Supporting healthcare organisations to eliminate racism

Joan Saddler and Lena Samuels on tackling racism and the role of healthcare organisations, systems and leaders.
Joan Saddler OBE

21 December 2022

What role can healthcare organisations and systems play in eliminating racism? In this episode, Matthew talks to Joan Saddler OBE, director of partnerships and equality at NHS Confederation about the organisation's anti-racism strategy and why tackling racism improves conditions for all communities. He also hears from Lena Samuels, chair of Hampshire and the Isle of Wight ICS, about the impact of racism on the frontline and why the pursuit of genuine inclusion can be a joyful process.

Health on the Line

Our podcast series offers fresh perspectives on the healthcare challenges of our time and ways to confront them. Tune in for interviews with the movers and shakers making waves across health and care

  • Matthew

    Hello. In this edition of Health on the Line, I'm proud that we'll be focusing on anti-racism. First discussing the Confed’s new anti-racist strategy with my colleague Joan Saddler, and then exploring the practical importance of this work with ICS chair, Lena Samuels.

    For some lucky people, this is a time of year when they can wind down and relax. Sadly, as we all know, the reverse is true of the health and care system. Industrial action has now been heaped onto the already massive winter pressures our leaders face. Responding to what we've heard from our members, we at the Confed have become increasingly outspoken about the need for the government to enter negotiation in good faith and for the trade unions to work with leaders to try to minimise the harms and risks to patients.

    As well as talking to members just about every day about winter challenges, I've also been asking them about their experience of system working. These conversations have been given an added relevance given our role in supporting Patricia Hewitt's review of accountability in the NHS. Patricia has come up with some powerful principles in the initial interim part of her work, and we're really looking forward to working with her in the New Year as she explores how to apply those principles. We'll be looking to engage members from across our systems in those conversations.

    Finally, before I speak to Joan, this has been our first full year of Health on the Line. So, thanks for listening. Next year, we're going to be trying out some new ideas. So do please keep tuning in. And I do hope that despite everything, you have a merry Christmas and a happy New Year.

    Matthew speaking with Joan Saddler

    I'm delighted to be joined on this edition of Health on the Line by a colleague of mine. I don't think I've interviewed a colleague on Health on the Line before. So that's a bit of a thrill. Interesting to see how that interaction works. The colleague who's joining me is Joan Saddler OBE, director of partnerships and equality here at the NHS Confederation. And we're taking this opportunity, Joan and I, to have a conversation to mark the publication of the Confederation's new anti-racism strategy. Commit, Understand and Act, is its name. So, Joan, first of all, I suppose I have to say welcome to Health on the Line, but in a way it's your podcast as well. It's our podcast. But anyway, welcome, Joan.


    Thank you. Yes, it's our podcast.


    And how are you?


    I'm good. Very good. And glad to be talking about anti-racism. It's timely.


    So, I do another podcast for the RSA, and that's about books. And I always start with the same question, partly because it just puts people at their ease, but also because it is interesting in itself, or so I think, which is, why did you write this book is what I say. So, I'm going to ask you the same question, which is, why now? Why is it important for the Confed to be publishing the strategy now?


    Really important now because we're now starting to deal with, so what do we do now that we've got all this information, particularly from the Worforce Race Equality Standard that has held a mirror at least for the last six years, that tells us racism is a problem in the NHS, right? So now we're lining up not only resource but offers to our members. And we're writing a strategy that is more than just a programme that is short term. It's a strategy that the board totally is behind in terms of saying, we will support our members, particularly after the disproportionate impact of COVID-19 and also the Black Lives Matter movement. There's something to be done, and it's about time we start actually actively being anti-racist rather than talking about equality and racism.


    Let's look at the other way that the report, which I commend to everybody, it's a short, powerful piece of work, very oriented on what we can do. It's not long and wordy, but very focussed.

    It's got a structure, hasn't it, Joan, around this notion of commit, understand and act. Let’s look at these three things in turn.

    By commitment, I think what we're saying is that the starting point has to be a real desire, a deep desire, to address racism in all its manifestations in the health service, but also in terms of the outcomes that the health service achieves.

