Cabinet Secretary for NHS in Scotland running two-tier employment equality cultures

Jeane Freeman, 

Cabinet Secretary for Health

Jeane Freeman, Scotland's Cabinet Secretary for Health, alongside her Cabinet colleagues and the Permanent Secretary, helps run a government employing 9,239 staff, with 700 or 7.6% of them identifying as disabled people.  This and other workforce equality information was made available by 30th April 2019 in the government's mainstreaming equality report for 2019.

Jeane Freeman also runs the NHS in Scotland, employing 164,114 people at March 2019.  Jeane Freeman does not make all of Scotland's 22 health boards tell her staff how many disabled people they employ [as well as how many staff identify as non-disabled, and how many refuse to identify their status because they don't trust their employer with it].  Instead, she and we need to read 22 employee information reports published by 22 health boards to find out what that figure is.  Jeane Freeman has never explained why she does not want that data aggregated and at her fingertips.

Of the 22 health boards, just 13 had published the required data sets by 30th April 2019.  Complying with the law on equality appears to be a low priority for much of the NHS in Scotland.  From those data sets it is possible to identify that out of the 97,170 NHS staff covered by the reports, just 1,002 staff [1.03%] identified as disabled people.

It is not that government itself is doing especially well in employing disabled people.  The government's own report compares the 7.6% of government staff identifying as disabled with a benchmark in the shape of a population figure aged 16-64 of 16.6%.

Whether Jeane Freeman and colleagues are running a 2 or 3 gold-star employment culture when it comes to disability equality in government is of no great comfort to disabled people who work in, or who would like to work in, the NHS in Scotland.  

What disabled people should demand from Jeane Freeman is that she insists the officials responsible for delivering a 7.6% employment rate for disabled people in government should be meeting as a matter or urgency with the officials responsible for running the NHS in Scotland and sharing with them the key elements of the approach which has delivered a 7.6% employment rate for disabled people.  

Has NHS Scotland given up the struggle to eliminate racism ?

The overarching reason the law requires public bodies like Scotland's health boards to gather and publish equality profiling information on employees is to get them to use that information to show how they are meeting their general equality duty.  In other words, health boards [and the rest of the public sector] need to actively use the information they gather on their workers to show how, as an employer, they :

• Eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act.
• Advance equality of opportunity between people who share a protected characteristic and those who do not.
• Foster good relations between people who share a protected characteristic and those who do not.

Research carried out last month looked at the actual data published in April 2019 by Scotland's health boards on their employment of Black Minority Ethnic [BME] people.  The reason health boards are required to publish this data is to allow scrutiny of their performance in whether racial discrimination continues to exist in the employment culture and practices of health boards.  

There are at least 3 major talking points revealed by the research.

Firstly, 8 health boards chose not to comply with the law and publish their workforce data by 30th April 2019.  Various excuses for non-compliance were on offer and various promises that it would be published anytime between end-May and August 2019.  None of which excuses are relevant.  There is no sub-clause or 'get out of jail card' in the specific equality duties [see pages 21 and 22 of the research report] which allows health bo

Only the ... Cabinet Secretary for Health can insist
and ensure that all health boards comply with the law

ards to ignore the deadline for whatever reason.  One of the consequences of this casual approach to compliance with the law is that it means accountability and scrutiny are perverted by the inability to compare and contrast performance across all 22 health boards.  It also adds to the creation of a corporate workplace culture where compliance with the law on equality is somehow less than important.  Only the Equality & Human Rights Commission and the Cabinet Secretary for Health can insist and ensure that all health boards comply with the law.

Second, in order to know whether any public body has managed to eliminate racism from its employment practices and cultures, there needs to be the calculation of almost a 3-D model of what the workforce would look like if all racism had been eliminated, showing BME workers in an optimum profile along the horizontal [numbers] and vertical [pay scales] axis of the workforce.  Added depth and texture would come from data sets on length of service, reasons for leaving employment, access to training and promotion success indicators for BME and non-BME workers.  Any scrutiny of the reports published by health boards [hyperlinks are included in the research reports to allow access to what each health board has published] reveals that the only evidence of workforce modeling is a rather tired and inadequate reference to data from the 2011 Census.

For instance on page 18 of the NHS Health Improvement Scotland report, the benchmark used to compare actual BME numbers/ratios of staff is that of the 2011 Census.  NHS HIS is not alone in doing this.  Even Scottish government as an employer cites the same data benchmark when reporting on its performance in relation to employment of BME people [see page 114 of report] - 4% of the 2011 Census population identifies as BME.   This has always represented a flaw of such reports, as few if any of these and other Scottish public bodies of any size will recruit employees exclusively from within the borders of Scotland. Given that reality, it might be more germane to reference the census data for the UK – which estimates BME people to account for at least 14% of the population. 

