Purpose - The purpose of this paper is to examine the business case for ethnic diversity in the British National Health Service (NHS). It seeks to contextualise issues around diversity within the current political environment, and identify the barriers to diversity in the NHS. The business case has been very strongly argued as justification for introducing both managing diversity and equal opportunity initiatives - here the paper examines the inconsistencies of using that argument, and maintains that the only justification worth presenting is that based on (deontological) moral arguments. Design/methodology/approach - The paper is conceptual in nature exploring the respective cases for diversity using a broad range of the available literature brought together as part of a rapid evidence assessment. It does so in order to make some far-reaching claims about the future justifications for active diversification of senior management in key public sector institutions. Findings - The distinctions between the business and moral cases are false, in that both have ethical reference points. However, the business case is not only difficult to translate to public sector institutions; there are also evidential problems with its adoption. In light of this the conclusion here is that the moral (deontological) case is the only one that has any long term value for proponents of diversity. Originality/value - The value of this paper is that it examines the confusion that surrounds different cases for advancing diversity as a policy aim and presents a clear delineation of them. It also draws out some of the - perhaps deliberate - blurring of the cases and underlines the huge problems with this all too common approach. Ultimately, it suggests that morality (deontological) arguments have most purchase in public sector organisations.
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Introduction
The arrival of the current conservative-led coalition government frames the context of an intriguing time for those interested in matters of diversity and equality of opportunity, particularly in the context of the health service and the UK public sector more widely. Not only is the future structure and organisation of the National Health Service (NHS) currently at the forefront of public and political debate as a result of the Health and Social Care Bill, but the stance of the government on issues of diversity is causing concern in some quarters. Early in his premiership Prime Minister David Cameron announced that "multiculturalism" had failed. In its stead the coalition would advance a "muscular liberalism". A large part of this project involves enforced cultural integration, in the process ignoring institutionalised forms of discrimination ([96] Wright and Taylor, 2011).
However, despite this aversion to cultural pluralism there appears to have been little change in the declared policy aim of increasing workforce diversity inherited from new labour, with the public sector still being seen as having a duty to lead the way ([28] Equality and Human Rights Commission (EHRC), 2011). This no doubt reflects the reality that some groups continue to be significantly disadvantaged in the labour market, in particular black and minority ethnic (BME) groups, our specific focus in this paper ([27] EHRC, 2010; [63] National Equality Panel (NEP), 2010; [38] Heath and Yaojun, 2010; [62] National Audit Office, 2008; [73] Platt, 2007; [7] Cabinet Office, 2009). According to [74] Race for Opportunity (RfO) (2008) there may still be a colour bar to management jobs in the UK, 33 years after the passage of the Race Relations Act 1976. The "most disturbing conclusion" from the report is that this shortfall between ethnic minorities' representation in the UK working population and their share of management jobs shows no sign of narrowing.
At one level, the NHS can be seen as a major success story in that it has long had a diverse workforce, but mirroring the wider context of management profiles - ethnic diversity in the upper echelons has remained disproportionately low ([54] Law, 1996; [65] NHS Institute for Innovation and Improvement (NHS III), 2009; [29] Esmail et al. , 2005, [14] Crisp, 2011):
People from Black and minority ethnic communities make up 35 per cent of its doctors and dentists, 16.4 per cent of the nurses and 11.2 per cent of non-medical staff. However at the top of each NHS organisation, the boss is almost always White. There are more than 600 NHS trusts, health boards, local health boards and health and social services boards in England, Scotland, Wales and Northern Ireland, and fewer than 1 per cent of them have a Black or minority ethnic chief executive. The contrast between snow-capped summit and the mountain base could hardly be more stark.
This quote reported in The Guardian ([10] Carvel, 2003) by Trevor Phillips, former head of the Commission for Racial Equality (CRE), vividly underlines the nature of the problem.
