Can Do Health & Care - Thinking Differently Together - May 2022

Suffolk and North East Essex Integrated Care System (ICS) 1. Introduction Online event Wednesday 18 May 2022 ‘Thinking Differently Together’ about… What will it take to create a genuinely equal, diverse and inclusive workforce in health and care? The health and care workforce has employed a wide diversity of people since the NHS’s inception in 1948. But we know that not everyone in our workforce has the same experiences and the same opportunities. Frontline staff live with abuse from colleagues and people using their services, and there is a lack of representation of ethnic minority, disabled and LGBTQI+ people in senior leadership positions. These inequalities have only worsened during the Covid-19 pandemic. Our event explored these inequalities, and ways we can address them to create a genuinely equal, diverse and inclusive workforce. The event was chaired by Harprit Hockley, Head of Equalities and Inclusion at NHS England and NHS Improvement. Harprit explained that equalities is her passion, so it is great that the ICS has given inequalities in the workforce a platform and the opportunity not only to hear what is happening locally and more widely, but also to have the space to talk about some of the challenges we face. Harprit Hockley Head of Equalities and Inclusion NHS England and NHS Improvement 1 | Suffolk and North East Essex Integrated Care System

2. Start with Why? Talking about diversity and intersectionality in our health and care workforce David Akinsanya, ICS Central Team introduced a film of Louie and Karn reflecting on their lived experiences of working in the NHS. Louie: You will not forget the first time you set foot in this country. It’s February, it’s very cold, you don’t know anyone, if you are twenty something you are old, a new nurse. You come in and you see your name ‘welcome Louie Horne’. My mind was racing during that time, I don’t know who I’m going to end up with, I haven’t met any of the people I’m going to be working with. Those things play into your mind. You can’t get rid of your whole being, you’ve got your language, your religion, ethnicity, nationality; and all these things affect when you actually start working. You come in and people just expect you to hit the ground running, but you are very new, you don’t know all the new set of laws in this culture. So it wasn’t a very god first few months. People watch you like a hawk, instead of watching me they should have supported me by saying ‘this is how it’s done’. You get a few days’ induction and if you’re not resilient it is very difficult. Every day I used to walk on Felixstowe seafront and cry while walking because of the cold, the loneliness. You are from a country where you are very much familial, and you don’t have any of that support. Now, 20 years later, I provide pastoral support to new nurses coming here within each community. There is a community for people coming from India, one for people from Bangladesh, from African countries. I am talking about my experience years ago but that doesn’t mean they don’t have bad experiences now, because they do. If we have a diverse workforce where everyone’s culture is embraced and understood, and everyone’s aware of it, it creates more understanding between nurses. We can’t undo who we are. But we know that according to research that accents can be a cause of disengagement, so some people who don’t want to listen to my accent will unconsciously disengage with me. One nurse, who looks very young, a patient said to her ‘I don’t want to take that paracetamol off you, you don’t look old enough to be a nurse’. So you explain yourself, you say ‘I have got my degree, this is your medication can you please take it?’… ‘No, I want an English nurse’. It’s painful for the nurses and some managers actually let that happen. They say, ‘It’s patients’ choice, can you move to another ward’, and that is traumatising for that nurse because she will think that every time she will be moved on because her face doesn’t fit. These are not big things we are talking about, it is the micro-aggressions. I always tell the nurses I support to communicate effectively. Because sometimes they shut the door, they cry, and they don’t tell anyone. They say they won’t deal with it and then they become sick with it. To communicate effectively is actually being assertive and saying ‘I’m not comfortable with what you just said.’ Another of my colleagues told me they are not happy for a Filipino to be in charge of a ward, they actually told me ‘I will not leave my ward with that agency Filipino nurse in charge!’ Everyone was looking at me, I was actually facilitating the conversation, and it took my breath away that I couldn’t react properly. I ended up going to my office and getting very upset about it. How about those junior Band 5s who have just arrived in this country? It’s still there. Louie Thinking Differently Together | 2

