Tackling racism: case studies

In 2018 the Royal College of Psychiatrists in Wales endorsed a project into Cultural Competency in Mental Health Services, developed with their third sector partner, Diverse Cymru. This was following the College's position statement on Racism & Mental Health. 

The Cultural Competency Certification Scheme is a practical resource and workshop programme funded by the Welsh Government, independently validated by the United Kingdom Investor in Equality and Diversity (UKIED) and delivered by Diverse Cymru.

The scheme supports workplaces to explore commonly held unconscious bias and to develop their cultural competence, so that their services and employment practices are fair and equitable. This approach benefits both the workplace staff and service users.

The uptake into the programme has grown​ continually; there are over 100 teams or units involved in different stages of the work, and every health board in Wales is signed up.

In 2022, the Scheme won the Health and Wellbeing Award at the University of South Wales Innovation and Impact Awards 2022, and in July 2022 it went on to win Race and Ethnicity Champion, Initiative or Campaign of the Year at the Wales Online Diversity and Inclusion Awards 2022.

The Cultural Competency Scheme is a part of helping to achieve the Welsh Government’s Anti-Racist Wales Action Plan, published in June 2022, and has received praise and support from the First Minister of Wales, The Rt Hon Mark Drakeford, who recently said of the Scheme:

‘We as a government are proud to fund the Cultural Competence Certification Scheme because we recognise the importance of developing good practice to ensure that the services that organisations provide are fair and are equitable.’

In 2019, after the Royal College of Psychiatrists had celebrated Black History Month for the first ever time, a group of black staff approached the Chief Executive to propose the setting up of a staff forum – the African Caribbean Forum (ACF) – to provide an outlet for those interested in issues pertaining to people of Black African and Black Caribbean heritage.

The idea was that the forum would allow staff to discuss issues connected to race faced both at work and outside of work. It also provided opportunities for non-Black colleagues to better understand how different lived experiences can be for marginalised groups and/or those with protected characteristics.

The group was set up shortly after the conversation with the Chief Executive, with its work being enthusiastically supported by the Senior Management Team – which had just launched the first-ever set of College values of Courage, Innovation, Respect, Collaboration, Learning and Excellence.

Successes of the ACF have included:

• the publication of a resource for all staff called Allyship and Combatting Systemic Racism, in the aftermath of the murder of George Floyd, which went on to be the most downloaded document in the history of the College intranet
• the publication of Guidance for Race Equality in the Workplace, which was developed by the ACF to supply guidance to staff on best practice on race equality in the workplace – and was also downloaded via the College intranet many times
• reflective conversations online on race and racism – which have been opened up to all College staff to attend
• lunch and learn sessions, celebrating the Black experience
  
• blogs on race, racism, dual heritage matters and allyship.

For Black History Month in 2020 the ACF was able to bring together a range of voices from multiple areas of the mental health space, some of which hadn't previously been given a voice. Staff worked with healthcare providers, mental health champions, campaigners, as well as psychiatrists, and members.

The ACF has also worked with the College to purchase a library of books on the black experience, for staff and members to access.

All of these outputs have received widespread positive feedback and praise from College staff.

Since the ACF was set up, the forum and the College have worked to strike a balance between the aspirations of members of the forum, on the one hand, and wider College activity, including resourcing and staff time – as well as other protected characteristics and College priorities, on the other. Moving forward, the ACF and the College will continue to work together to celebrate Black voices, diversity and race equality.

The ReMEDI project challenges the traditional structures which have been found to inhibit the progression of people from minoritised ethnic groups. The programme centres on individual interaction to address discriminatory practices, with inclusive practice framed as a skill to be learned and developed.

In 2018, the ReMEDI project was rolled out in  Guys and St Thomas’ NHS Foundation Trust.

Ethnic minoritised staff (mentors) were paired with White senior leaders (mentees)  to collaboratively explore mentees’ attitudes,  beliefs, and values.

The mentors provided the mentees with feedback, allowing them to critically reflect on how their behaviours might be modified on an individual and departmental level.

The focus was not on finding fault in the mentees, but on enabling an environment which encourages openness, honesty and trust, and a safe space with a growth outlook.

The programme was deemed to be successful,  despite only running for six months. The mentees exhibited positive changes on individual, departmental, organisational and symbolic levels, such as the use of more inclusive language and compliance with targets.