In this paper we explore the barriers to achieving an ethnically diverse leadership faced by the NHS. "Leadership" is defined broadly to include both senior management and representation on governing bodies, which is not ideal but the intricacies of these distinctions need more time and space than are currently available. We engage here in a theoretical exploration based on a rapid evidence assessment of the literature on ethnic diversity, equal opportunity and diversity policies, the theoretical justifications for such policies and the concept of leadership. Rapid evidence assessments involve gaining as comprehensive a review of the evidence as possible within a restricted time period on the policy area/issue at hand. It is:
[...] a new approach to harnessing robust research evidence for policy makers in a more focused and timely way than many other secondary research methods. [It] orders and filters research evidence in a similar way to a systematic review. However, systematic reviews require considerable effort and time. REAs are more likely to meet the urgent timescales of decision makers ([6] Butler et al. , 2005, p. 1).
The review progressed through four stages ([57] Macmillan, 2006, p. 11):
(1)] the initial search for seemingly relevant material (via a predetermined strategy);
(2)] obtaining relevant material;
(3)] assessing material for relevance (through an established protocol); and
(4)] assessing the evidence (using an assessment pro-forma).
This was carried out over three months in 2011, between August and October. The assessment was conducted in advance of an empirical, multi-method research programme.
In a future paper we will outline the methodological issues in more detail, but for now we intend to outline two areas of conceptual importance. First, that the stated rationale for pursuing diversity as a policy objective has become profoundly muddled. Second, that there is little clarity about what diversity means for the NHS in terms of either desirable means and ends. However, this paper does not explicitly discuss the policy options by which diversity is pursued (but see [45], [46] Johns, 2004, 2005), since it is a related, but separate issue.
Initially we discuss the specific situation in the NHS by underlining the representation of BME communities in leadership roles, before drawing out the important distinctions and tensions between diversity and equality of opportunity in theory and practice. The way in which diversity is defined and measured is critical but often remains unclear, as is the basis for pursuing diversity whether in general or leadership terms. When competing claims - framed as justice vs utility (the business case), are set side-by-side we suggest that the most consistent argument for the NHS to diversify its leadership profile is the moral case. As a public sector organisation doing what is right should take precedence over what is expedient (especially since the business case is largely unproven) though maybe, as we ultimately posit, there is a direction the NHS can take which better reflects its service ethos.
The ethnic profile of NHS management
A report produced by [75] RfO (2009) claimed that 33 years after the passage of the 1976 Race Relations Act the share of management positions per se occupied by BME groups had barely altered. Indeed there was real concern, based on statistical projections, that the situation may well get worse. In 2007 the representation of BME groups in the workforce was elevated when compared to the general population, 14.1 per cent as opposed to 12.1 per cent, but that only 8.3 per cent of senior managers were from BME backgrounds. However, it did claim that in comparison with the private sector more had been achieved by the public sector overall.
Nevertheless, when we turn to the NHS specifically, [29] Esmail et al. (2005) state that BME groups continue to be under-represented in senior professional roles. London had the highest numbers of BME workers (15.1 per cent in 2007), but this fell well below the proportion in the general population, which was 39.6 per cent. Similarly, for middle managers, London had 10.1 per cent in 2007 (7.3 per cent in 2004). Across the NHS people from minority ethnic groups accounted for 16 per cent of the NHS workforce in 2008 and 30 per cent of nurses and doctors, but fewer than 10 per cent were in senior management roles and only 1 per cent reached the position of chief executive ([8] Care Quality Commission (CQC), 2009; see also [29] Esmail et al. , 2005).
In recognition of patterns like this the [33] Government Equalities Office (2009) and Cabinet Office set targets in 2009 for diversity in public appointments, appointments that include non-executive directorships and various forms of committee membership, accompanied by a cross-government action plan ([7] Cabinet Office, 2009). This meant that by 2011, amongst other things, "Asian" and BME groups should comprise 11 per cent of public appointments (up from around 6 per cent in 2008/2009).
Despite the negative evidence on diversity, the NHS has recognised that there are problems in relation to diversity as a concept and has been working since 2000 to bring about change ([54] Law, 1996). In 2000 The Vital Connection was published outlining governmental expectations of the NHS in terms of equal opportunities running until 2010 ([15] Department of Health (DoH), 2000a). This was supported by a framework strategy detailing the operational aspects, supported by national development programmes such as Positively Diverse ([16] DoH, 2000b) and the Improving Working Lives Standard ([17] DoH, 2000c). In 2004 a ten-point Race Equality Plan was implemented ([18] DoH, 2004) and an Equality and Human Rights Director was appointed.