My message to non-ethnic minority colleagues is not to look away when they hear or see any form of discrimination or disparity because it is there. So if someone says ‘this is my experience’ then hear that person. I am very, very grateful to be in this country. David: In this country we should be grateful that people are prepared to give up their lives in their home country to come here to service the NHS. Karn: My personal experience is that I have worked in roles where people have been quite free to be hostile to LGBT people. And it shouldn’t really be a surprise if people think about it, because the national conversation for decades has been that it’s OK to be anti-LGBT. A very senior colleague let me know that they didn’t approve of same sex relationships, they were quite open about it, but no one actually challenged. I think that is a very typical experience today, because people don’t feel that if they say anything they are going to be understood. The common reaction that you’ll find, and this is true for a lot of people in minoritised groups, is that everyone around you will say ‘oh I’m sure they didn’t mean it that way’. That’s what you get if you start opening up about the experiences. I don’t think they are trying to sweep it under the rug, they just don’t want to believe bad things happen. There is a general lack of understanding about what it means to include LGBT people, for example everybody talks about what they do at the weekend, or their homelife in general, and that’s just normalised, but the same isn’t true for LGBT colleagues. About 50% of people are not out in the workplace. That tells you that it would be a big disclosure to say ‘I went out with my boyfriend to the cinema’, and people are feeling they can’t do that. I have supported a non-binary person, they were seeing some gaps in patient care at the time and they were trying to challenge that, but the people around them didn’t know how to respond. The impact on that colleague was that they felt if they had a problem, no one was going to be there for them. The sexualisation of lesbian colleagues is an issue. One colleague disclosed they were bisexual and the reaction of one of the males in their team was ‘that’s every man’s fantasy’. Again, in the moment, no one challenged that statement. Any NHS organisation will tell you that we expect everyone to be confident to challenge and we expect all of our staff to know how to respond when there is inappropriate conduct, but that reality isn’t always there. Covid forced us to work on Teams and that really brought our staff network to life. We did previously have in person network meetings but we are quite spread out. To really bring it to life and feel a community is difficult so being able to promote over Teams really helped the 50% of people who were not out at work or not completely out. Allyship is absolutely essential. You can’t get anything done by yourself as there aren’t enough of us, but with allies everything becomes possible. For example we have just started our Pride planning, the staff network is coordinating as we have our vision. We have been able to go to the wider staff population and say that you don’t have to be LGBT you can come as an ally, and we have been overwhelmed with the number of people who have forward and said they will help. David: When people do join in Pride it seems as though the problem has been solved, but you are saying that beneath that people are still fearful of coming out, and of talking to their colleagues about what their issues are. Karn: I have had abuse with myself and my partner, just out and about; one day we had two incidents of abuse within 10 minutes. We can’t make people like LGBT people, it’s really up to them. but what we can do is help them understand the impact that certain things will have, how to avoid them and how to provide the care, which is what we are all here to do. Karn 3 | Suffolk and North East Essex Integrated Care System

Why a diverse workforce is key to our ICS ambition of health equality for all Suffolk and North East Essex ICS is committed to tackling health inequalities among the people we serve. We know that in reality some people have few problems staying healthy and getting help with they need it, while others don’t even know what could be available for them. Equality means that everyone has the same starting point, but too many people still suffer disadvantage in accessing treatment and care. Sharon Rodie, ICS Central Team In our ICS we want to work towards equity, where people who need extra support to access services get it, so there is a level playing field. But ideally, we want liberation, where there are no barriers for anyone. This applies to not only people who use our services but our workforce too. A diverse and inclusive workforce is one that is representative of local people, and so can represent them. We need to be representative of people with protected characteristics and diverse cultures, and those impacted through class, poverty and other adverse life experiences in our local population. Representation needs to be throughout the organisation, not just at the bottom, so there are diverse voices at every level. And it is not just about employing a diverse workforce. A diverse and equitable workforce is one that gives people a voice and the power to achieve change. To achieve that, people need equality of opportunity to progress to senior positions so that they have the power to truly influence. A lack of diversity in the workforce impacts on the care we provide in a range of ways, highlighted in Roger Kline’s 2014 report ‘The “snowy white peaks” of the NHS: a survey of discrimination in governance and leadership and the potential impact on patient care in London and England.’: Care will not be genuinely patient/user centred. Care will not be available, accessible, or delivered in the right way because organisations won’t recognise or respond to the barriers people face or the level and complexity of their needs. Recognising those needs means a set of shared values and commitments to understand why inequalities arise and what we can do to put things right. It means developing culturally competent, sensitive staff who are confident to ask people what they need. It means co-producing services that are flexible and responsive, and investing in the people and communities who need it most. Incidentally research shows boards with higher proportions of women members are better at making decisions, are more sensitive to other perspectives, are more efficient and transparent. Thinking Differently Together | 4

