Change is an interesting word which could mean improvement, transformation, a replacement with another, a variation or another version of the same. Change may be static, on a continuum, incremental or transformational. Change may mean a recycling, refurbishment, and repair. However, when it comes to racism and inequality, change cannot mean improvement, repair, recycling, or any other term that is not absolute. This is fundamentally because no aspect of racism or inequality is good, worth saving, worth recycling or retaining. Just like a single dandelion left on a lawn can very quickly reinfect or take over the lawn and environ, any permissiveness of racism, inequality unfairness is like sparing that ready to disperse or the seemingly harmless bright yellow petals. Even without multiplying, with its inherent ability to outcompete surrounding plants, a dandelion represents privilege, power and inequitable access to resources within its ecosystem. It poses risks to the health, wellbeing and productivity of others.

No matter how we choose to dress any improvement around inequality in healthcare workforce, inequality remains if there is no equality. No change is adequate without equality. We cannot eliminate inequality by improvement or partial change. We can only redress equality by commitment to real change. Any improvement in redressing racism as commendable as they are, remain improvement, but not equality.

In my view, the concept of improvement does not work when it comes to racism. Focusing on transformation by taking bold steps to tackle the minutest incident of discrimination decisively is what will bring about the change that is long overdue.

I recently heard someone in their 30s who was born in the UK say, ‘I do not think racism will end in my lifetime” In the moment, I struggled with their pessimism because I couldn’t wait to see the end of racism and to celebrate like when the Berlin wall came down or when the end of apartheid was declared. However, after careful consideration and comparison of the WRES data from 2016 to 2023, I saw their point but stubbornly hold on to my optimism.

Comparing the WRES data over an eight-year period, shows improvement in representation but not in experience. Out of the six standards focused on monitoring the experiences of the global majority staff, there were slight improvements in two standards and worsening experiences in four. The strategy for increasing representation has so far worked. However, the WRES data shows a correlation between increasing representations and the increase in the number of people experiencing discrimination. So, at best, the strategy has succeeded in increasing the number of people who experience inequality in the NHS rather than experience inequality outside the NHS through exclusion from the NHS workforce. The data shows that the focus on improvement is not effective, and my optimism is illogical.

The data shows a variation in the form of racism and inequality experienced by the global majority. It shows an inclusion in the workforce but an exclusion from thriving within the workforce. Even when we see improving representation through the ranks of the NHS to board level, inequality and racism mean that the experiences of those people are not as positive as their Caucasian counterpart and their effectiveness in impacting health care delivery for patients is diminished by their own experiences.
 
The data shows we are achieving inclusion, and diversity but failing to achieve equality which is what is guaranteed in law from the (1976) Race Relations Act and subsequent Equality Act (2010).

I long for equality, and transformation in racism, not just improvements. I wish that the conversations or avoidance of conversation, the actions and inactions, the weathering effect of racism, the anti-racist statements without actions, the show of progress, the litigating about racism would end with my generation and that we can have real change.

The futility of the current improvement strategy is concerning and reinforced by the NHS staff Survey 2024 which shows an increase in the number of staff experiencing discrimination and a reduction in the percentage of staff who felt their organisation acts fairly with regard to career progression or promotion, regardless of their protected characteristics. The survey indicates a need for rethink and a transformative strategy.

According to the online dictionary, transformation is a state of marked change in appearance nature and character. When it relates to equality in healthcare, transformation is deep-rooted change, and not veneered Equality, Diversity and Inclusion. Transformative change comes with replacing wrong actions with right ones regardless of the complexity of the situation. It comes with collective commitment to turning the page on approaches including behaviour management of alleged perpetrators of harassment, discrimination and victimisation. We cannot witness change in the experiences of Minoritised Global Majority staff when alleged or perpetrators of discrimination and bystanders do so with impunity, while victims or potential victims are victimised and forced out of their jobs. In the case of Michelle Cox V NHS commissioning Board, the manager moved on to another job within the NHS while the experience ended Michelle’s career within the NHS. Such strategies do not effect change on a school’s playground, and neither will it within the NHS. Every response to alleged racism counts. 

We may not see an end to racism if the focus remains on improvement and not on transformation. The supposed improvement so far is the enemy of the required real change, which is unqualified equality. For as long as global majority staff have an increased likelihood to enter the disciplinary process, have an increased likelihood to be offered non mandatory training, and have increased likelihood of experiencing discrimination from a manager or colleague, they will continue to be overrepresented in lower bands, and the 'snowy white peaks' with emerging, disproportionate and determinate patches of other colours will remain. We will be far from achieving equality in healthcare. We will continue to achieve some form of representation which relieves the guilt of inequality and racism without ending either.

Achieving a degree of representation but not a balance of power and equity within the sphere of that representation, results in minoritisation. In my view and experience, the representative conforms to the predominant culture or risks being ostracised or labelled as the troublemaker. One of the lessons from the Michelle Cox’s Employment Tribunal case is that representation and promotions are not evidence of equity or change. With just representation, the NHS becomes a macrocosm of its communities with its embedded and enduring inequality and racism. This is a position the NHS cannot assume given it was built and is sustained by a diverse and international workforce whose voices are untiringly hoarse from asking for an end to racism and inequality in healthcare workforce.

Equality is a state not a process and therefore change when it comes to equality is transformational. It cannot be transactional, incremental or implemented as a piecemeal. It is a balancing of the scale every time there is an imbalance in the equilibrium. Equality is what is guaranteed in law not a process of improvement.