Belonging in the NHS
Dorset County Hospital NHS Foundation Trust (DCH) have made equality, diversity, and inclusion central to their approach to both staffing and delivering services. They are keenly aware that this is an ever-evolving area in which there will always be more to do and are clear that the trust is very much on a journey rather than an organisation which has found all the answers. As Dawn Harvey, chief people officer, puts it: "We have a plan, we're moving forward, we're seeing some real positivity, we're also getting many bumps in the road, it's foggy at times, and we are evolving."
DCH and the wider South West region is increasingly dependent on people of colour to deliver services to patients. While the population demographic is only 3% minority ethnic, DCH’s staff are 11% minority ethnic – and the trust has estimated that this will increase to 24% by 2025. Dawn Harvey is clear that "we know the links between the staff experience and patient experience", and improving both is why the trust is so keen to ensure that all staff are included, heard and able to contribute in their workplace.
In 2019, the Workforce Race Equality Standard (WRES) indicators showed that DCH was in an overall positive position when it came to staff inclusion. However, the trust’s executive team felt that this was unlikely to reflect the lived experience of minority ethnic, disabled, and LGBTQ+ staff. The trust board requested a series of staff listening events to test if this theory was true. These were ran by the organisational development team, and the findings confirmed that staff from minority groups were indeed having a worse experience than the WRES data suggested.
The board was clear that this was unacceptable, and that an environment of psychological safety needed to be created in order for staff to feel empowered to share their experiences and change to be enacted. The findings from the listening events proved that previous approaches to equality, diversity, and inclusion that the trust had engaged in (which focused on unconscious bias and privilege training) were not going far enough. Staff needed to be given the knowledge and skills to lead in different ways, rather than to focus on single issue actions, and wider cultural change was required.
Setting a course for leadership naturally starts from the top, so the trust board began what Dawn terms “a journey of self-discovery”, specifically in order to better understand the ways in which racism impacts the lived experience of people of colour. The board committed a significant amount of time to get this off the ground. They undertook two full away days with an overnight stay, led by external facilitators Eden Charles and Ben Fuchs, who challenged their understanding of themselves and society. Eden and Ben focused on moving mindsets away from single issue approaches such as the makeup of interview panels, and towards wider questions – what is the history of racism? What have we been led to believe? How do we change the way we see the world? Board members were encouraged to share their own stories and show vulnerability to connect at a human level. This was followed by other colleagues from minority communities sharing their stories with the board, to support for a deeper understanding of race inequity, racism, and wider inequalities.
The board were galvanised and able to understand issues of racism and inequality in a more immediate way. They were clear on the fact that for DCH to realise ICS ambitions to drive change on health inequalities, the organisation must celebrate diversity and put inclusion at its core. Operationally, this shift in attitude meant that equality, diversity, and inclusion was no longer an HR-led initiative, but a board commitment to improving their organisation. This board buy-in, Dawn says, has been the key enabler of the trust's ensuing work on cultural change.
Transforming people practices
In addition to refreshing the trust’s strategy to align with the ICS commitment to reduce health inequalities and improve social value, Dawn’s team started work to overhaul people practices – specifically around recruitment, appraisals, talent management, performance management, and disciplinary action. Feedback on the trust’s culture, and lived experiences from staff, was collated and used to inform the redesigns sponsored by DCH’s transforming people practices programme.
As well being informed by various data collections, the trust’s staff networks co-designed these new practices, which were each given sponsors from the executive team. DCH runs networks for minority ethnic staff, members of the LGBTQ+ community, staff with disabilities or long-term health conditions, and staff who are carers. This meant that the executive team were hearing directly from staff in minority groups about what they thought change needed to look like from the outset. In overview, these changes are currently:
- Guides created to support managers and candidates at the application, interview and offer stage.
- Values based assessment introduced for HCAs, instead of traditional interviews. This is a key part of DCH’s work as an anchor institution for values and opportunities for employment, and they are working on rolling this out more widely.
- Recruitments champions introduced to interview panels in targeted areas for senior role (band 7 and above), to support impartiality and challenge bias. Support for panels to be receptive to the champions’ feedback is crucial for success in this area.
Appraisal and succession planning
- Board papers regarding the staff appraisal process explicitly state that "the quality of the conversation is more important than the paperwork".