Patients will not have access to all the best clinicians and support staff. If staff experience bias and discrimination in recruitment, progression and their daily experiences, they will leave their job and possibly their profession. That means patients and service users won’t benefit from their expertise and their particular understanding of their needs. People will be less satisfied with the care they receive. We don’t know the reasons, but research shows a correlation between the treatment of ethnic minority staff and the care that patients receive. In organisations where ethnic minority staff are discriminated against, patients see the organisation as less sensitive to their needs and less approachable. Organisations will have lower productivity. If staff are treated unfairly at work, this means lower staff morale and higher sickness rates. Time and money is spent on managing complaints and grievances. It means damage to the organisation’s reputation and failure to recruit and retain the right staff. Organisations will innovate less. Staff with diverse experiences can share them to inspire new thinking and new ways of working. Different cultural approaches to treating mind and body can benefit not only those communities used to these approaches but everyone. A diverse workforce therefore helps to prevent misconceptions and ignorance so we can provide better quality services for all. This film was made by Young Health Ambassadors in Ipswich, who are part of our ICS’s Community Ambition programme funded by NHS Charities Together. It highlights what happens when we fail to understand the diversity of the people we serve or recognise their lived experiences. We should listen and do all we can to avoid repeating the mistakes we make far too often. 5 | Suffolk and North East Essex Integrated Care System

On exploring what more we need to know, and what more we need to do in equality, diversity and inclusion, we should focus on three areas: data, talent and place. Data In my first job working in inclusion I was hungry for data, believing that once I had all the data I could share it and everyone would be on the same page; together we would find solutions. But data doesn’t equal will. We can have all the data we need and it would make no difference. The private sector is jealous of the amount of the NHS has available, but in my conversations they also questioned the lack of progress that has been made in some areas. We still need a data driven approach, but we need to use it in the right way. During the Covid vaccination programme I, with colleagues in NHS England, compared vaccination uptake rates with patient safety outcomes data and started to see correlations between places with poor vaccination rates and key data like A&E and cancer waiting times. The data allowed us to make the case to do more with the vaccine programme, as it showed that low uptake was not only about the vaccine itself, it was about how people feel about their treatment and their attitudes to healthcare. We could do more to make the data we have richer, and we need to ensure we contextualise it. I recall being told about a case of sexual harassment, which was dismissed because some elements of the case could not be corroborated. However if you took a step back and looked at the trust’s overarching data you could see it had a general problem with sexual harassment and the retention of female staff. Utilising data in context enables us to take better decisions. There will always be gaps in data so we need to be more agile with what we do have. Talent Too much effort can be placed on addressing a perceived deficit for under-represented or discriminated-against groups, in particular around race. This suggests ‘we will put you on a course for people similar to you, and then after that you can go on the course for everyone’. I do not believe that’s how it should be done, because the person doesn’t have a deficit. It is discrimination that means certain people do not have the opportunities they should. We can either give positive action courses equal status with other courses or change the wider programme to put in place thresholds that accommodate more people from underrepresented groups – whether its race, gender, LGBT+ etc. Sometimes, our approach to talent management has the best will in mind, but the actions we take worsen the situation. People may complete these programmes and still not have the opportunity they need, so clearly we have got something wrong. I am also sceptical about some of the other ways we implement talent management such as ‘stretch opportunities’. Unless a stretch opportunity is leading to something at the end, all we are effectively doing is saying to the person ‘we had a problem and we needed you to help us with it, now you can go back to what you did before’. We are not talking about people who don’t have talent, we are dealing with a system where we are trying to break down the discrimination that prevents them progressing, and this requires us to think differently. International nurse recruitment, as Louie Horne has described so well, is a model that recruits nurses and then asks them to integrate and 3. Understanding the story How diverse is our local health and care workforce – and what more do we need to know? Marcus Riddell Senior Director of Organisational Development, Essex Partnership University Foundation NHS Trust Thinking Differently Together | 6

assimilate to how we do things here. When difficulties arise we should ask whether the issue is that the international nurses may not want to assimilate, or whether it is the welcome they have received - if existing staff are prepared and ready to help them integrate. I recognise that it is unusual for Black people like me to get into senior roles in the NHS. It wasn’t because I haven’t experienced racism - I have - but I was able to navigate the system to be able to progress within the environment. None of the development programmes give you the tools to survive and thrive in environments that are fundamentally discriminatory. Development programmes need to offer this too and we are just starting to look at how we do this in EPUT. Place Developing relationships between the NHS, our workforce and communities is a major focus for our ICS. Some areas of our ICS, for example Clacton, have high levels of deprivation, which is partly caused by a lack of access to a range of things including employment. If we are genuine about NHS organisations being anchor institutions, we can create opportunities for people to work in the NHS or other sectors. We have to ask ourselves if we are anchor institutions because we say we are, or because we do things to make it so. There are clearly opportunities to work in the NHS, but NHS organisations can also establish strategic partnerships with sectors including the commercial sector, for example supermarkets or hotels, to get people into employment. A lack of bravery might be preventing us from doing this, but we have the intellect, and the talent, so why not do it? There are estates directors thinking differently – looking at housing developments and so on, so we need to continue to think imaginatively. Place is also about inclusion. If you start to address what happens in places you can start to address the intersectional issues that people face. In any area of high deprivation people you will have poor access to all manner of services, and this tends to affect certain groups more. Summary Thinking differently is hard but doable, the more difficult thing is taking action. We are doing the right thing by thinking first, the challenge for this ICS will be how we turn that thinking into something tangible. We can do this, but we have to be willing to put the work in. What did we learn about diversity and inclusion during the pandemic? We learned a great deal during the Covid-19 pandemic and it is critical that we don’t lose those lessons, we must build on what we have already started. In Ghana we have a word, ‘sankofa’, and this means that it is important for us to take time to reflect and learn from the past, if we are going to do something positive in the future. The pandemic was one of the worst things to happen to humanity in a generation, we all lost a lot, friends, family, jobs, health and wellbeing. The Dalai Lama said, ‘when you lose, don’t lose the lesson’. Reflecting can help us in creating a truly diverse, equal and inclusive workforce in health and social care. The Ipswich & Suffolk Council for Racial Equality is celebrating its 45th anniversary this year, and our work in all that time has been to shine a light on inequalities and the challenges that face people from racially minoritised backgrounds. NHS Foundation Trust Essex Partnership University Phanuel Mutumburi, Director, Ipswich & Suffolk Council for Racial Equality 7 | Suffolk and North East Essex Integrated Care System