The importance of an accurate benchmark when checking performance on delivering employment equality is underlined when looking at employers of staff drawn heavily from the population of central Scotland.  At one end of the central belt is Glasgow with 11.6% of the population identifying as BME as at the 2011 Census.  At the other end is Edinburgh where 8.3% identify as BME.  It would not be unreasonable to expect NHS Greater Glasgow, NHS Lothian and Scottish Government all to be aiming for a much higher proportion of their workforce identifying as BME than the Scotland-wide Census figure of 4%.  Factoring in the real geographic recruitment [international] pool from which the major NHS Boards and government find staff and it seems clear that a workforce profile of 4% identifying as BME would represent an under-performance and an indicator of continuing racial discrimination. 

Finally, this year's research examined reports for any evidence that health boards were using the data gathered to better perform the general equality duty.  The overarching finding is that not one of the 22 Boards has offered clear evidence that they have used the employee information gathered to help them better perform the general equality duty - eliminate discrimination, advance equality of opportunity or foster good relations. 

The data revealed by the reports of those NHS Boards which have complied with the legal deadlines, considered alongside an analysis of what has been done by those NHS Boards to use the data gathered to better perform the general equality duty, combines to reveal a sector which has become immersed in and focused on the process of gathering and reporting on data.  

This imbalanced focus by the public sector on process, to the exclusion of action on eliminating racial discrimination, was recognised as a significant flaw in previous decades of work on equalities by Scottish government when publishing draft proposals for the current specific equality duties in 2010/11. This research suggests that flaw remains robustly alive at the heart of the NHS in Scotland and that only equally robust strategic change and leadership will enable the NHS to embark on the scale of work necessary to eliminate the institutional racism which continues to disfigure the profile of the NHS Scotland workforce.  The NHS in Scotland is happy to expend time, effort and resources on the window dressing of race equality.  No amount of window dressing can hide the fact that the shelves are bare when it comes to evidence on work to eliminate racial discrimination.  It is as if NHS Scotland has simply given up the struggle to eliminate racism from its employment cultures and practices.  

Woman doing the bulk of the work in NHS Scotland but men taking home most of the pay

For too many decades now women have had to drag employers to the steps of the courts [and sometimes in to the well of the courts] just to get paid what the law requires - equal pay with men for work of equal value.  I am unable to recall a single example during those decades of exploitation by men of where any employer gladly, willingly and with a joyous smile, ensured that not only henceforth would women get the same pay as men but that their pay packet would be wedged thick with back-pay from all those years of being discriminated against because of their gender.

In NHS Scotland, blossoming under the fragrant leadership of Cabinet Secretary for Health Jeanne Freeman, the equal pay gap between women and men is heading in the wrong direction.

In 2015, when most of Scotland's 22 Boards got around to publishing pay gap data, the aggregate for all of NHS Scotland was 18.85% - men earning more than women by hourly pay average.  In 2017, a check-up on NHS pay gaps found that instead of panic setting in at 2015 and all hell breaking loose about how the 18.85% gap needed to be closed under the barn-storming leadership of Shona Robison, the gap had grown to 19.99%.  Sadly and 2 years on, the 2019 pay gap reports published by most of Scotland's Boards - a few didn't think it important enough to publish reports by the legal deadline of 30th April - showed that the change of leadership from Shona Robison to Jeanne Freeman found the gap had again increased - from 19.99% to 20.77%

For those trying to get an insight into how this can have happened I would commend a read of some of the equal pay gap reports published by Boards.  One in particular which I found highly informative is from NHS Grampian's 2019 pay gap report.  The following is a screen shot from that report and shows the core data sets which make up the pay gap at NHS Grampian.

In another part of the same report, the position taken by the Board on the NHS Grampian pay gap is summarised as 'negligible'.

The underlying problem in NHS Scotland on why the pay gap is so large and why it is not being reduced is in the occupational segregation which props up the current model of working in the NHS.  

At December 2018, the NHS Scotland workforce [140,710 whole time equivalents] relied on women to the extent that 77.3% [equivalent to 108,907 FT jobs] of the work carried out across the NHS was done by women.  Of that overall figure, 40.1% [43,681 equivalents] work part time.  