    Joan, you've been in this space for quite some time. Where do you sense that kind of level of commitment is now? I mean, if I was to describe it, I'd say there was a kind of moderate level of commitment from some people, but really not universal and not that deep. Then we had Black Lives Matter moment, and it felt then there was a real change, a much deeper commitment. But in the last few months, a combination of a kind of anti-woke backlash and also just the incredible pressures the health service of under is under has kind of slightly lessened that sense of collective commitment. Would that be your view as well Joan?


    That's an interesting one, actually, Matthew, because what I pick up is that from our members, our leaders, they have seen that backlash, particularly in terms of woke-ism, a word I don’t really use because it makes no sense in the current media parlance. But they've seen that. And they said actually we’re chief execs, we’re chairs, we don't agree with this, actually. And what is it that we can do to actively now be anti-racist? So that's one thing. And again, that's not the full survey of all our members, but that's the feel I'm getting. And the second thing is they want to know how do we then ignite that commitment into something else?


    That's heartening. So, you feel that we have passed a certain point that the people aren't going to be knocked off track now that that commitment to tackling racism, other forms of bigotry and exclusion, but we're focusing today on racism, that is deep. It's not going to be knocked off by a few newspaper headlines or a couple of kind of comments by politicians.


    No, it won't be knocked off. But there is absolute risk in us not being able to properly formulate what it is we want chairs, chief executives, non-executive to get right. What is the ask? What is the support we can give? And that's the bit that we've got to be very clear on so that it fits the operating framework of this time where there is anti-discriminatory feeling not just within the NHS but in the public in general. There has been this stoking of wokeism and our leaders will put their heads above the parapet and actually it will be challenged, they will be challenged. And so we need a way of making sure we're speaking with them, we're arming them and we're making sure that their commitment then isn't diffused by all of this challenge that will invariably come. Because what we do know about racism is that if you're going to challenge it, if you're going to be practically anti-racist, then actually the challenge will come. And that can be on quite a personal level, which our leaders maybe haven’t experienced before. So, we need to arm them.


    Interesting, I would share that view. When I speak to leaders, the commitment they have to tackling racism and tackling inequality both within the workforce and the population isn’t something that I have to ask them about, it's very often one of the first things that they want to talk about in terms of their mission. But yet, let me make a little confession to you, which I think does point to the need to be vigilant on this. And for none of us to kind of be complacent about our commitment.

    So, the other day I was chatting to a journalist, who was a sympathetic journalist, talking about the health service and the financial challenges that it faces. And she said something along the lines of: ‘I know, Matthew, that it's all this stuff that says you're spending huge amounts of money on racism awareness, training and diversity officers. I know this is just a kind of crude attack on you.’

    And I found myself saying that's absolutely right. It's a tiny amount of money and what I should have said, of course, was, well, yeah, but that's important investment. If we are spending money on training people about racism, we are spending money on getting people to understand what is involved, to be genuinely diverse, to tackle health. And of course, that's money well spent. I mean, it's because we didn't spend that money and didn't spend it in the right way that we find ourselves in the situation.

    And I know this programme's not about me, Joan, but, you know, after that, I reflected on how quickly I myself got into a kind of defensive, oh, no, it's only a little thing at the edges, don't talk about it - rather than defending it.


    There are two things for me there. And thank you for sharing that, because people almost get into this defensive stance which is learned behaviour in healthcare. And so, I'm just talking about for now.

    If we think about where we've come from as leaders in healthcare, where in 1948 we set up the NHS to tackle essentially inequality, so people didn't have to choose between feeding their children or paying for a doctor or medical care. So essentially that was one of the big drivers in the setting of the NHS.

    We've now got into a position where if we say, well, we're actually spending money on that core proposition of making sure that people stay well, that we're free at the point of need, and that all people, irrespective of who they are, can access the service. Apart from the class divide, which was very prevalent in 1948, then spending money on tackling such inequalities, whether in the workforce or for those who we provide a service for, those patients and people using our services. That should be critical to how we use our resources.