Alan Lally Francis, Head of Influencing, Association of Chief Executives of Voluntary Organisations (ACEVO) We see that in health, education, employment, housing and other areas, we are talking about the same issues today as we did in 1977. Since the pandemic hit people have been coming and telling us about their experiences, and they are disheartening. People were coming to ask for help in fighting Fixed Penalty Notices, and these were frontline workers who were out working in frontline jobs in health and social care or in factories. At that time everyone was being told to stay at home, and yet some of these people who were helping put food on our tables and looking after our sick were being stopped and searched by the police. In Suffolk and the East of England, social media and some of the newspapers were saying that it is these people who were out and about, who were causing problems and worsening the pandemic. For thefantastic people, who were literally running towards danger to help us while we were isolating at home, to then have that experience, was one of the most difficult things that we had to support people with. We did help as much as we could, but it was clear that this group, disproportionately from diverse backgrounds, was negatively and unfairly impacted by the pandemic. People were losing jobs, falling ill or dying; they lacked proper protective equipment as they found themselves redeployed in areas outside their professional training and expertise. We are proud of the role that people in our communities played in the pandemic. In Suffolk we came together under the #whatarewemissing? initiative, which was an opportunity for our authorities to really listen and reflect on what our communities were saying. We listened to our different communities, and they told us how wanted to be supported, and we have seen that when we do work with our communities, we can build something really positive. But I can also see that we are slowly starting to lose some of that momentum, and it will be a shame. Our communities will not forgive us for that. My rallying call is to ask that we all come back together with the same momentum. Some of that momentum was driven by people feeling uncomfortable, and they still need to feel uncomfortable as those inequalities still exist. We need to continue to listen to our communities, to work together with them and to build on the positive things we did during the pandemic. Racism and inequality in the Voluntary, Community and Social Enterprise sector Currently only 9% of charity employees and 6% of chief executives are from Black, Asian and minority ethnic (BAME) groups. The term ‘BAME’ can be problematic and should not be homogenised as there are lots of layers and varied experiences within different communities. I am a first-generation immigrant with one parent who is from Pakistan and the other from India; one is Catholic and the other Protestant; my name before marriage was Francis, and after marriage is Lally Francis; all of these situations do not ordinarily happen, and we need to recognise complexities like these in people’s experiences. There are fewer people from BAME communities in the charity sector than in the public and private sector. The figures are particularly problematic in a place like London where 40% of the overall population is BAME with only 12% representation in the sector. We know that diverse organisations perform better, adding inclusion to organisational culture produces vibrant teams, it leads to better Thinking Differently Together | 8

of respondents said that they had experienced, witnessed or heard stories about racism in their time in the charity sector of respondents felt that they needed to ‘tone down’ behaviour or to be on their ‘best behaviour’ in order to fit in in the charity sector people had been subject to ignorant or insensitive questioning about their culture or religion people had been treated as an intellectual inferior respondents had been subject to excessive surveillance and scrutiny by colleagues, managers or supervisors 222 114 outcomes and encourages workplaces where people can be their authentic selves. The charity sector, like the NHS, has done an amazing job during the pandemic, being at the forefront of looking after people and their communities. The perspective of the charity sector, like the NHS, is that they are all good people, but there is good and bad in every sector. The charity sector has had a reckoning, recognising that we have all fallen short, and at times been complacent, over the years. We would expect in a sector working with inequalities that there would be a greater representation, but as I have shown, this is not the case, particularly in senior roles. In 2020 ACEVO published the Home Truths report, not to question whether there is a racism issue in the sector, but to talk about the extent of the problem. The launch in May 2020 coincided with the outpouring of grief and anger around George Floyd. The report looked not only at representation but also the cultural experiences of BAME communities in the charity sector. Our survey of almost 500 BAME staff found significant numbers had experienced direct or indirect racism, many felt they needed to tone down their behaviour to assimilate, and many were subject to micro-aggressions. 50% 68% 147 9 | Suffolk and North East Essex Integrated Care System