Following these successes, the Southeast Regional Equality, Diversity and Inclusion team reviewed current reverse mentoring programme models and launched an evidence-based initiative in  October 2020.

The programme was aligned with the People Plan priorities of “Belonging in the NHS” and “Looking after our people”, with efficacy measured at each programme stage. It sought to support the organisation to achieve Model Employer goals.

Three core areas were addressed: Confidence,  Complacency, Convenience, with themes linked to workforce indicators including within the WRES.  Following participant feedback, psychological support sessions (in between mentoring sessions)  were incorporated into the programme.

Sessions aimed to enhance self-awareness and provide a space for reflection. 

The session facilitator was from a minoritised ethnic background and was a WRES Expert, with extensive experience of training and facilitating diverse groups in various settings, including Senior Board level leaders within the NHS. Themes included power dynamics, racial identity and guilt. 

Evaluation showed that overall, most of the participants (both mentees and mentors) found the psychological support integral to the mentoring experience. It was regarded as being therapeutic,  enabling reflection and improving self-awareness within a safe space.

East London Foundation Trust

The Trust employs approximately 7,000 staff, c.53.7% of whom are minoritised ethnic. ELFT undertook an overall trust-wide strategy alongside what the Trust refers to as “values and treasures.” It is important to note the ELFT Board had committed to meaningful change, therefore the metrics were not the drivers of this work. There was also a recognition that change takes time.

 Tangible outcomes based on the 2022 WRES submission include:

1. Band 8c to VSM roles increased from 19.7% to 22.5% in non-clinical roles and 17.1% to 19.6% in clinical roles in 12 months (WRES Indicator 1).
2. Relative likelihood of minoritised ethnic staff entering into formal disciplinary process has declined from 1.95 to 1.45 (WRES Indicator 3).
3. The Trust board is 52.6% minoritised ethnic; this has remained consistent since 2020 (WRES Indicator 9).
   

Processes

Two major areas were addressed: Representation in senior positions and disparities in disciplinary rates for minoritised ethnic staff.

For improving senior representation, active succession planning for the CEO, Executives, Clinical/Service Directors and deputies were put in place, using the Leadership Academy’s Talent Management Methodology.  Equality analysis was undertaken on all protected characteristics to enable the Trust to identify how it can be more diverse in senior roles 

For disparities in disciplinary rates there was an acknowledgement that many cases were linked to mental illness or some staff’s were becoming mentally unwell during these processes.

A Fair Treatment Process was implemented.  QI methodology was also integral and it was led by a service user. This entailed:

• anonymised case summaries being reviewed by the People Participation Representative
• the policies, processes and materials used being reviewed and revised 
• developing a “just culture”
• surveying staff “were you treated fairly/with compassion?”
  

ELFT employed a dedicated member of staff to deliver pastoral care for any non-medical staff on disciplinary process. This included occupational health reviews, addressing wellbeing and ensuring regular check-ins. The plan is to expand to medical staff next.

Culture

This was underpinned by the ELFT “Treasures”: Quality Improvement and Co-production.

Quality Improvement

• Ensuring an adequately funded training programme that every member of staff, including leaders experienced. This allowed a “common language” across the organisation. Training sessions were mixed, with a diverse range of staff from across the organisation.

Co-production

• A People Participation team was established, consisting of both staff and service users. It valued the pre-existing skills of service users, with all members having an NHS email address and receiving training focused on harnessing skills and adding value. The team was part of the “Gold Command” during the Covid-19 pandemic, set up in part to coordinate an effective response to short-term emergencies.
• The ELFT “RaCE” staff network supported co-production efforts. Initiated in 2017, it became well established within the Trust, with approximately 400 staff.  The network is autonomous but is supported by an executive sponsor. It has financial resources to help with its running, for example by funding conferences and venue costs and paying for external speakers. The Network Chair received protected time (approximately one day a week) to focus on co-ordinating the network meetings and activities.

Key success factors and enablers:  Success has been attributed to targeted actions to thoroughly embed a culture of Quality Improvement methodology and co-production. This provides methodology and built-in accountability to both staff and patients. Having a People Participation Team and thriving “RaCE” network were key contributors to success. In particular, having organisation support for the network in terms of senior leadership, sponsorship and ensuring staff have “cover” to attend network meetings and be involved.

What would ELFT do differently if they had their time again? In relation to Vaccination as a condition of Deployment (VCOD), a reflection was that the Trust could have communicated more about the work that was going on behind the scenes, acknowledging and voicing the impact on staff earlier.