Men accounted for just 31,803 [equivalents] or 22.6% of the entire NHS workforce.  Of them, just 3,615 worked part-time.

From research first published in April 2018, the NHS vertical pay axis and distribution of women and men up and down that axis was revealed for the first time.

62.06% of the cohort of women employed across NHS Scotland are paid up to £25,806. For men, the proportion of their cohort paid up to £25,806 is 49.16% - a substantial 13% points to the detriment of women.  Put simply, in the NHS women are almost 5 times more likely to be in low paid work than men.

Curiously, Scottish government as an employer has a much less discriminatory pay culture than NHS Scotland.  The table below shows the equivalent spread of women and men along the vertical axis of pay within government.

All of this leaves Jeanne Freeman, Cabinet Secretary for Health in a rather awkward spot.

She presides over an increasing equal pay gap in NHS Scotland.

She presides over structural occupational segregation in NHS Scotland.

None of the NHS Boards [which have pay gaps of over 5% and which discriminate against women] who report to her have published plans for closing the pay gaps.

None of the NHS Boards who report to her have published plans for eliminating the occupational segregation which discriminates against women.

Jeanne Freeman - will she condone the continuing 
exploitation  of and discrimination against women 
within and across NHS Scotland

Her choices are stark.  Condone the continuing exploitation of and discrimination against women within and across NHS Scotland ?

Or intervene and demand NHS Boards draw up clear action plans which will deliver gender equality in the pay and employment structures and cultures of NHS Scotland - and deliver that in the lifetimes of the women on which NHS Scotland has been built ?

Equality - in another galaxy, and far, far, far away from the reality of what is happening Scotland's Councils

Recent research into data published by Scotland's Councils on whether equality of employment opportunity is being delivered for people who identify as Catholic, or for BME people, or for disabled people, shows that across all of Scotland's 32 Councils the reality of such equality is like yet another Star Wars movie - in another galaxy and far, far, far away.

For disabled people, the average across 32 Councils shows that just 2.25% of those employed in all 32 Councils identify as disabled - when population data shows almost 20% of Scots identify as disabled.



Catholic people fare little better when it comes to getting work in a Council.  Just 4.59% of all Council workers identify as Catholic, when Scotland's population has almost 16% identifying as Catholic.  Just 3 of Scotland's 32 Councils do manage to show that equality of employment opportunity can be delivered, leaving the other 29 unable to evidence that discrimination against Catholics has been eliminated.

With Catholics and disabled people largely marginalised by Councils when it comes to work, the performance of Councils on race equality in employment is equally far, far and yet even farther away than even Spielberg could have imagined.  The average rate across all 32 Councils shows that just 1.13% of workers identify as Black Minority Ethnic [BME].  At the same time, population data reveals 4% of Scotland's population identifying as BME.  Some city Councils have a population profile where the data reveals a much higher proportion identifying as BME and yet it is only in 3 non-city Councils out of 32 where the workforce profile matches or exceeds the local Council population profile of BME people.  The other 29 Councils in Scotland are unable to provide evidence that race discrimination has been eliminated in their workplace practices and cultures.  

All the evidence available suggests that there is a clear lack of desire or will to change what is institutional discrimination across Scotland's Councils.  Government is making no overt or muscular effort to trigger the radical change required.  The Equality & Human Rights Commission [EHRC] has surrendered any active enforcement of the regulations which were framed to secure the delivery of equality in the workplace.

Equality is clearly an alien concept to those responsible for running Councils, government and the EHRC, which is probably why equality remains a reality which exists as far, far, far and even farther away as it is possible to kick down the road and into the future of work to be done by someone else, in some other century and perhaps even on some other planet when the earth itself has been allowed to expire.

NHS in Scotland unable - or unwilling - to audit equality training and demonstrate whether it is reducing and eliminating discrimination or maintaining the status quo

Changing the status quo is never easy.  The natural instinct of those in charge of the status quo is to keep things as they are because it invariably means life is comfortable for them and people like them.

Several decades ago laws were introduced and work started on what is now commonly termed 'equality', triggered by a number of issues around overt racism in the UK.  That anti-racism work has been going on since then and growing to encompass work aimed at ending discrimination experienced by disabled people, women, lesbian, gay and bisexual people, Catholic people and others.  While in those intervening decades we have witnessed how we have the capacity to create huge change - from mobile phones to pictures of the surface of Mars - it seems that no matter how much effort we put in to 'equality' the same people continue to remain exiled, through discrimination, to living on the very margins of what we call society.