There has been a lot of defensiveness and fragility in the sector. While working in international development, I was told by a white person that diversity isn’t about race, the message being to keep quiet and know your place. Diversity is meaningless if the conditions aren’t safe. I am glad that the conversation has started in the sector, there are some good initiatives on social media and elsewhere such as Charity so white and #NonGraduatesWelcome and Show The Salary who are helping to move the sector to more equitable practices. There is also a charity governance code so boards now have a clear framework on how to make progress in equality, diversity and inclusion (EDI), particularly around race. What more can we do to tackle this issue? A recent survey highlighted ‘the big resignation’ where people have more expectations about where and how they want to work. two thirds said that an organisation’s approach to EDI was very important to them, so it would be remiss of any organisation not to take this seriously. There are a range of ways that leaders can drive change: • It is important to reframe this as an opportunity not an obligation. • We need to do the basics such as not Anglicising names, having diverse panels and paid internships. • Leaders should recruit openly instead of appointing from their networks (where they will just in effect be appointing themselves). • Having ‘desirables’ in job descriptions is unhelpful: either you need something or you don’t. • An increased focus on retention is important, as recruiting is great but stopping people from exiting is very different. • Everyone’s experience is similar but different, so recognising intersectionality is vital. • ACEVO has asked our members to sign up to eight leadership principles to address diversity and race, and 130 have signed the list of commitments. Our approach is simple: organisations report to us every year and if they are not progressing they come off our list of signatories. • Publishing data, tables and plans on representation. Publish your ethnic pay gap, report publicly on your EDI targets. Transparency and explaining helps avoid the ‘tick box exercise’. • Create and share transparent safeguarding and support processes for affected groups. For example are there safe spaces for people? Do people feel they can trust to go to their manager if they experience racism? Often they don’t, and instead talk outside, and to each other. There are some challenges, but just encourage everyone. None of this will be resolved overnight, quick fixes won’t work so look longer term. A lack of flexibility on this work and being unable to adapt can sometimes hinder progress, so be creative and trial new things, mistakes will be made but don’t let perfection be the enemy of progress. Surround yourself with people who will say, ‘your heart is in the right place, let’s stop this and try that’. Support the diverse groups in your sector; even if it is not perfect, which it often isn’t at the outset, the offer will be much more appreciated than the silence, denial or defensiveness that so often comes from a fear of getting it wrong. You can read the full report by ACEVO and Voice4Change England (2020) Home Truths: Undoing racism and delivering real diversity in the charity sector here. Thinking Differently Together | 10

Diversity and inclusion in the care provision workforce It is important to recognise and understand how the historical issues and perceptions of social care workers contribute to the inequalities they face. Social care staff are perceived to be unskilled workers, with many people unaware of the amount of training they have to undertake. It requires skill to communicate and negotiate with the vulnerable and sick and to undertake specialised tasks. Registered nurses working in the care sector do not get the same recognition as colleagues in the NHS, and this affects morale and status. Care staff are paid low wages. The care sector has been chronically underfunded for years, so providers can only afford to pay staff the national minimum wage. Commissioners do not take into account the disparity between wages for unsocial hours when determining the fee structure, and there is no parity between social care staff and NHS healthcare workers in terms of skills and salary. Both employers and customers expect overseas workers will work long hours and unsocial shifts, because their work ethic is seen as stronger than their British colleagues. Carers have to be available at the time the client specifies, regardless of the pressures on staffing. A significant percentage of society regards care work as menial, and there can be bullying by some customers to ensure that their needs are met immediately whatever the cost to the carer’s time, rota or even feelings. Gender and racial discrimination is not unusual. Customers often stipulate that they only want female carers who are white British, and some will refuse ethnic minority care workers. Some white British care workers are unhappy to work with ethnic minority colleagues, and ethnic minority staff can experience jealousy from white British colleagues if they work well and are rewarded or promoted. Some white British workers feel that the overseas workers have come to take their jobs and their hours. Staff and customers’ criticisms of ethnic minority care workers include `they can’t speak well’, `they don’t understand’, or ‘they are too rough’. British care workers are often not prepared to invest time to teach and train their overseas colleagues to achieve the standards we require, even though they are an asset and will help them in the long run. There are significant challenges for the whole workforce. Recruitment of care staff has stalled as people are not prepared to work long hours, weekends and evenings. Since the pandemic some people have revisited their work life balance, so are limiting their work to only social hours. Those who will work unsocial hours eventually burn out, feeling `put upon’ and that rostering is unequal. Female carers are also often juggling work and home commitments but are often labelled as inflexible. Workplace culture can be such that it does not promote equality/diversity/inclusion in the workplace. It is common for care workers to form cliques with one dominant member and others acquiescing just to feel included. This may be under management’s radar and so is neglected. Some organisations lack flexible work practices, which means some part-time workers will be excluded. Mentors in the workplace can prevent unrest and encourage good practice in a very stressed environment. How we can move towards more inclusion, diversity and equality: • Educate our leaders and managers to recognise the strengths and benefits of an inclusive, equal and diverse workforce. They should lead by example and learn from different staff’s work ethics and commitment to upskilling themselves. • Appoint members of staff who truly believe in the benefits of a diverse, equal and inclusive workforce as Champions. They can meet regularly with staff face to face or virtually to provide help, guidance and supervision. Prema Fairburn, Chair, Suffolk Association of Independent Care Providers 11 | Suffolk and North East Essex Integrated Care System

