Ethnicity, Equality of Opportunity and the British National Health Service

Paul Iganski, David Mason

• Publisher: Routledge
• Year: 2018
• Topic: Politics & International Relations
• eBook ISBN:
  9781351748964
• Subtopic: Health Care Delivery
• Index: Politics & International Relations

This title was first published in 2002: Numerous reports have identified the serious problems of under-representation of, and discrimination against, minority ethnic groups in the British NHS. It is widely argued that this both raises issues of social justice and undermines the quality of service to minority ethnic patients. Nowhere are these problems more acute than among the largest occupational group in the NHS - nurses. This book reports the results of research carried out for the English National Board for Nursing, Midwifery and Health Visiting to evaluate NHS equal opportunities policy. Drawing on additional original research involving interviews with key policy actors, this fascinating book examines the prospects for a national strategy linking the business and justice cases for the delivery of greater equity in employment and service delivery.

1 Introduction

This book explores the provision of equal employment opportunities in the British National Health Service (NHS). As we shall see, despite sustained exhortation to improvement, and repeated high profile national policy statements and initiatives, there is evidence of long-standing racism in NHS employment practices. At the same time, there is little convincing evidence of systematic attempts to implement nationally developed commitments at the local level; that is, where health care is delivered. The central section of the book draws from a research project commissioned by the English National Board for Nursing, Midwifery and Health Visiting (ENB), carried out between 1996 and 1998 (Iganski et al., 1998),¹ on the recruitment and retention of members of minority ethnic groups into training for nursing, midwifery and health visiting.

Our discussion of the findings of this research is placed in the context of a wider consideration of racial exclusion and equal opportunities in the NHS. Given that nurses represent the largest occupational group in the Service, and are also those most closely involved in the day to day care of patients, their experience arguably has implications for recruitment and selection practices in the NHS more widely. In addition to highlighting such wider practical lessons from the research findings, we also seek to place our discussion of policy questions in the context of a conceptual interrogation of key arguments and debates about equal opportunities and of ethnic difference.

Terminology

Before proceeding, it is important to clarify the terms that we use in this book. The term ‘minority ethnic group’ (and its counterpart ‘ethnic minority’), while widely used in policy and lay discussions, is not self-evidently unambiguous. It has, moreover, frequently been contested on both intellectual and political grounds. While it is widely understood in Britain to denote a category of people whose recent origins lie in the countries of the New Commonwealth and Pakistan, which groups should be included, and how they should be distinguished and designated, remains a matter of considerable debate. In practice, the criterion which identifies those to whom the term normally refers is having a skin which is not ‘white’ (what, in the United States, would be designated ‘visible minorities’). One consequence of this is that ‘ethnic minorities’ are treated in many discussions as an undifferentiated category, with characteristics and experiences in common that differentiate them sharply from the rest of the population (compare the discussions in Ballard, 1992; Field, 1987; Modood, 1988; 1990; 1992. See also the discussion in Chapter 7 below). In addition, the important differences between the experiences of men and women are also frequently overlooked (Anthias and Yuval-Davis, 1992). This usage also tends to underplay the increasing diversity of experience of members of different groups (see Modood et al., 1997 and Chapter 7 below).²

Despite these problems and the intellectual reservations to which they inevitably give rise, we were constrained in our research design both by the research brief and the form in which data were available. These data themselves reflect prior decisions about which patterns of difference merit measurement and these, in turn, reflect the patterns of disadvantage (and discrimination) which are known, or thought, to characterise the experience of different groups. In this context it should be noted that increasing concerns about the apparent under-representation of some groups in the nursing workforce coincided with the initiation of ethnic monitoring of applications and admissions to nursing, midwifery and health visiting education.

The data available to the research team were contained in the admissions database of the Nurses and Midwives Central Clearing House (NMCCH). These data record the self-classification of applicants in terms of the ethnic group categories used in the 1991 Census:

White

Black - Caribbean, Black - African, Black - Other (please describe)

Indian, Pakistani, Bangladeshi, Chinese

Any other ethnic group (please describe)

To these, the NMCCH added an ‘Irish’ category in 1994.³

In what follows, the term minority ethnic group is deployed in a way that reflects the conventional usage discussed above and the constraints of the data available. As in Census derived data, members of minority ethnic groups are, then, deemed to be those who have classified themselves in terms of one of the ethnic categories other than ‘white’. It should be noted, however, that we have preferred the term ‘minority ethnic group’ to ‘ethnic minority’ in order to emphasise the plurality of groupings involved and to encourage a recognition of the diversity of experience characteristic of the groups in question.