In an effort to understand why we have collectively failed to change the status quo, I looked at how employers trained staff in how they could help the employer change and eliminate discrimination in how they functioned.  I thought NHS Scotland would be a good sample of the public sector to examine and sent all of Scotland's 22 health boards a Freedom of Information request and focusing on critical aspects of how they trained their workforce in 'equality'.  You can read the research report here.  There are quite a number of revelations.

One of these is the focus of this blog.

Boards were asked for evidence that they evaluated the training they give staff [over 163,000 work in the NHS in Scotland] on equality and eliminating discrimination was actually leading to a measurable reduction in discrimination and that they were on track for eliminating discrimination.  

The research showed that there is no viable evaluation going on across NHS Scotland of whether equality training is doing what it should.  Considerable resources, time, creativity and effort has been and is being given over to training NHS Scotland staff in eliminating discrimination and on the Equality Act 2010 - yet there is no real check or audit or evaluation as to whether discrimination is being reduced, eliminated or indeed if it is increasing.

One Board, NHS Dumfries and Galloway, did grasp the scale of the challenge in evaluating equality training in relation to the goal of eliminating discrimination :

Equality training should eventually lead to a workforce which has a greater understanding of equality and diversity in relation to both staff and patients. It is hoped that over time, we will see a reduction in complaints which relate to equality and diversity and that greater awareness will be reflected within our staff Dignity at Work survey. Training and awareness features as part of our equality and diversity outcomes report and mainstreaming report but is something within which success is difficult to measure as it requires change to our culture which happens over a long period of time.

Credit to NHS Dumfries and Galloway for recognising the scale of the challenge.

Jeane Freeman
Cabinet Secretary for Health

The reality remains that significant resources are being used across NHS Scotland to train staff in equality - and no-one is checking to see if it offers value for money or if it is eliminating discrimination.  If the NHS is unable to show discrimination is being eliminated as an employer, it is more than likely that it is unable to evidence that it is eliminating discrimination in how it delivers health services.  Will Cabinet Secretary for Health, Jeane Freeman change the status quo in the NHS when it comes to equality or maintain it pretty much as is in the same way as her predecessor ?

Inferior equality training provided for most NHS Scotland staff - institutional discrimination remains deep rooted.

Changing the status quo is never easy.  The natural instinct of those in charge of the status quo is to keep things as they are because it invariably means life is comfortable for them and people like them.

Several decades ago laws were introduced and work started on what is now commonly termed 'equality', triggered by a number of issues around overt racism in the UK.  That anti-racism work has been going on since then and growing to encompass work aimed at ending discrimination experienced by disabled people, women, lesbian, gay and bisexual people, Catholic people and others.  While in those intervening decades we have witnessed how we have the capacity to create huge change - from mobile phones to pictures of the surface of Mars - it seems that no matter how much effort we put in to 'equality' the same people continue to remain exiled, through discrimination, to living on the very margins of what we call society.

In an effort to understand why we have collectively failed to change the status quo, I looked at how employers trained staff in how they could help the employer change and eliminate discrimination in how they functioned.  I thought NHS Scotland would be a good sample of the public sector to examine and sent all of Scotland's 22 health boards a Freedom of Information request and focusing on critical aspects of how they trained their workforce in 'equality'.  You can read the research report here.  There are quite a number of revelations.

One of these is the focus of this blog.

When asked how the equality training was delivered most Health Boards indicated they used a mix of e-modules and classroom settings.  Two Health Boards [Grampian and Orkney] were unequivocal - they used what they called 'face-to-face' training.  Those Health Boards explained :

"All of our Equality and Diversity training is delivered “face to face”. Research done by another Health Board and followed up by NHS Grampian and NHS Orkney has shown that “face to face” training is vastly superior to e-learning in this field for a number of reasons"

If we accept the position of NHS Grampian and NHS Orkney - that their face-to-face method of training delivery is 'vastly superior to e-learning' - then it is reasonable to conclude that much of the equality training delivered by the other 20 Health Boards in Scotland is vastly inferior.

Jeane Freeman, Cabinet Secretary for Health

Is this single issue the reason why NHS Scotland seems unable to pull up the deep roots of institutional discrimination which are in evidence from the employment data the Health Boards publish on a regular basis ?  I have sent a copy of the research report to the new Cabinet Secretary for Health and invited her comment on the superior/inferior delivery of equality training across NHS Scotland.  

Blowing the bloody doors off institutional discrimination in Scotland ? It is easier to open the gates of heaven.