    Yet we've learned almost not to talk about inequality because in the latest terms it seems wokeist - ridiculous! So, I think back to the support we need to have our members take that commitment further. It's about how we arm them with that strategic nature of what it means not to perpetuate inherent inequalities in the policies and procedures within the NHS. Which as leaders, we can do.

    My colleague who co-facilitates the BME Leadership Network, talks about this quite a lot. We can perpetuate such behaviours unless we're actively aware of them and then we're supporting people not to do so. It's one of the strategic conversations we'll be having with non-executives, particularly as chairs and also executive directors and CEOs, as to how we arm them with that information.

    But this is notwithstanding that racism is in our society, right? So, let's just put it here on the table now. There will be some colleagues who are racist. That sounds a bit stark, but that is the evidence. That's what we're dealing with. What we're doing is we're going with, let's say, that tipping point of members we know want to actually challenge racism.


    And I think we have to understand commitment as having two dimensions.

    One is a personal commitment. It is about whether or not you yourself are up for trying to make change happen, recognising that you might be part of the problem, willing to ask tough questions.

    But it's also about saying, look, it can't just be about your own kind of conscience because that's not strong enough. And it's not about individuals, it's about structures. So, you therefore got to also say, look, commitment is about building capacity, institutions, which make sure that even if you, as an individual stop, thinking about and working on this, you're going to be reminded.

    And that's where I think the role of our BME Leaders Network is really important. So that's about saying, look, we are committed to this, but you know, we've got a powerful group of people we bring together who are going to make damn sure that if there are signs that we are no longer committed, that they're going to get us back on track.


    Most definitely. And I like the proposition of two areas. We know that personal racism, we all have some ‘isms’ in us. But personally, if we deal with those issues, but actually within the NHS, it is structural and systemic barriers that we really need to remove. We need to challenge them. We need to tackle them. So, what are they? And it goes further than recruitment processes.

    It's about the way people access services or not. It's about the judgements we make on who receives particular services. There is so much that we can do if we really systematically start looking at what are our policies and procedures that mean that the NHS, either by design or default, is racist.

    Again, hard to countenance, people think, are we? Well, okay if we talk about sexism, it's almost there is no challenge. And I'm juxtaposing these just as an example that we can challenge when we think it is the right thing to do and we're committed to it. So, we wouldn't countenance having conferences where there isn't very near 50 per cent women who make up our population, who are also represented in our conferences. We wouldn't countenance that there aren't women at the top of organisations.

    When it comes to racism, Dr David Williams, Harvard professor, talks about the empathy gap when it comes to talking about people from racialised communities and dealing with racism, there is an empathy gap that can be scientifically evidenced where people don't feel as though these communities are deserving. You know, that's quite stark when you think about it.

    So again, I'm giving you that as an example to say, let's start to remove that systematic barrier that might appear in our policies. The ability for somebody to have a subjective choosing of who is promoted and who isn't. Let's start really challenging some of those things that happen that then affect the care we also give to patients. Because if that’s happening to staff can you imagine the impact on the healthcare we're giving the patients.


    Yeah, thanks, Joan. And just to say before we move on from commit to understand, that in the strategy, under each of these headings there we identify some of the things that we are doing that we're offering to our members. So under commit offering for folks to join our ICS diverse boards and improvement programme, which is for NHS chairs and chief executives, access to support for chief executives and chairs, our leadership framework for health inequalities, our improvement programme there, and also access, as I said, to our BME Leadership Network.

    Now moving on to ‘understanding’, lots we could talk about here, but let's just start with the relationship between what we refer to often as EDI territory, which, and you'll help me if I get this wrong, is primarily about employment practices, and then the health inequalities agenda, which is primarily about how we serve our patients, how we treat our patients. Joan, what, when we think about understanding, how should we understand the relationship between analysis and action in those two areas?


    The analysis is that actually within health we separated out what legally we are supposed to do by being accountable for following the Equality Act, which separated out the Act into two different silos.