What advice do ELFT have for other organisations wishing to translate their work: Leaders recommend others wanting to act against racism should be brave rather than avoid the issue, accept that they may not be getting it right first time but accept that humility is key.

Improving outcomes for International Medical Graduates (IMGs) - meeting the educational needs of stranded migrant doctors during Covid-19.

This case study illustrates that when IMGs are adequately supported, educationally and pastorally, they can thrive in exams and their careers.

This humanitarian action has lessons for how we can better support IMGs in ordinary times.

At the beginning of the Covid-19 pandemic, 267 IMGs from 27 countries were stranded in the UK.

They had come here to sit for Professional and Linguistic Assessments Board (PLAB) exams, which had been cancelled because of the lockdown and they were unable to return home for a range of reasons, including lockdown in their home countries, financial costs, and visas.

Many were stranded without social networks, funds, and accommodation. A number of diaspora groups for IMGs from different countries pulled together funds and people resources to create a response. Although more extreme, this is not dissimilar to what IMGs new to working in the UK may experience.

IMG volunteers and the British Association of Physicians of Indian Origin (BAPIO) provided mentorship, education and training to the 267 IMGs (with wraparound support including accommodation, and pastoral care for 31 of the group). This case study discusses the educational element.

The facilitators for the education and training were IMG trainees, consultants, and SAS doctors who followed a democratic approach to facilitation.

Educational components included three 60-minute sessions per week, mainly held online. The training covered a range of didactic, interactive, role-play and group work approaches. Reflective components included three 60-minute sessions a week held online for four weeks.

These sessions were facilitated by UK, non-IMG GP/ SAS doctors. The doctors facilitated open communication, created a safe space, and explored aspects of well-being. This approach encouraged the asking of questions during teaching sessions, as well as the planning of self-study, keeping wellbeing in mind.

Themes covered across the sessions included:

• Specific clinical topics
  
• Safety, including safeguarding and duty of care
  
• Professionalism
  
  • Concept of a good doctor
  • Consent
  • Confidentiality
  • Professionalism in the context of the structure of a consultation
  • Giving and receiving feedback
• Communication
  • Shared decision making
  • Breaking bad news
  • Active listening - the difference between textbook ‘tick box’ questions and those sensitively asked, such as when taking developmental histories
  • Exploring what is ‘difficult’ in ‘difficult patient’ scenarios and trying out communication styles that are respectful and do not compromise patient autonomy
  • How to write a good CV
  • For specific communication skills, the Liverpool Communication Assessment Scale was used. This allowed the students to be familiar with what is meant by communication in medical teaching in the UK and how to objectively observe, as well as deliver it.
    

Outcomes

Of the 31 stranded doctors who were provided with accommodation, 81.7% passed the PLAB exams and 95.2% successfully joined the NHS in various posts. This is significantly higher than average PLAB pass rates (MWRES Indicator 4).

Success factors

A teaching coordinator was present at each teaching session hence being able to link in the learning from previous sessions and assuring continuity as well as consistency of the delivery of teaching.

Having IMGs teach new concepts was thought to be better received than if taught by non-IMGs, and the learning was easier to assimilate. It avoided creating a sense of otherness and at the same time the democratic process allowed an experience of flattened hierarchy and the collaborative spirit.

The sessions of the reflective group - facilitated open communication, the experience of a safe space, and the exploring aspects of wellbeing. This further helped in asking questions during teaching sessions as well as planning of their self-study keeping wellbeing in mind.

The mix of students from different countries and religions allowed discussions on cultural differences and similarities further establishing a sense of fraternity as clinicians that is beyond one’s racial and cultural identity. Most importantly the students were able to experience that their success and their wellbeing truly mattered to the teachers.

When asked what could have been done differently, the volunteer IMGs advised that the following would have helped:

• Having both non-IMG and IMG doctors to demonstrate good and poor communication skills in a consultation. It was thought this could help dispel the myth that it is one’s colour or one’s accent that is responsible for the perception of poor communication skills.
• Recording role-play sessions and improving feedback skills.
• Reflecting on recorded role-play sessions to discuss the principles of GMC’s ‘good clinical care’, including raising concerns. This would have been important in changing the perception of raising concerns – from being understood as a punitive process to the possibility of it being regarded as empowering.
• Having recordings or sessions with IMGs who have a successful career in the UK to demonstrate that embracing learning and acculturation can pave the way to success.

