What regulation of NHS managers must deliver for minoritised ethnic patients and staff

The Government’s intended approach to regulating NHS managers

In November 2024, amid mounting public scrutiny over the role NHS managers in patient safety failings, the Government launched a consultation on whether to introduce managerial regulation and accompanying professional standards.

NHS managers play an essential role in steering the daily operations of the health system. They deliver against wide-ranging demands, often under intense pressure and with strained resources, and work to transform and improve care for patients.

Central to their role is a responsibility to manage and mitigate risks to patient safety by fostering a culture in which patients, families, and staff can raise concerns and have them addressed. While most NHS managers carry out tireless, resoundingly positive work, this responsibility has clearly faltered, and duties are not being consistently upheld.

Successive high-profile public reviews and inquiries have highlighted poor NHS leadership as a contributing factor in patient safety failings over the past two decades. It has been well-evidenced how managers’ conduct, and misconduct, has a determining impact on workplace culture and staff practice, which in turn influences patient safety and care quality. For Black, Asian and minoritised ethnic patients and staff, the negative impact is acute and disproportionate.

Following the consultation and the publication of the 10 Year Health Plan this July, the Government shared their proposals, which outline the intention for new regulation to apply to board-level managers and their direct reports in the NHS. Under the responsibility of the Health and Care Professionals Council (HCPC), a statutory barring scheme will be introduced in which NHS managers who commit serious misconduct or silence whistleblowers will be barred from taking up other senior roles. The register will solely identify those who are unfit to be appointed to a board-level or direct reporting role, rather than those who have met a set of educational and fitness standards to practice.

A missed opportunity to address ethnic health and workforce inequity?

While we agree that there must be a way to stop unfit people from leading NHS organisations, bluntly mandating good practice through punitive mechanisms alone will not achieve true accountability, raise professional standards, nor improve patient safety and care quality.

True transformation demands investment in managers’ professional development, a clear framework of expectations, and a commitment to tackling systemic inequity. We are concerned that the Government’s intended approach risks missing critical opportunities to address the role that managers can play in reducing ethnic health and workforce inequity, and ultimately reducing the human and financial costs of racism. As currently set out, this regulatory approach risks unhelpfully diverting attention from other key drivers of poor NHS cultures and replicating the inequitable, discriminatory practice impacting racially minoritised staff across the health system.

We welcome the commitments from the Government and the HCPC to further consult and engage externally on the development and implementation of this regulation. With the commitment to establish a college of executive and clinical leadership to support and professionalise managers across the NHS, and the Department of Health and Social Care’s imminent publication of the revised Long Term Workforce Plan, we will work towards ensuring that a race equity lens is embedded in approaches to tackle workforce inequity and improve patient safety.

The NHS Race & Health Observatory’s response

In our full response to the consultation, we outlined our view on how this regulation should be approached, prioritising equity, engagement, and empowerment. As the Government continues to develop their regulatory approach, accounting for the following considerations will be essential:

1) Minoritised ethnic patients face disproportionate harm, and NHS managers have a crucial role to play

The NHS Race & Health Observatory has contributed to a growing body of evidence indicating that avoidable harm and patient safety incidents are disproportionately experienced by minoritised ethnic patients. This is rooted in racism and entrenches ethnic health inequity. A recurring, driving factor is care providers’ dismissal of minoritised ethnic patients’ and their families’ concerns. This troubling pattern can be observed across the healthcare system, from maternity to sickle cell care.

The Government has stated that the primary purpose of this regulation is to enable ‘the removal of unsuitable managers who have committed offences or who have been found to be unfit.’ While we agree that barring those who have endangered patient safety is necessary, this approach does not reflect the Government’s intentions to further develop, professionalise, and upskill NHS managers, as they outlined when first launching the consultation. On its own, removing unfit leaders will not enhance professional standards – especially when the barring criteria have yet to be fully and clearly outlined.

NHS managers must be equipped to proactively recognise and tackle dismissive practice among clinical staff and ensure that managers themselves are held accountable for listening to patients and the workforce, to deter inaction or dismissal when concerns are raised. In our consultation response, we argued that this regulation must be accompanied by a fully resourced package to develop and support NHS managers to carry out their duties effectively: investment in managers’ professional development, a clear framework of expectations, and a commitment to tackling systemic inequity. We strongly believe this is the only way to improve trust and confidence in the quality of NHS leadership, among patients, the public, and staff.

As the Government and the HCPC develop the regulatory criteria, we will continue to make the case for a balanced and coherent approach which aligns with our existing work to embed anti-racism leadership across the NHS. We aim to ensure that the regulation complements the routes to accountability outlined in the 10 Year Health Plan, the proposals in the upcoming revised Long Term Workforce Plan, as well as the activity of the future college of executive and clinical leadership, to support and professionalise managers across the NHS.