    The Equality Act talks about dealing with both workforce inequality and health inequality in the same breath. We separated out the two things into silos in healthcare historically. Why? That's not for me to answer. But the Equality Act says you have to tackle workforce inequality and you have to tackle access to services. The services people get, the outcomes people receive. That is also within the Equality Act.

    So, there's a spurious kind of wall that's gone up, and I'm not sure why. If we look back at what our accountability is for, reporting currently within the NHS on tackling both workforce and health inequalities, that's currently within the equality delivery system 2022. That's a system that's been around since 2011, and the equality delivery system simply says, how are you doing on workforce and how are you doing on some of your chosen areas to tackle inequality? And that was since 2011.

    Now we have the place where EDI is talked about, as just being about workforce when actually it never was. And under our mandatory reporting, it isn't. But not disputing. I'm really glad that we've got a lot more money being thrown into health inequalities now.

    So, let's work with what we've got. There is NHS England totally supporting the workforce agenda and tackling inequality. We will work it. There is a health inequalities programme that has received a lot more prominence in the last couple of years with some great leadership by the national director of health inequalities. Let's work with them. And I suppose what I'm saying is our members are now saying how do we bring these two areas together so we can report on them? And that's the bit where we need to again work with where our members are; they want to keep them separately, we’ll keep them separate.

    But actually there's something about understanding your accountability for reporting on these areas is under the same Act and the Act says, here are nine protected characteristics, but we don't want you to just report on that. We want you to report on those groups as well as other groups that may be facing hardship, such as the traveller community, such as those who live in rural areas. We want you to be able to make sure that you fulfilling your public sector equality duty so that in fulfilling that duty you're making sure that you are having due regard to the needs of these people.

    And indeed you're fostering, challenging inequality and making sure that those groups receive the services they should. So what we do then, here at the Confederation, is play to the two agendas because our members are in different places. Some keep the issues separate, some keep the issues working together. We'll follow that logical trajectory. If you're going to tackle inequality, really it needs to be talking about all of them, don’t you think?


    And it's always seemed to me that although we don't achieve the level of diversity at the most senior level that we would aspire to, we do, nevertheless in the NHS have a very diverse workforce. And, you know, if you want to find out why, it's proving to be difficult to make preventative strategies work, for example, in minority communities, then who better to speak to than your own staff from those communities in order to understand what they think might be happening?

    So, I think that these are linked because, you know, human beings can experience both a sense of exclusion and prejudice at work and also be part of communities that feel that.

    Now, Joan, one of the great assets we've got when it comes to this question of understanding the foundations of racism, particularly in relation to health outcomes, is the Race and Health Observatory (RHO) and the work of Habib and his team there, you know, a small team but achieved an enormous amount in terms of what they've produced and the impact they've had. I know you work really closely with the chair and the chief executive of the RHO but that's such an important asset for us, isn't it? And it was quite a struggle, I think, to create the RHO.


    Yes, it was. I think when we started as an NHS, taking seriously the idea that we needed to understand the evidence base, particularly from a workforce point of view and more latterly from a health inequalities point of view, which we are doing now. But back then in 2015/2016, we didn't even have a workforce race equality standard. And so the Equality and Diversity Council, which I co-chair with the NHS chief executive, chief exec at the time led a conversation at the EDC that said, should we have a focus on the workforce race equality standard?

    After quite a hard-hitting and very interactive discussion, let's put it that way, the WRES was agreed, the Workforce Race Equality Standard, and that set the train for us being able to say actually we need to do a lot more in terms of race and health in the NHS because everything we've done before is not yielding the results you would like to see that we're actually tackling, bringing down the inequities for racialised communities in health.

    And so WRES was formed and then later on, only two years ago, the current chief executive, along with the then chief executive of the NHS, agreed funding for the Race and Health Observatory, and what a triumph. We now have a bank of UK-based data and evidence, well-evidenced academic research that talks about at least 12 different areas, through 12 publications, of problems for people from racialised communities, the staff from racialised communities, and a bank of evidence as to what organisations, our members, can do about those issues.