If the goal of artists is to open the gates of heaven[1], then the aim of equality work must be to blow the bloody doors off[2] the institutional discrimination in Scotland which keeps so many people living at the margins of what we call society.

For much of this decade, opened with the Equality Act 2010, I have been wondering why it is that measurable, visible progress with eliminating discrimination has become so ponderously slow.  I was recently reminded of just how pitifully slow it is when someone else put it into a slightly different context.  In an article from the Independent newspaper on Equal Pay, Young Women's Trust chief executive Carole Easton said "at the current rate [of progress], today's young women will be retired before equal pay becomes a reality".

If we are to change the pace on making equality a reality and ensure the privileged status quo gives ground in our life times, it is critical to understand what it is behind the eye-wateringly slow pace of change.  In an effort to try and narrow down the reasons for the delays to the core causes, I undertook some research into one of Scotland's biggest public sector employers, NHS Scotland.  As at March 2018, the 22 Health Boards which make up NHS Scotland were reporting that they employed 169,467 people.  Training and re-training almost 170,000 people must suck up a lot of resources, so I used a freedom of information request to ask them all what was the aim of their equality training, how they delivered it, and how they checked whether the training they provided was actually helping them to eliminate discrimination from their roles as employers and service providers.  

The key findings revealed by the responses go some way to explaining why equality keeps getting kicked down the road in the public sector in Scotland.

• Some Health Boards use ‘fair’ or ‘fairness’ in conjunction with equality, sometimes conflating the two. Given that achieving equality requires the elimination of discrimination and that ‘fairness’ is a relative state, it is likely that the confusion between discrimination and fairness will, for as long as it continues to inhabit the corporate thinking of public bodies, simply serve to sustain institutional discrimination.  It is possible to imagine that this confusion is a deliberate act with the clear intention of delaying the arrival of equality and the elimination of discrimination
• Many of Scotland’s 22 Health Boards are doing equality work - and the training in it - because they have to, by law, not because they are passionate about it and believe it is the right thing to do.  
• the NHS in Scotland lacks clarity and coherency on why equality training is being delivered.  This means that for many staff their journey towards eliminating discrimination will find them arrive at some very different places and often that will not be a place where discrimination has been eliminated.
• NHS Grampian and NHS Orkney use classroom-style training and declare this approach ‘vastly superior’ to online delivery of training, meaning the rest of the NHS is using an inferior training delivery model
• NHS Health Scotland provides mandatory ‘unconscious bias’ training to all managers. Yet the Scottish Parliament’s Equal Opportunities Committee reported in 2016 that ‘unconscious bias’ training is “not the solution and can serve to mask underlying negative attitudes towards people from an ethnic minority background.”
• From the 169,000 workers Health Boards reported as working for them at March 2018, they were only able to positively identify that 37,398 of them had received equality training
• quality assurance as a concept is poorly understood and little or no quality assurance of equality training content across the NHS is actually being undertaken
• all Health Boards were asked what methodology they used to evaluate the effectiveness of equality training in helping them eliminate discrimination in their roles as employers and as service providers. This research reveals that there are no regular, structured checks being made across NHS Scotland on whether the significant efforts, time and resources being invested in equality training are yielding an equally significant reduction in and clear path to the elimination of discrimination in the NHS as an employer and as a service provider

In brief, NHS Scotland has for some years now been training one of the biggest workforces in Scotland on equality and the elimination of discrimination - and has not a clue whether that training is making any difference at all, good or bad.  In order to change from what the NHS is now and what it needs to be when discrimination has been eliminated, the NHS needs to construct a 3-D model of what it will look like once the changes have been achieved.  The Cabinet Secretary for Health doesn't know what the NHS should look like with discrimination eliminated, nor does the Chief Executive of NHS Scotland, and nor do the Chief Executives of each of the 22 Health Boards have a 3-D model of their own workforce or service profiles.  

The NHS in Scotland is training workers to help it change and reach a destination it is unable to describe in any detail.

The present leadership in Scotland in the form of government ministers, senior civil servants advising ministers, and the senior staff running the 22 Health Boards, are clearly culpable in the shambles of how NHS staff are being trained to play their part in eliminating discrimination.  Not only are they not prepared to blow the bloody doors off institutional discrimination in Scotland's NHS, they have locked the doors and thrown away the keys to ensure that institutional discrimination remains securely parked in Scotland's public sector.

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[1] Ed Ruscha, https://www.theguardian.com/artanddesign/2018/jun/12/ed-ruscha-interview-america-decline-course-of-empire-national-gallery

[2] Charlie Croker, The Italian Job