In 2019, Sussex Partnership NHS Foundation Trust, initiated a “Balint and Reflective Practice Group" for International Medical Graduates. This consisted of fortnightly sessions, mostly online, which was facilitated by an IMG consultant psychiatrist with a Balint Group qualification.

The group was made up of 12 IMGs from Sudan, Nigeria, Brazil, India, Egypt (4 men, 8 women) who had been in the UK for 1-4 months and none of them had previous experience of Balint Groups.

The group supported IMGs with processing and verbalisation of acculturation. It started off with very practical things like housing, GPs, visas, etc, and then moved on to basic differences in medical interventions between home country and UK managing social issues.

Themes covered included: Power and powerlessness, autonomy, pressure of the system, making mistakes, isolation of being a doctor in a team and how to have a voice in a team setting, communication with angry patients and carers, changes in way of relating to patients (and colleagues), giving and receiving feedback.

Outcomes

The intervention has led to several successes. Seven participants have progressed to trainee or consultant status or a promotion elsewhere (MWRES Indicator 2).

The rest continue to use the group and value it.

Participants’ confidence to use their “fresh eyes” to ask why things are done in a particular way, has facilitated clinical improvement in teams (MWRES Indicator 10). No complaints have been made against the IMG participants, either from public, patients, colleagues or employers (MWRES Indicator 3).

Success/enabling factors

The project was sponsored by the Director of Medical Education, with time allocated to the facilitator. The facilitator is an IMG consultant psychiatrist who had knowledge of working with groups as well as being able to support discussion about clinical psychiatric management of cases. He used active administration i.e. - noticing when someone was missing and contacting them, letting people know that they are being kept in mind. Being online made it easier for people to attend (only worked because had met face-to-face initially).

Case Study: Engaging SAS doctors in a provider trust

In West London NHS Trust, there are approximately 50 SAS doctors employed on a variety of contracts, the majority of whom are minoritised ethnic staff, and a significant percentage are IMGs. In 2022, the Trust developed two “Appreciative Inquiry” workshops in order to better engage with its SAS doctors and improve their sense of feeling valued and belonging.

Appreciative Inquiry” approach is a Quality Improvement method that uses a “5-D co-design cycle” to (1) Define focus, (2) Discover, (3) Dream of what could be, (4) Design what should be, and (5) Destiny – implementing the collective design.

Outcomes

13 SAS doctors attended one workshop and 17 attended the other, with some overlap.

The workshops had a positive impact on SAS doctors in the areas of MWRES Indicators 9 and 10:

• 100% felt more engaged with the Trust.
• 94% felt more valued by the Trust.
• 82% felt a greater sense of belonging in relation to the Trust.
• 88% felt the issues that mattered to them had been understood by the Trust.

Senior managers fed back that it was: “probably the most important initiative for retention we have done” and “humbling and eye-opening.”

Within the workshops four main issues emerged as important for SAS doctors:

• Recognition, respect and reward
• Support, supervision, training
• Career progression
• Adequate resource to do the job properly.

This led to developing four working groups with a combination of SAS doctors and key enablers from the Trust corporate structure to design and deliver on the four main issues described above.

Actions so far include: a board development session, development of an SAS-specific intranet page and WhatsApp group, regular away days and the development of a remuneration group to explore ways of aligning capacity gaps and demand issues in the Trust with SAS doctors’ time.

Success factors

Sponsorship and promotion at an early stage was key. The workshops had sponsorship from the Medical Director and Director of Workforce and Organisational Development. There was early engagement with the WLNT Communications team to successfully promote the workshops to SAS doctors, making use of the Trust intranet, personalised invitation emails and phone calls, adverts and a promotion video featuring the Trust Medical Director.

It was important to make it attractive and easy for SAS doctors to attend. This was achieved by asking line managers to facilitate attendance, providing adequate notice to cancel clinics and holding workshops off-site in a hotel with good quality catering. The workshop carried CPD points for SAS doctors.

Senior managers were invited to join as guests (not as leaders or experts) to hear from SAS doctors and collaborate with them to plan actions. This led to the co-production of action plans and was cited by SAS doctors as highly validating.

When asked what could have been done differently, organisers advised the following would have helped:

• Formal feedback from managers as well as SAS doctors.
• On site and shorter workshops to encourage improved attendance.
• Alignment with agreed actions and Trust strategic plan.