• Celebrate employee differences by highlighting their strengths, commitment and performance. Social engagement enables sharing of culture through food, music etc. and contributes to team building. • Listen to employees concerns and, respond in a proactive way through sensitive engagement with all parties involved to find workable solutions and implement immediately. • Engender a culture within our teams that values all staff and actively promotes their career aspirations through job promotions or upskilling. • Use positive images of a diverse workforce in marketing brochures, newsletters and service user guides. • Communicate organisational goals clearly and monitor progress, so that staff teams can see progress. • Work with health and social care partners to educate and increase awareness amongst our customers of the diversity of the social care workforce, as well as the need to respect our policies and practices on equality, diversity and inclusion. How employers can help recruits from overseas: • Ensure recruits are welcomed on arrival, have accommodation, and undergo carefully tailored training on care, operational philosophies, cultural awareness (UK), and working as a member of a diverse workforce. • Help them to obtain a bank account, National Insurance number and GP practice, and signpost to the nearest amenities (shops, post office, fuel station). Where required, arrange driving lessons and loan a pool car initially. Arrange a buddy with a British member of staff. • Encourage recruits to converse in English to improve their communication skills, and some may need accent-softening classes. Good language and communication skills help the recruits to overcome some of the problems they could face when dealing with customers/ service users. • The whole process needs to be handled sensitively whilst at the same time acknowledging the skills and knowledge of new recruits. Incredibly powerful testimony from Louie and Karn. As someone who is neurodiverse its often treated as a deficit but it’s important to think of it in terms of talent and different way of experiencing the world. Thinking Differently Together | 12

4. How we can work together to make a difference Our strategic approach in the East of England: anti-racism strategy Development of the NHS East of England anti-racism strategy started in January 2020, when our regional Human Resources Directors’ (HRD) Network highlighted that they had seen data year on year that showed no sustainable improvements in achieving the Workforce Race Equality Standard. The pandemic then hit, demonstrating the stark disparities and longstanding health inequalities. In July 2020 the NHS Chief Executives forum gave us a commission to focus on race as a priority, to look at how we could better support the workforce. From September 2020 we held a number of events bringing together a wide range of stakeholders including HR teams, Equality, Diversity and Inclusion (EDI) teams, trades unions, and staff networks, to interrogate the data and to explore how we should prioritise action so we don’t just drown in the challenges of EDI. In July 2021 we formally launched our anti-racism strategy, which I see as the start of this work, as having a strategy and a plan won’t achieve the change we need, it is by having sessions like today’s and having people lead change, when we will start to see improvements. The graphic below describes at a high level our strategy. There are four pillars to our approach: • Providing education and encouraging commitment; • Creating environments of civility, respect and safety where bullying can be recognised and tackled effectively; • Increasing senior level representation and retaining talent so we can modernise our services, as well as widening representation in decision-making; and • Achieving systemic and sustainable change through policies that mitigate against inherent biases in recruitment, retention and disciplinary procedures. Through these approaches our primary goal is to improve the experiences of our staff. Harprit Hockley, Head of Equalities and Inclusion, NHS England and Improvement 13 | Suffolk and North East Essex Integrated Care System