    And so, with the Race and Health Observatory, we're working on making sure the information is disseminated and our members are using that evidence so that we start to close the inequality gap and making that connection from the workforce to health inequalities is something again. The Race and Health Observatory is doing very well and very much supported by my team here at the Confed, across the Confed group.


    And there are other aspects of this understanding in relation to the kind of reporting within the NHS which you've spoken about already. Also, this growing interest in population health, of course that's critical to the ICSs purpose.

    So that for me is about a broader, deeper shift that we're trying to achieve from an NHS which incentivises activity to an NHS that incentivises outcomes. And it seems to me if you incentivise outcomes, you immediately start to think about health inequalities in the ways that you don't really if what you're focussed on activities. And then I think we also refer, don't we, in the strategy to some particular offers we have for certain kinds of critical figures within the health service. For example, our project working with the NHS England chief nursing officer around anti-racist practice in nursing and midwifery, because we've seen in some of the unfortunate challenges we've had in certain maternity services that sometimes racism is a dimension of what's happening there.

    Let's turn Joan then finally to Act. Because I would say going back many, many years, there's been this kind of credibility issue, which is you're committed, you can talk about it, you understand it. But in the end, why is nothing changing? You know, why is nothing happening? And I'm interested, Joan, in what you feel is critical to turning all of this into action.


    So, we're talking about a reformation that possibly is uncomfortable, that potentially throws up the order of things and throws out the current order of things, when we look at reforming power structures and systems. Those power structures and systems enabling racist practices impacting communities need to then be forensically looked at.

    Now the proposition. Some of our members might say, well, do we know that? And what we do need to do is work with members to look at the evidence of where some of those racist practices are impacting our communities. We know this is happening in maternity services, we know it is happening in sickle cell services. Increasingly, we have evidence of elective care practices where there is unequal access to elective care services. Again, the Race and Health Observatory has the evidence, and it's about helping our members to work through what it means to dismantle the structures that have enabled inequality, that actually help everybody.

    Once we start doing that, we can see that happening when we look at harassment and grievance processes. Dawson and West at the King's Fund specifically point to the corollary that when you make things better in terms of processes and procedures that impact racialised communities, you can see the better response and raised performance for all staff when it comes to bullying and harassment. So, there is something about using the evidence.

    The second thing I'll say is that our Confederation-wide commitment to tackling equality and diversity and inclusion is based in evidence. And so when we see the gaps in evidence, we start to drill down to what more can we do? So again, our Women Leaders Network, for LGBTQ+ Network, we all have slightly different things that we're targeting actually because there are problems in terms of leadership or how people use services for all our groups. But the BME Leadership Network targets something that is just about people being able to be in leadership. And our anti-racism strategy then says, well why have we only still got I think it's either ten or 12 chief executives now, which is a great improvement on the three or five that we had three years ago.

    But Matthew, let's do the maths. You know, surely we should be having at least 20 per cent of people in healthcare who work for the health services. Surely that should be 20 per cent across the leadership strand as well. What we're seeing is at the bottom of the pile, if they're lucky, in the middle. So, there's something about acting on the evidence to go past commitment to making sure that we're lining up.

    What do target's outcomes look like as we support our members? And that's what we're doing. A key part of the strategy saying we're going to actively support members to increase the numbers of people from black, Asian and minority ethnic communities in the workforce to hit the targets that the Workforce Race Equality Strategy has outlined for the last six years.


    You know, it's critical in both employment outcomes and health outcomes that ultimately we measure our efficacy in terms of a shift in the outcomes, in the actual numbers; if it's not there in the numbers, then it doesn't matter how much commitment or understanding there is, we’ve still a long way to go. And, Joan, as you mentioned the way we decided to underline this commitment to action in the strategy was to ask our colleagues in the other networks and the other nations within the Confed about the work they were doing in this space, trying to underline that this is not just about the work of the kind of EDI team or the work of the Race and Health Observatory, this is the work for all of us. And so, in the strategy, we refer to the work in the primary care team, the mental health team at Northern Ireland office, Wales office.

