races. We tend not to question the fact that we always need to do outreach for communities that we're surrounded with, you know? So it's not like we're going out looking for those communities. I mean, some of the places that we have now in cities in this country are so diverse, it's going to be hard for you to get out of your house and not run into anybody that's not diverse. But we're still using very much the same mindset, the same tools, the same approaches to the planning and delivery of services. And to address that systemically, we need to disrupt some of the thinking and beliefs that those services were predicated upon.

Speaker2: [00:18:39] And I think some of the work that we've done at brap with NHS trusts, and you've worked with them across the country, you also make the difference between, look, the actions you can take can be transactional or they can be transformative. What does that mean? Can you unpack that? Because that sounds like quite an important distinction. 

Speaker1: [00:18:55] It is a hugely important distinction. And in Too Hot to Handle, we've put together quite a simple table of transactional. Transactional activities in the main are tend to be the things that we favour because we can count them. We've got two of these, three of those, four of those percentage increases. But as you said earlier on in the podcast, the data that we collect, it kind of goes up and down. And sometimes we're not able to actually understand the difference that we make or what has made the difference. With transformative activities, you're really looking at root causes. So instead of addressing the symptoms of racism, you're kind of trying to take racism off the table. You're trying to say, what is it that we need to do to address root causes? And of course, in health, we understand that quite well. But what we're not really used to doing is applying those principles to a problem like racism.

Speaker2: [00:19:52] So an example of that would be transformational.

Speaker1: [00:19:55] So if we're looking at, for example, the numbers of disproportionate numbers of people of colour, people who are racialised as black or brown within mental health services, for example. Some of the transactional approach might be to, you know, look at greater representation in the health service from people from those backgrounds. A transformational approach would be saying, actually, do we need to be doing something different for these folks. Because you might be changing what people look like, but unless you change what they think and what they do, they're going to have the same outcomes. 

Speaker2: [00:20:43] Representation is not simply the answer.

Speaker1: [00:20:44] Representation is not simply the answer. So you can have somebody that looks the part that says the same old thing. So you know, in mental health, for example, if I was just to continue with that example, you'd kind of need a really different way of thinking of your psychological interventions, you'd need to recognise racism, perhaps as a key ingredient of mental health wellbeing. So many times because I'm also training to be a psychotherapist. So many times people have not been able to talk to anyone from a psychotherapeutic background about racism because it's not understood, it's not taught. So there's lots of things that we do which try to address the symptoms, try to address what people currently experience without stopping the things that are causing those symptoms. And really that's the difference between transactional and transformational.

Speaker2: [00:21:40] Thank you. Because that's really important. As you say it's not a surface level because it all change in a positive way is to be applauded. But you're taking it at a deeper level. And one final point, and it's quite a big one that you've tackled before in your work, is that this change, whether it's language, whether it's the mindset, whether it's transactional or transformational is going to require some courageous leadership. And I know that's work that you've done. I mean, what you're saying, I think if we can't be optimistic, we can be prisoners of hope at least. Can you sort of explain how important that courageous. You've got to stand up for something I think you've said before.

Speaker1: [00:22:21] Yeah. It's interesting you started with a Baldwin quote because another quote from him is "hope is invented every day". And I couldn't do this work if I wasn't hopeful. And we have been working with leaders of all backgrounds, but intentionally working with leaders who are white. And part of the reason we've been working with white leaders is that, as I said earlier, white people think that race has nothing to do with them because that's what they're socialised in believing. How can you lead an organisation that is extremely diverse and complex if you don't think you've got the skills to lead the organisation because you've got a large percentage of people of colour? So we're dissuading people of that. And what we're saying is that good 21st-century leadership means you have to be able to talk about race. You need to be understanding of racism. You need to challenge race and racism, not just out there, but in yourself, because we're all socialised into this. And by all I mean also people who are black or brown, it's really difficult to grow up in this country or even in the world without ingesting in some way ideas about race and racism. So we're doing lots of work, courageous, brave, difficult work with leaders so they understand this stuff so they can be confident. They can be competent so that they recognise this is a skill set and something they can understand and learn, and not something innate, because that's what we've got to get away from. We've got to get away from this idea that I know more about racism because I look a certain way and my experience doesn't necessarily mean I have all the answers to it. 

Speaker2: [00:24:03] Absolutely. So what you're saying, if you were to give some advice to leaders as we enter, what's going to be a new NHS ten-year plan, etc., tackling this is going to be fundamental, as you said in your open letter. So I guess the leadership piece or in fact the advice to everybody. The journey begins with self. 

Speaker1: [00:24:24] The journey begins with self because no one can make you confident. You've got to be confident. You've got to do the work to understand why you're not confident, and you've got to do the work and the learning to try stuff out. It's the same. I mean, a colleague of mine uses this really good analogy of babies walking. And you know when a baby starts to walk, it falls down. And because the baby falls down, you don't say, oh, you fell down, you can't walk anymore. I'll put you in the pushchair forever. And it's the same with race. It's complicated, it's complex. It's ever-changing. We're not going to get it right all the time. Even I don't get it right all the time. But you need to get up. You need to do it because we've never been as diverse and we've never been as complex as a society. This is a kind of learning edge for everybody here. And it's exciting. So, yeah, it's horrible. It's depressing. It's, you know, it's all of that stuff when you're on the receiving end of racism. And I don't mean to be, you know, I don't know, ridiculing of, of those experiences, but what I do mean is there's some huge opportunity to apply leadership in a way that it's never been applied before. I mean, think about the kind of organisations we could create if what you came to work and experience was great inclusive work, fantastic teamwork where people addressed racism in themselves, where they challenged things so you didn't have to do it all the time where you felt comfortable, authentic, all of those things. 

Speaker2: [00:26:08] Safe enough to take risks?

Speaker1: [00:26:09] Yeah. Yeah. I mean, it just not only makes for a great teamwork environment, but it also makes for much better patient care. So this is a fantastic opportunity, but you can't address it through a tool kit. You can't address it by listening to a podcast, even though it might be really good. But you need to address it by doing the work and by continuing to do the work. 

Speaker2: [00:26:32] It's a very exciting vision. I think your mission at brap is to have a more equitable society confident in its diversity. So you seem to be brimming with that despite the challenges. 

Speaker1: [00:26:43] This is an opportunity. You know, you can't. I mean, people are so wonderful in all of their guises, and it's just really unfortunate that we don't remember how we can create some of that opportunity if we become better than ourselves, really. And I think this is the opportunity that we have to be the thing. And the NHS. I mean, think about the mission of the NHS. If we can't do it within our NHS, there's something wrong. We really have to think about how we create these organisations and how we create places where people and patients can be served to the best of their abilities. 

Speaker2: [00:27:25] On that very, very hopeful, and inspiring note. Professor Joy Warmington, thank you very much for your time.

Speaker1: [00:27:30] Thank you very much.

Speaker2: [00:27:31] It's been a pleasure. If you've enjoyed this episode of Voices of Care, please like, follow, or subscribe wherever you receive your podcasts. And if you want to learn more about how we're turning the dial on health and social care debate, please visit newcrosshealthcare.com/voicesofcare. In the meantime, I'm Suhail Mirza. Thank you very much for joining us today, and I look forward to seeing you on the next episode.

Speaker3: [00:27:52] Voices of Care. The healthcare podcast.