Case study: Barts Health NHS Trust

Introduction

Barts Health NHS Trust (BHT) is a group model acute and community trust covering five different hospitals across East London. The trust has developed an organisational approach to equity, for both their staff and patients, underpinned by their 'WeBelong' strategy. Data from their ethnicity pay gap is considered as part of action planning and evaluation of interventions.

BHT has a diverse workforce with 60% of their staff from an ethnic minority background. The trust's gender and ethnicity pay gap report published in May 2023 revealed they have a median ethnicity pay gap (EPG) of 18.2% and a mean ethnicity pay gap of 18.3%. These figures have remained static since the previous year's published report. Whilst exact workforce make up may differ across each of their hospitals, collectively their EPG is in line with findings from their Workforce Race Equality Standard (WRES) report, which shows that ethnic minority colleagues are underrepresented in upper pay quartiles and amongst the very senior managers (VSM).

BHT is able to disaggregate their data due to a combination of high ethnic diversity among their workforce and high levels of ethnicity self-declaration within the Electronic Staff Record (ESR) system and within the NHS Staff Survey. This has enabled them to consider the experiences of individual groups, pinpoint where inequality exists, and take targeted action based on variation between different ethnic groups. For example, the data shows that Bangladeshi colleagues consistently have the lowest median pay. As a result BHT have developed a range of programmes to support local residents who are heavily represented in the lower pay quartiles into employment within BHT and worked with the Mayor of London's 'Design Labs' programme to make this work as effectively as possible.

Interventions

• The 'WeBelong' strategy, which was enabled by insights from their ethnicity pay gap reporting and provides a strategic approach to tackling identified disparities.
• Having a dedicated equality, diversity and inclusion (EDI) forum at each hospital.
• Future VSM programme for staff in Agenda for Change (AfC) bands 8c to 9, to help people enter senior and executive roles. The programme includes a commitment to ensure 50% of the cohort is from an ethnic minority background.
• Talent management framework which focuses on:
  
  - Encouraging colleagues from underrepresented groups in leadership roles to have conversations about their career aspirations at their appraisals, using the 'Scope for Growth' model. These colleagues are then supported with guidance, examples of available opportunities and how to match these to their career goals. They are also directed to development opportunities and advice such as stretch assignments and apprenticeships and can undertake experiential learning initiatives.
  
  - Succession planning involves examining senior roles that are predominantly held by white men, recognising underrepresentation of both women and ethnic minority staff within senior leadership, and having transparent conversations with these postholders about their future plans, whether that be retirement or relocation. This provides visibility within the organisation about when certain roles will be available, allowing people who may want to take on those roles adequate time to prepare.
  
  - Creating a talent pool through the establishment of a talent pipeline, and a clear matching process for vacancies. The trust will invest in these individuals to realise greater potential through a process where each hospital executive board reviews upcoming opportunities and matches them to staff within the talent pool. This programme is set to launch in autumn 2024.
  
  - Career development workshops for colleagues in AfC bands 5 to 7, where the majority of the ethnic minority workforce is currently concentrated. These workshops cover essential skills such as CV writing, interview techniques, and guidance on advancing to band 8 roles. They have provided the trust with insights into colleagues' motivations and future aspirations. Every senior leader at VSM level is a mentor or coach for people in AfC bands 5 to 7 and have career conversations with their mentees.

• Compassionate leadership training to upskill managers and leaders at all levels to embrace diversity as a step to eradicate bias around recruitment.
• Delivery of cultural intelligence, allyship and active bystander training through a 'train the trainer' model. The model upskills both existing experienced trainers with the trust to deliver new content, and staff seeking to widen and develop their training skills, whilst also providing a more financially sustainable delivery model which supports wider organisational rollout of the content.
• Application of a data led approach to enable prioritisation of interventions to individual business areas. BHT uses employee relations data triangulated with other sources of insight, such as Freedom to Speak Up reporting, staff survey data or organisational development interventions, to target areas where there are reports of bullying and harassment to enable timely and more focused centralised support.

Impact

As a result of these interventions, the representation of ethnic minority staff in AfC band 8A and above roles has increased by 8% since WeBelong was originally published, with 40% of ethnic minority staff in band 8a and above roles. This progress can be attributed to the development efforts focused on band 5 to 7 progression.

An ethnically diverse recruitment panel is now appointed to every AfC band 8a and above interview, including an inclusion ambassador (IA). The IA doesn't necessarily have to be from an ethnic minority, but they will have undergone specialised training which includes unconscious bias training and how to have challenging but constructive conversations if they recognise unfairness in the process. Monitoring of outcomes has shown an increased likelihood of an ethnic minority candidate being appointed when an IA is present on the panel compared to when one is not.

Although it may be difficult to draw a line directly from these interventions to impact on staff and patients, tracking WRES metrics and producing detailed WRES reports over the last five years has shown that the programme of work is having a positive impact on WRES metrics. Impact on the EPG is also being monitored but it is anticipated that positive impact will take longer to filter through to the data.

Challenges

The trust operates as a group model across five distinct hospitals which creates complexities when implementing standardised interventions. Strategies and initiatives are developed at the group level and then implemented by the management structures of each hospital. However, the pace of implementation and priorities varies across hospitals, which can affect the equity of the schemes across the group. Additionally, each hospital has variation in both workforce demographics and, as individual specialist sites, the opportunities available for promotion. These factors, along with different organisational cultures within each hospital can influence the ethnicity pay gap.

The 'train the trainer' method for commissioning EDI training within the trust has proven to be a successful and cost-effective alternative to hiring external trainers. However, challenges arise in maintaining the trained cohorts due to poor retention, and attractive employment opportunities outside the organisation. For those who remain, it has been important to find incentives beyond monetary rewards to encourage continued participation in training.

We are being curious about what the data is telling us, trying to do the triangulation with other indicators and coming up with plans and interventions that are more sustainable and practical.

Delvir Mehet    Group deputy director of people

The trust has found that colleagues face challenges progressing beyond AfC pay band 8a once they have progressed from AfC pay bands 5 to 7 and struggle to reach to AfC pay band 9 and VSM levels. This issue is reflected in the 3% reduction in ethnic minority representation in their upper pay quartile, decreasing from 44% in March 2022 to 41% in March 2023 (Barts Health, 2023a). Their VSM development programme is one initiative created to address this.

Learnings for the board

• EPG data should be used in triangulation with other indicators to inform the 'whole picture'. Board members must retain a sense of curiosity when examining the data and seek to understand the underlying causes of any disparity and use these insights to identify and develop sustainable interventions.
• Disaggregation of data is key to building engagement and taking targeted actions. For group models, having group level data alone will not create either the desired impacts or provide the required buy in for the different hospitals within the group. Both the data and actions must be more tailored to a more localised level.
• Progressing racial equity should be a standing item on the agenda to maintain a focus on delivery against any related actions.
• Having actively engaged executive sponsors of staff networks can assist the board to stay focused and develop their understanding of lived experience.
• Language is important but should not delay action. Begin the work and you will be able to evolve the language and definitions over time.
• Having a board level director for EDI helps to link all work together.
• Results against this agenda take time and require the board to remain resilient and focused, especially if you don't get the results you want initially.

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