    And so, Joan, you know, this is a isn't an easy question to answer, I know, but how supported do you feel across the Confederation that this is an agenda which we are trying, I don't think fully yet, but that we're trying to own. And that's certainly I know what Victor, our chair, expects from us.


    The ownership by my colleagues, there's absolute commitment. And what I like about this strategy is there's a phase one that says, here's what we're doing. And it's quite inelegant, actually, because when you tackling racism, that's what it is. It's not smooth, it's not nicely packaged.

    Some of our networks will be doing a lot more than others, but they're doing something and it's showing. And then it's saying within the next six months we're going to work with each of the networks and our internal corporate functions because we have an internal strategy and objectives that we need to fulfil, also, in terms of anti-racism, we're going to work with those networks to really make these offers member-led but also appropriate to each network and what that priority is to solve something when it comes to anti-racism from each of your networks.

    And that's the second phase that we'll be working on. So, this is an honest appraisal of where we are now, my colleagues are really open to having that guidance. That idea of how we bend our resources so we are actually doing what it says on the tin. And we're tackling racism as opposed to a wider equality, diversity, inclusion target, that isn't really a target.


    And I found that one of the moments in this process that was very powerful was when you and I said to our colleagues in the executive team, look, we want this report to refer to what all of our networks are doing in this space. And some of our colleagues said, well, I'm uncomfortable with that because we're just not doing enough. And I think you said, well, look, that's the point.

    The point is, let us make the commitment to try to act across the Confed, and if there are areas where we don't feel we've developed a big enough offer, we're not clear enough about, well, let's be open about that. And actually, I think that was a really, the NHS - we often say we don't want to blame culture in the NHS. And then sometimes we say that, but then when it comes to things we really care about, when we feel let down by our colleagues, it's very easy to adopt the kind of language of blame. And so I thought that was a really powerful moment when our colleagues trusted you, me, enough to say, look, okay, this has made me realise that we need to do more. And it felt like an empowering moment. And I'm glad that there is material to report, action to report, across the Confed in the in the anti-racism strategy, but a lot more to do as well.


    Leading this work is challenging because you're doing something that hasn't been done before. We're talking about an anti-racism strategy, not a race equality one, an anti-racism strategy. And as Dr Adam Rutherford pointed out, he led on our BME Leadership Network annual lecture, he pointed out it’s not enough to be non-racist, and we're bringing out a blog on that soon that will be available to members, but it's not enough to be non-racist. You have to be practically anti-racist. And to me, that means just sticking your head above the parapet all the time. Leading on inclusion issues across the piece and then digging deeper into those issues, that actually are hidden.

    So, the empowering moment is when we brought the strategy to our trust board that said we're not going to just put in a load of training and development for people. We are going to do a little bit of that. We're going to make sure that our members are focused on the strategic priorities that say how are you viewed in your community as a place where people feel they can bring their whole selves to work? Remember, our Shattered Hopes report is telling us that over 70 per cent of current BME leaders don't want to stay in the NHS too long because they are suffering racism. That's the kind of context we have.

    So if we as an organisation can support members to understand the story of anti-racism and then actually deal with that story in terms of who wants to come to work for us, not only are we covering off a critical workforce issue, which we know is you're going to need staff and you're going to need to attract staff, but our board also said, okay, let's go for how we make sure that organisations are strategically dismantling policies and procedures that enable racism. Let's make sure that we don't do a soft touch, smooth paper, and the discussion we had at the board when they signed this off, which had challenge and which had support, is where we need this agenda to be. Not that everybody nods their heads and then kind of says, Well, we won't deal with that, thank you very much. We'll just let them get on with it.

    There's some real momentum that we need to translate out to our members, that this is real for us, we’re putting our own house in order because we're not known as an anti-racist organisation, the NHS Confederation, that's one of the tasks. But then how can we enable our members to be known as an anti-racist organisation as well? And that's about a lot of intention. And that was really a supportive moment for me.


    You know, I think what that underlines is that the Confed’s new strategy ‘commit, understand, act’, our anti-racism strategy is not the destination, it's not the endpoint. It is a milestone in what will be a very long important and in the end, I think, joyful journey. Joan thanks so much for joining me today.