The challenges in improving EDI are longstanding, so what will be different this time? Our senior leaders are taking responsibility and are leading from the front, so we are working with our chief executives and ICSs to implement this change. We have taken a partnership approach, asking people what would help, in other words ‘Nothing about me without me’. The joint regional strategy means we are all working towards a common goal. Very often in efforts to improve EDI, a list of interventions is created in response to the latest data. Instead, we need to look at the evidence base for systemic changes, including evidence from research and from other sectors. We also need to share the best practice that is already happening regionally and nationally, to make it easier for people to affect change. We need to take joint accountability, as change is the responsibility of us all. We also have to engage with our communities to improve staff experience. As well as our strategy we have started to publish resources on our website, including a toolkit and guidance on recruitment and promotion practices and educational material. We also want to broaden our reach to other protected characteristics. england.equalityeoe@nhs.net @HarpritHockley www.england.nhs.uk/east-ofengland/nhs-east-of-englandequality-diversity-and-inclusion/ Thinking Differently Together | 14

The approach to equality, diversity and inclusion in local authorities I am working currently between two council areas, Babergh and Mid Suffolk District Councils and Kensington and Chelsea Council where I am working on recovery after the Grenfell tragedy five years ago, one of the most challenging programmes in local government at the moment. In equality, diversity and inclusion it is important that we think differently. Like other institutions, councils have an equality framework for local government and an equality standard, and foremost in the framework is that councils are asked to understand their communities. This means we should make sure that our workforce is inclusive and representative, and that when we commission services we do that in the context of equality and diversity. In terms of inequalities, we know the disproportionate impacts of Covid, and in local government we share some of the institutional issues around race that we see in the NHS workforce. George Floyd’s murder became a flagship moment across local government. For the first time institutions understood the power of privilege and the impact it had on the decisions we were taking. Public Health England published its report on reasons for disparities in Covid and mortality, but it is important to recognise another underlying story. When minoritised communities first came to this country, in the context of the history of colonialism, imperialism and slavery, if we knew then what we know today about the trauma experienced by those communities, I don’t think the NHS would have been able to cope. If we think about how inequalities have continued to manifest over time, with Covid as the most recent, we see that privilege has never been properly targeted to help address the issues. One significant factor is the Euro-centric lens that we apply to policy and practice, so anti-racism is really important. A couple of years ago in the European Championships, when three Black players missed a penalty, Gareth Southgate said that he recognised he understood what it was like to miss a penalty but had not realised the additional impact of racism in that situation; in fact, minoritised communities had immediately known what would happen. Gareth Southgate talked about how it was right to be uncomfortable about privilege, and people need to use the strength of their privilege to do something different. Our strategies need to be more productive, reflective and inclusive of the people that we say we are going to support. I worked in Oxford with the community to co-produce an anti-racism charter, which we did in partnership, and with institutions recognising their responsibilities. We thought about how we could develop a kitemark, for example, and how to really develop a culture of inclusivity. Inclusivity is different to equality and diversity. For example as a Muslim, I would have been afraid post 9/11 to come to work in a shalwar kameez and talk about Ramadan due to how I would have been perceived, and in fact many of us stopped being who we are. When we talk about inclusivity, we talk about how we want the ‘whole person to attend’ but that does not happen; when I work in institutions I put on the Euro-centric veil in order to get on, to develop and to be promoted. I can share that as one of the few minority Directors nationally who has worked in a number of institutions, the higher up the chain you go the more of the imposter syndrome you feel. You become more aware of moving away from the safe spaces within communities where you can have a dialogue, and you find the philosophy at the top of organisations is not inclusive. At the moment the country is at a crossroads. It is likely that the latest census will show that diversity has grown, including growth in mixed race relationships. Minoritised communities account for around 6-7 million people and by 2030 the number is projected to rise to 25-30 million, so the case for change and evolution is significant. We need to move away from the traditional NadeemMurtuja, Interim Director of Communities & Wellbeing, Babergh and Mid Suffolk District Councils 15 | Suffolk and North East Essex Integrated Care System

Euro-centric approach and paying lip service to equalities, to start a new dialogue. We know the answers to EDI, so why don’t we just get on and implement them? The answer to that question is significant in itself. There are some practical solutions. In Oxford we published a disability pay gap, which was really important as it enabled us to break down the disability profile within the different tiers of the organisation. This helped us to better understand where people were not progressing, where we were not developing talent in the organisation. We also applied an intersectional lens to understand the multiple barriers people face. We could be more business-focused around EDI, so if we want a more representative and inclusive workforce we need to ask senior managers to develop this talent, and if they don’t, we need to ask why we are not maximising our return on their investment in people. Focusing on a return on investment helps tackle issues of imposter syndrome and achieve representation right through the organisation. We should also think about enabling people to be themselves. There is a business case for diversity. We are in the middle of a cost of living crisis, and minoritised communities are going to be impacted; if we don’t prevent that it will cost the public purse a lot more. Here the alliance model can have real value, by doing things collectively as a system to drive place-based delivery, and to share intelligence better within the system and through people telling us the issues that affect their lives. I am keen that we recognise and maximise the skills that exist within communities through grant programmes that give people the power to understand their strengths and address the issues that directly affect them. We can also connect development of talent in the workforce and the outputs and outcomes of what we do. In Babergh and Mid Suffolk we are developing a community leadership programme which incorporates participatory budgeting, bringing community representatives and democracy together so that we really understand our communities and don’t apply a one-size-fits all approach. We ensure that our actions are co-designed with the communities they are intended for, rather than imposing upon them, and we are driven by inclusivity. In this way change is led by, shaped by and owned by communities. I believe that local government thinking about equality, diversity and inclusivity is in a positive space, it has to be because of the need to tackle the impact of Covid, the cost of living and the significant inequalities in our communities. Need to add to the narrative understanding and exposing privilege. Addressing micro aggressions and origins of bias also needs to be addressed to truly be inclusive. Thank you Sharon Rodie a clear and powerful message. Our diverse health and care workforce is the most powerful asset we have in tackling health inequalities. Thinking Differently Together | 16