- The principal of "know your people" is paramount. The aim of the appraisal process is for staff to have an annual conversation focusing on reflections, performance and behaviours against objectives, career aspirations, all supported by more regular check-ins. These conversations must start with wellbeing.
- Simplified appraisal paperwork which enables productive conversations, to ensure staff feel listened to, valued and supported.
- Appraisal training for managers is under review, with sessions and resources created for appraisees to help them recognise the part they play in the appraisal process, how to prepare and to clarify alternative routes for the appraisal conversation if staff feel they are not being heard and supported.
- Early conversations with new staff to find out more about their values, career aspirations and strengths. Career drop ins for staff with the trust's education team have been instated to support this.
Just and learning culture in performance management and disciplinary policy
- This is an area of continual improvement, with a primary focus on achieving a culture that gives staff the confidence to speak out safely and resolve issues quickly and informally.
- The lived disciplinary experiences of staff were compiled into a report, and used as pre-reading for the inclusive leadership development programme (more detail on this initiative is below).
- Disciplinary policy being transformed from process-centred to people-centred, based on work undertaken by Mersey Care, the revised policy from Cornwall Partnership and the findings of DCH's lived experience exercise.
The transforming people practices programme is very much ongoing, and Dawn envisages its work as evolving and improving in perpetuity.
DCH also developed an inclusive leadership development programme, which began in June 2021 for all staff in band 7 and above. Dawn stated that the focus of this programme is "seeing differently, responding differently, leading differently". By disrupting culture, creating conditions for vulnerability and connection, and using redesigned people practices, the trust is giving its staff a solid foundation for leading in a new way.
The programme aims to equip the people that will have the biggest influence on the lived experience of staff from minority groups with the understanding, skills and behaviours to develop truly high performing, equitable and inclusive teams. This entrenches a lens of inclusivity to the organisation’s approach, which can then be used to address health inequalities across the Dorset population.
Dawn is clear that this programme is exceptional. "It goes deep. It creates conditions for people who are on that programme to be vulnerable, and to connect with their own humanity." The idea is that setting this vulnerability alongside education to see the world differently prompts the trusts’ leaders to think "how do I respond and lead differently, now I know everything that I know, and I’ve got different view of the world?"
The programme has had huge success, with an average 90% uptake of invitees in its first two months.
Obstacles and enablers
Dawn notes that the commitment to culture transformation has been challenging and difficult, as well as rewarding and energising. Shining a light on poor behaviour and a lack of equity has encouraged more staff to come forward with concerns than before.
While this is welcomed and expected, it is not easy. There was also a distressing incident in which an art display at the trust, #IamDCH, was defaced. The display features portraits of staff that make up the 76 nationalities employed at DCH. While the vandalism horrified the majority of staff, Dawn notes that it was another useful learning experience to highlight the intolerance that exists, and within which staff have been working. Board buy-in therefore remains fundamental because, as Dawn says, "when disrupting culture people become uncertain – you have to have real buy-in at a very senior level when people start to get uncomfortable."
Patricia Miller, DCH's chief executive, has also been an invaluable champion of this work. She holds a unique position in the trust to influence and support change, with personal experience of some of the issues they are trying to tackle as an organisation. This has helped internal buy-in among staff and created a clear unity of direction.
To measure the success of these workstreams, DCH uses a people performance dashboard. This dashboard links to the pillars of the People Plan, inspired by The Royal United Hospitals Bath NHS Foundation Trust's own approach to a performance dashboard. All acute organisations have monthly workforce reports, with key performance indicators (KPIs) – standard metrics are sickness, turnover, vacancy rates, and agency spend. Dawn has taken this workforce report and broadened its KPIs to include wider cultural indicators:
- quantitative and qualitative data, by division and department, including big picture national staff survey, WRES, and WDES data
- quarterly pulse survey engagement data
- employee relations case data
- shortlist to hire demographic data
- exit interviews
- freedom to speak up themes
- informal vs formal disciplinary resolution
- appraisal data that focuses on the quality of the conversation, not simply the number completed.
Dawn's approach is that while annual findings are important, it is more important to the work of culture change to be able to see how the dial is shifting monthly, and where tweaks need to be made.
The key message from DCH's work is that equality, diversity and inclusion require a continual and honest focus, right across the organisation. While programmes that highlight white privilege, or talk about white fragility have some value, they don't automatically lead to change. It is only by committing to disrupting an existing culture that real change can be delivered.