    Thank you.


    Matthew speaking with Lena Samuels

    After chatting to Joan, I caught up with Lena Samuels, who is chair of Hampshire and Isle of Wight Integrated Care Board. Lena, we're going to talk about some of the issues I've just been discussing with Joan. But before we do that, tell us a bit about yourself. You are chair of the ICB, but there's lots of other things that you do as well.


    So, my career in actual fact, has spanned a variety of different disciplines from starting in further and higher education, moving into PR and comms and now really predominantly within the NHS, and as you say, chairing the Hampshire and the Isle of Wight Integrated Care Board.


    And I think you run a company as well providing communication and training for people in leadership, human rights, child protection. Have I got that right?


    You absolutely got that right. And that's taken me to wonderful parts of the world, working for UN Women and UNICEF and looking after and predominantly training people in the public sector on protecting vulnerable victims and witnesses. That's been one element, as well as working on the leadership agenda for and policing, health and NGOs and so on. So, I have a handful of people who I look after at the moment, but then it's just a handful. There isn't a huge amount of time to do much else at the moment.


    Tell me about the particular challenges you think, in terms of equality, diversity, inclusion in relation to the health service?


    I think my initial reflections of that are we speak about the agenda as if it were a very broad and all-encompassing agenda. And I think it's important to recognise that people have a variety of different experiences and whilst they have different experiences, as with many organisations and sectors, it's sometimes very difficult for people to be able to feel safe enough to speak up. And people are worried about the onward implications for them and any judgements that may be made. So I think we have to think very carefully about how we create the right environment for people to thrive and to be able to feel that they can speak up when they need to.


    And Lena, you've been a leader observing these issues, experiencing these issues for a long time. So for me, there's a conundrum, which is that if I think about what's happened during my life, I've seen racism go from something that people would casually express, tolerated on mainstream television, to something which now to be accused of being racist is know there's not many worse things to be accused of, but yet when you see surveys of how people from black or minority ethnic communities experience life, they seem to feel there really hasn't been a decline. Their experience of being excluded, of being ignored, of being marginalised, of suffering racism is, if anything greater than it has been in the past. What do you think is happening there?


    I think there might be a cultural shift in the external narrative in terms of people, a bit like smoking, knowing that it's not culturally acceptable, socially acceptable to perhaps hold the point of view this of those who would not and uphold. But perhaps privately people may still hold different views. And when working with individuals, cohorts of teams, the safe space I mentioned should be for everybody. It should be not a case of people worrying about talking about their thoughts and ideas are, of being afraid of judgement, or being afraid of being politically incorrect, but actually being able to bring forth the values that people hold, the reasons that they hold them and the behaviours that they subscribe to or may do covertly or sometimes in an unintended way. So, I think we probably need to move forward to be able to allow people to speak in a non-judged way in order to begin to perhaps change genuinely at the heart and mind what people think and feel. And you can't do that if people are tiptoeing around, if you like.


    So as a leader, you have a responsibility to try to improve the health of the population of Hampshire and the Isle of Wight. But you also have a responsibility to oversee a system getting the best out of the people who work for it. When you're talking to other leaders or to colleagues, how do you talk about the effect of racism in terms of the impact on people's health and in terms of the impact on our capacity to get the best from our colleagues?


    It's important to bring to the fore the impact that racist behaviour has on individuals. It really creates an absolute negative consequence on people's mental health and wellbeing. And it's very difficult for an individual to manage that and the associated stress and anxiety that that causes. And of course, people can be distressed for some considerable time after they've had an experience, and particularly then if they're holding back and they're not speaking out. So we think it's really important for leaders to model inclusive behaviours and to really strengthen allyship because there are a lot of really strong and positive allyship behaviours, if I could describe it as such, where people do step forward and call out in a supportive way the behaviours or attitudes that may not be appropriate, but also ensuring that everything we do in every way it is wired into the way that we think, in the way that we behave. Because if we don't get it right for our people, we’re most definitely not going to get it right for our populations.