Methods and Data Sources

The ENB commissioned research, the findings of which we explore below, aimed to:

• map the national pattern of applications, from members of minority ethnic groups, to pre- and post-registration nursing, midwifery and health visiting courses;

• identify the ratios of applications to offers of places, and of these to rates of acceptance, among members of different ethnic groups;

• investigate recruitment and selection practices;

• use the evidence accumulated to advise the ENB on the future development of equal opportunities policy.

For the analysis of applications to pre-registration training we used data provided by the ENB covering all applications made through the Nurses and Midwives Central Clearing House (NMCCH) between 1993 and 1996. We present the results of our analysis in Chapter 4. The material presented in the chapter updates our earlier reports (Iganski et al., 1998; Iganski et al., 1999) as it incorporates more recent data from the Nurses and Midwives Admissions Service (NMAS) covering applications from 1997 to 2000. We discuss both data sets in more detail in Chapter 4. We had originally hoped to conduct a comparable analysis in respect of post-registration training. However, no nationally compiled data were available at the time of the research commissioned by the ENB, or since.

We had two broad areas of concern for the research into recruitment and selection practices. First, we were interested in evaluating whether selection processes used by nurse education and training institutions had incorporated equal opportunity policy guidance offered by the ENB and by other bodies like the King’s Fund Equal Opportunities Task Force. Second, we were interested in whether nurse education and training institutions specifically targeted minority ethnic groups in their recruitment measures, and if they did, what could be learnt from their activities. These research aims suggested an in-depth qualitative approach, as the goal was to learn from and to be able to evaluate, recruitment and selection policies and practices. We therefore needed to establish a clear understanding of how recruitment and selection actually worked in practice.

The ideal research strategy would have been to observe at first hand recruitment and selection processes in action. However, even if it were possible for us to observe all the processes themselves - and it is questionable whether we could have been present at all of the activities involved - such a strategy would be highly resource intensive. The next best approach was to use individuals, who occupy key roles in regard to the policies and practices, as informants. In effect, such an approach involves an ethnography of the policy process, whereby the researchers construct an understanding through the perspectives of the key actors involved. Whilst informants each have their own particular perspectives, commonly bounded by the role they play in the policy processes, the strategy enabled us to put together a picture by validating one respondent’s perspectives against another’s. This strategy is also resource intensive due to the length of discussions needed with key informants and the number of individuals commonly involved in recruitment and selection activities who might appropriately serve as key informants.

Working to the resource constraints of the project, our investigation of recruitment and selection processes was carried out in eight nurse education and training institutions. We discuss how we selected these institutions in Chapter 5. Each institution served as a case study, as we constructed an understanding of the processes at work in each of the institutions separately, although in this book, and in our earlier reports, the findings from the institutions are combined into an aggregated account. This approach to presenting the research findings was thought to be necessary to ensure the anonymity of the case study institutions and individual respondents. Conscious of the sensitivity of the issues under investigation and of the harm that could be done to the careers of respondents by careless research design or reporting, we took great care to preserve individual anonymity and confidentiality. Nurse education centres are referred to only by pseudonyms and, with the exception of one case of good practice, care has been taken to present the research findings in aggregated form, rather than as case studies of each institution. Respondents were fully briefed about the nature and purposes of the research and were given an unconditional right to withdraw at any stage. Most of our interviews were tape-recorded - with the respondent’s permission - and the tapes transcribed by a transcription service which was asked to sign a confidentiality agreement.

As discussed above, we had two broad areas of concern for the investigation of recruitment and selection practices. First, we were concerned to discover whether selection processes utilised were consistent with equal opportunities good practice. Second, we were interested in whether nurse education and training institutions specifically targeted minority ethnic groups in their recruitment measures, and if they did, what could be learnt from their activities. Different data collection and analysis strategies were applied to the two areas of investigation. In order to investigate selection policy and practice, the Heads of each of the eight case study centres, together with the senior managers with overall responsibility for selection in the centres, were first asked to ‘talk the interviewers through’ the processes by which applicants are selected for training. The aim was deductively to evaluate whether the processes used by the institutions had incorporated the policy guidance offered by bodies like the King’s Fund Equal Opportunities Task Force and whether there were areas of selection practice where there was the potential for unfair practice or discrimination to occur. Our lines of enquiry are discussed in detail in Chapter 5, but, in outline, we asked about selection criteria, procedures for shortlisting and interviewing, the training provided to staff involved in the selection processes, and the monitoring of selection decisions. The various elements of equal opportunity policy guidance provided a checklist for the topics covered in the discussions. The data were also analysed deductively with the elements providing an analytic structure and a format for the presentation of the findings in Chapter 5.