2) Racism against minoritised ethnic staff is ignored, and managers are part of the problem

The racism, bullying, and harassment that minoritised ethnic staff face from colleagues, including managers, have long been reflected in consecutive NHS staff surveys. The NHS is the largest employer of minoritised ethnic staff in the country, but its ethnic diversity is not a precursor to inclusion. The troubling extent of managers’ refusal to tackle reported racism has also been widely reported, and the punitive repercussions victims can face after speaking up deters the raising of concerns at all. In a survey of over 1000 minoritised ethnic NHS staff, 57% of respondents stated they would not raise a concern of race discrimination for fear of repercussions from their line manager or organisational leaders.

In our consultation response, we argued that education, leadership, and cultural safety skills which are rooted in anti-racism must be prioritised. The Government’s intended approach risks missing critical opportunities to embed sustained, meaningful cultural change in the health system through developing and supporting NHS managers.

As the Government and the HCPC develop the regulatory criteria, we will continue to affirm that attempts from NHS managers to prevent minoritised ethnic staff, patients, families, and carers from raising safety and wellbeing concerns (including race discrimination), and attempts to cause detriment through retaliatory, punitive action, must be explicitly considered serious misconduct.

We welcome the Government’s commitment to aligning this regulation with existing legislative frameworks, and we reiterate that the regulation must require the improved use of existing, proportionate measures to address other concerns, such as temporary suspension and remediation.

3) Minoritised ethnic staff are silenced by managers, and patient safety suffers

It has been evidenced that the inequitable treatment of minoritised ethnic staff can prevent them from raising patient safety concerns. This is reflected in the most recent NHS staff survey, in which only 71% of respondents felt safe speaking up about clinical safety concerns, and only 56% believed they would be listened to. The impact is acute for minoritised ethnic staff, with the British Medical Association finding that minoritised ethnic doctors are nearly twice as likely not to raise patient safety concerns for fear of being blamed. Should they raise patient safety concerns, they face a heightened risk of detrimental treatment from managers. This includes a disproportionate likelihood of NHS managers initiating formal disciplinary processes. The most recent figures demonstrate that minoritised ethnic staff are 1.25 times more likely than White staff to be taken through a formal disciplinary process in over 50% of NHS trusts.

In our consultation response, we outlined that in the context of increasing minoritised ethnic representation at board-level, without supportive, developmental measures, there is a material risk that a statutory barring mechanism could exacerbate an existing pattern: leading to minoritised ethnic managers being disproportionately sanctioned.

It is therefore profoundly worrying that the Government’s response to the consultation makes little reference to discriminatory practice and inequity. In our own engagement, the key message we repeatedly received was that the regulation system must be equitable, and not replicate the existing, discriminatory practice evidenced across the regulatory system. These issues have been recently spotlit in, for example, an independent culture review of the Nursing and Midwifery Council, as well as in reports and guidance by the General Medical Council and the Professional Standards Authority for Health and Social Care.

As decisionmakers develop the regulatory criteria, we will continue to advocate for them, and for the proposed college of executive and clinical leadership to account for the wealth of evidence on: the ethnic disciplinary gap, the racism and inequitable treatment faced by minoritised ethnic NHS staff and managers, and how this relates to poor outcomes for minoritised ethnic patients.

A necessary, critical step to achieving this will be decisionmakers’ concerted and sustained public engagement with minoritised ethnic staff, managers, patients, and communities.

Going forward, what will the NHS Race & Health Observatory do?

We firmly believe that leadership and cultural safety skills rooted in anti-racism should be a prerequisite for progressing into, and staying in, NHS management positions.

As this regulation is developed and implemented, we are clear that concerted and sustained public engagement with minoritised ethnic staff, managers, patients, and communities, will be critical – rushing this process would be a disservice to them.

The NHS Race & Health Observatory is developing practical, actionable tools for the NHS and health system, to ensure that community participation and co-production activity with minoritised ethnic patients, communities, and staff is impactful and enables lasting change. We are also conducting the first ever independent review into the ethnicity pay and progression gap and nationwide engagement events with NHS staff, as well as ongoing research into the bullying, harassment, and abuse faced by minoritised ethnic staff. We will continue to progress our work to improve ethnic equity in patient safety interventions, including Martha’s Rule, to ensure minoritised ethnic patients and staff have equitable recourse to robust accountability pathways.

This activity will produce practical and impactful actions to tackle ethnic workforce inequity in the NHS and will be critical to informing the approach of decision makers. We stand ready to work with the Government, the HCPC, and system partners to ensure this regulation achieves its most important goal: to ensure safe, high-quality care for patients and the public.

This consultation ran from 26 November 2024 to 18 February 2025.