    So, in our Confed anti-racist strategy, we use the structure of commit, understand, and act. Commit to anti-racism. Understand the nature of racism and the way that it impacts. And then act. There must be actions that follow from that. Does that kind of structure of commitment, understanding and action, do you think that's the right way of thinking about how it is we get from where we are to where we need to be?


    I think each pillar is absolutely spot on. I wonder whether I understand needs to come before commit because you can't commit unless you really know and understand what it means to be truly inclusive and to wrap your arms around diversity and to understand the consequences of when we don't get this right for our people and our populations.

    So, I think the understanding is absolutely important. I think it plays back to that, working through people's ideology and why they hold the views that they do. And then out of that then you can grow that sense of commitment through understanding and then that enables people to launch themselves forward, to act and behave in a different way. Because of course the behaviours are then what people see and either create the culture that people feel welcomed and safe and able to do the work that they want to do is for our people and to act positively.


    Yeah, I'm sure you're right. I guess it's all they all kind of go together. One leads to the other and then you stick around and think, gosh, we need to understand more. So, I speak a lot to two system leaders, we represent ICSs, and we talk a lot about how ICSs have to provide a different kind of leadership from the leadership we've tended to have in the public sector. Aa real focus on empowerment, on enabling, on facilitating, on adding value, not being a kind of traditional layer that focuses on kind of regulation or grabbing power for itself. So, within that context, within the idea that system leadership has a different kind of quality to it, what is it to be an anti-racist system? How do we combine that way of thinking about leadership with our commitment to anti-racism?


    I think our key role is to be an enabler, and we're connecting people in ways that perhaps they have not been connected before. We've been working through the way that we deliver our services, but we've never really had the opportunity to step back and look in together with a range of stakeholders. So, there's great practice in and around our system. We need to connect to that and we need to enable people to do things in a different way and in a better way for people.


    Yeah, and I've seen in some systems that a focus particularly on health inequalities can be something which does enable a different kind of conversation. It does enable people to put aside their kind of organisational differences and focus on a shared goal. Lena, at the end of my conversation with Joan, we talked about the idea that anti-racism should be a joyful process that often when we use that phrase, partly because of the way it's been demonised by various kind of political interests, it feels quite heavy, quite worrying. People feel frightened of what it might mean and how they might be exposed, or they don't know how to do it, or that it's focusing on negativity. But do you agree that actually if we get it right, the pursuit of genuinely inclusive, diverse cultures can be a joyful process?


    Oh, absolutely. And you know, that's the reason why we go on holiday, because we want to go and explore different cultures and find out about different ways of being, and listen and hear how a different way of thinking about things can sometimes have an impact on what we do and how we do it. And that is exactly the same thing that we need to be doing. We need to be celebrating our journey of exploration as we discover different cultures. I think what people might come to realise is that so much that we have prevailing in our own culture at the moment actually is no different from what we go and explore elsewhere. We have so much that over centuries and centuries we have adopted through explorations and it's become embedded in our way of life. So, when we think about originality, I think we have to really look long and hard going back way, way back, back before we then realised that actually we've always been blended cultures, people, stories and ways of living, ways of thinking, and in that we can celebrate what it teaches us to be truly human.


    Yeah, it's fascinating. That links, I think, doesn't it, to a kind of asset-based approach, which is one of the other things I hear from systems is particularly working with the community to develop a more asset-based approach to health and wellbeing.


    I think it's the lived experience, isn't it? I don't want to talk about people as assets because people are people. They’re not the sort of things that we move around on a chess board as such. People come forward with their lived experience, their ideas, their perspectives, their insights. And what you get from diverse communities is diverse ways of thinking and also diverse approaches to problem solving. So you can think differently about what we're doing, things that we have perhaps struggled with for some time. We suddenly realise that actually someone in our community has got a solution and we need to be speaking to them.

    So, I think it's about the insights that diversity brings for us that helps us to move forward positively with shared learning.


    Well, Lena, thank you so much for your time. It's great to talk to you and it's great to look forward to the work that will carry on doing with you and the Confed. Thank you.


    Thank you so much for the opportunity, Matthew.

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