For the investigation of recruitment measures, our second broad area of concern, we applied a different research style from that used in the investigation of recruitment practices. We used a grounded theory approach to the collection of data and to the data analysis (although it was in a modified form as we discuss in Chapter 6). Such an approach suggested itself from the research objectives. A prime objective was to learn from the experience of the case study institutions. A grounded theory approach is suitable to that objective as a fundamental principle of the approach is to generate ‘theory’ that is grounded in empirical data through an inductive process, rather than establishing a priori concepts or hypotheses that are subsequently explored or tested through the data (Glaser and Strauss, 1967). An inductive approach was suggested by the research objectives as, to learn from the experience of the institutions, we needed to develop an understanding of the complexity of processes - such as the antecedents, barriers, constraints, facilitators - behind the establishment and implementation of recruitment initiatives.

A grounded theory approach does not, however, imply that researchers can approach their data with a tabula rasa (Glaser and Strauss, 1967: 3), and that a ‘pure’ inductive analysis can be applied to the data (Pidgeon, 1996: 82). Researchers approach their data with their own initial perspectives (Charmaz, 1990), pre-conceptions and assumptions which will inevitably influence the questions that are asked and the interpretations made of the data collected. As the aim, though, is for the emergent ideas to be grounded in the data, and for authenticity of the ideas in relation to the experience of the researched, it is incumbent upon researchers to explore their potential biases and pre-conceptions and, where some are maintained and influence data collection and analysis, to make them explicit. The chief assumption with which we approached this project was derived directly from the original research specification provided by the ENB. This made explicit the link between patterns of ethnic representation and the formulation and implementation of equal opportunities policy. The implication is that, where under-representation exists, nurse education and training institutions should take active measures to recruit students from black and Asian minority ethnic groups for training in nursing and midwifery. The case for such measures is discussed in Chapter 3 of this book. This assumption meant that we did not set out initially to seek the views of the research respondents about whether targeted recruitment was desirable as a basis for deciding whether to ask about any recruitment initiatives. Instead, respondents were asked about recruitment initiatives first, then subsequently about their desirability, in an attempt to gauge the level of commitment to the initiatives. The difference may be subtle but nevertheless significant, as the prime goal was not to investigate desirability of the initiatives per se by using a large portion of the interview time exploring respondents’ views about the matter. Instead, the aim was to use the time exploring the respondents’ experience to find ideas for targeting that could be disseminated to other institutions.

Background

The ENB’s research specification made explicit a link between the representation of members of minority ethnic groups, among applicants and entrants to the nursing and midwifery professions, and the formulation and implementation of the Board’s equal opportunities policy. The implication was that continued under-representation would constitute prima facie evidence of an absence of equality of opportunity and raise questions about the fairness and equity of recruitment and selection procedures. It is important to note that such evidence does not provide conclusive proof that recruitment and selection processes are discriminatory. As we shall see, it is possible that under-representation is a consequence of a range of other processes and influences that lead to a lack of applications from members of some groups. In such circumstances, the point at issue would be less discriminatory selection practices and more a matter of a failure to proactively seek applications from under-represented groups. In the discussions in Chapters 5 and 6 below, we consider each of these questions in the light of the analysis of application and admissions statistics for nursing and midwifery training. As we shall argue in Chapter 7, however, it remains a possibility that under-representation of some groups is a result of differential occupational choice. In point of fact, it would be safe to conclude that this were indeed the explanation only if we could be confident that measures were in place that ensured bias free selection and appropriately targeted minority ethnic communities as potential sources of recruits. In other words, the first requirement would be an effective equal opportunities and positive action strategy, as advocated by the Codes of Practice of the Commission for Racial Equality and the Equal Opportunities Commission (CRE, 1984a; EOC, 1985) and the Employment Department’s Equal Opportunities Ten Point Plan for Employers (U.K. Employment Department, 1991).

Since the mid-1980s an increasing number of organisations have developed such policies or reviewed and extended earlier programmes. In the public sector, a number of local authorities and public utilities took a leading role while, in the private sector, large-scale employers with established reputations for good employment practice were prominent (Jewson et al., 1995). In the late 1980s, the CRE funded research designed to assess the impact of its Code of Practice on the awareness and behaviour of employers (CRE,...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of Figures and Tables
• 1 Introduction
• 2 ‘Racism’ and the British National Health Service
• 3 Equal Opportunity Policy and the NHS
• 4 Is the ‘Black Nurse’ an ‘Endangered Species’?
• 5 Selecting Applicants for Training in Nursing and Midwifery
• 6 Positive Action in Recruitment to Nursing and Midwifery Training
• 7 Social Change and the Health Care Agenda
• 8 Policy, Politics and Health Care
• Bibliography
• Index