Creating career ambitions for people with disabilities Essex Cares Ltd (ECL) and Essex County Council are collaborating on a new ground-breaking project helping adults with learning disabilities and autism to achieve aspirations of paid employment, changing Essex one employer at a time. The project came about by bringing lots of people together, and people with work aspirations in Essex told us that they want to be in paid employment, in the same way as non-disabled people. We started with a 100 Day Challenge to test ideas, and in the first year of our project the focus was on moving existing ECL customers from a traditional day centre-type environment into paid work, building on vocational training and work experience already offered by ECL. From April 2021 the scheme was opened to external recruits aged over 18 with a learning disability or autism. Our aim is to avoid people ending up in a statutory, institutionalised service when employment is achievable for them. The contract enables Essex County Council to work towards achieving the following outcomes: 3 More people with disabilities in Essex in employment. 3 People have reduced reliance on traditional day services. 3 People are supported to contribute and feel included within their local communities. 3 People’s independence is increased. 3 The Service maximises the use of assets. We asked our funders, Essex County Council, if we could do things differently. We have talked over many years about how people with learning disabilities and autism should be employed, we have done the thinking and defining, and now we are doing it. Despite Covid and three lockdowns, at end April 2022 we have managed to achieve: • 140 customers, including many who had never worked before, in paid jobs. • 9,700 days of Day Services freed up. • People are coming into our service and moving directly into employment, avoiding day centre provision. • The project is life-changing for some - one customer had been in a day service for 34 years and is now in paid employment. • 45 additional people are in voluntary work positions to gain skills before moving into work. Overall, the Inclusive Employment team has supported 2000 job applications, 275 interviews and 75 work trials. Our work trials have specific objectives, within specified timeframes, and are realistic. Our team includes Inclusive Employment Consultants, an engagement lead, job brokers, job coaches and sustainment officers. Sue Wray, Inclusive Employment Business Manager, Essex Cares Ltd “Our lives are very isolated, and I know that I, and others like me would feel more included if we were doing a normal job. It’s rewarding to know that you can succeed – no matter how long it takes.” Lori, Essex Cares Ltd Brentwood customer, who gained employment in December 2020 17 | Suffolk and North East Essex Integrated Care System

We provide support to our Inclusive Employers, and to date we have had 900 meaningful conversations with Essex employers and supported 65 employers to become Disability Confident. Our focus is on sustainable employment so that people can remain in work and progress, for example to increase their hours. Some people are now even self employed, starting their own businesses. Some of our people are graduates who just need extra help with applying and interview to secure a job. Some employers need support to make adjustments in the workplace, for example a quiet environment or time to think. We also use Access to Work where appropriate, provide job coaching and help ‘settling in’ to their team, easy read policies and risk assessments, and support with employee induction. Our partner employers also receive a digital toolkit so they can publicise that they are Disability Confident – although not all those who claim they are Disability Confident actually employ someone with a disability. We work with a wide range of employers, but we the NHS is not a partner employer, although we have tried to approach them and ECL is part of the local anchor network. It would be great if after today NHS organisations locally become Inclusive Employers, as there are many roles that our people would like to take up, for example digital or administration. Employers tell us that being Inclusive Employers has changed their organisations, and given them and their workforce a new lease of life. The journey for our people moving from Day Services to Inclusive Employment is described below, and includes comprehensive vocational profiling, the opportunity for vocational and accredited training, and a focus on employment sustainability. We have encountered some bumps along the road, including barriers from care providers, families, friends and carers as the person adjusts to change from a safe day environment to the world of work. We have encountered a lack of recognition of the person in their own right, needing official paperwork, ID, bank account etc., and help with travel. However we have worked hard to overcome these and we are really proud of all our successes. Thinking Differently Together | 18

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