The commitment to the fair representation of disadvantaged groups in top management teams is exemplified in the creation of the National Leadership Council (NLC) within the NHS, which is tasked to:
- Work beyond developing leaders and defining leadership posts to influence levers, incentives and barriers to participation of talented people from all backgrounds.
- Take particular actions both to attract, and to remove the barriers for, clinicians, and those from minorities, who will then be motivated to apply for leadership posts.
It also had a dedicated inclusion strand with an emphasis on innovation ([64] NLC, 2010), but this has subsequently been refined as "Leadership for Equality" (www.nhsleadership.org/workstreams-inclusion-contact.asp). The prospective benefits of a more diverse leadership have been identified as improving morale and productivity, exploiting the creativity and innovation latent within the organisation, as well as generating trust within service populations ([29] Esmail et al. , 2005). Before we move forward and engage with justifications for action, there are key definitional issues that require clarification.
What do we mean by diversity?
As stated above one of the key obstacles facing policy-makers aiming to diversify the senior management teams in major public sector institutions such as the NHS is to know exactly what the ultimate objective is. This lack of clarity is partly due to the confusion that defines much of the writing around equal opportunities and diversity, and the way in which these ideas have influenced the relevant legislation.
The first task must surely be to create the appropriate theoretical distance between active diversification and the equalising of opportunities. In too many instances these policy goals are inappropriately intertwined. For the sake of clarity the terms equal opportunities, equality and diversity need to be defined and the distinctiveness of each strongly underlined. Several authors conflate concepts that are in theory, and therefore inevitably in practice, distinct, and often, antithetical. For example, there is a modern tendency to talk of equality policies which arguably implies an outcome measure when the author, academic, professional or official is actually referring to instruments designed to achieve greater equality of opportunity. As articulated by [44] Jewson and Mason (1986) many years ago, equal opportunities policies are designed to make inequality appear fair. It is not about equality but simply justifying inequalities of outcome. Similarly when the terms equality and diversity are conjoined, in theory this is plausible, but not in the way they are used in the UK. In fact, it would be more accurate to eliminate equality from the debate altogether unless it is linked explicitly with opportunity. We suggest that this opacity in language is meant to narrow the scope of equality to make opportunity the only possible interpretation of it. The British NHS is as prone to these mistakes as others, frequently referring to equality and diversity policies with little attempt to clarify the nuances we have identified.
Most importantly, for our purposes, the link between equality of opportunity and diversity needs to be broken. In several places we have written about the different versions of equality of opportunity, namely, the formal, liberal and radical approaches ([47] Johns and Green, 2009). The only one of these which has any genuine relationship with diversity is radical equality of opportunity otherwise known as positive discrimination, and as this is currently illegal (except in a very limited number of instances) this is virtually irrelevant. Neither formal nor liberal approaches - both at the heart of UK equal opportunities legislation - have a strong association with diversity. Their principal object is to equalise opportunities, which means that as long as every individual in the identified target groups and communities has an equal opportunity to succeed they have fulfilled their potential. The fact that this remains very far from the case is not important for our purposes, what is important is that even in theory the aim is not to achieve diversity but to make sure opportunities are evenly distributed. If the assumptions that underpin this thinking are correct and that favoured characteristics are equally distributed across groups then diversity would naturally emerge, but, if diversity did not emerge (because of subtle/institutionalised discrimination, individual or culturally determined choices) this would be acceptable as long as opportunities are not openly restricted. We maintain this even though as [147] Law and Harrison (2001) point out liberal equality of opportunity can include goals and targets for under-represented groups, largely because there is no specific mechanism for fulfilling their achievement. Saying more at this stage would lead too far into a policy discussion but we do need to briefly move into this territory for a moment.
Managing diversity is concerned with individual, rather than group needs, and the case for diversity has been largely linked to business performance ([9] Carnevale and Stone, 1994). Managing diversity is seen by some to be a more positive way of approaching inequality, by focusing on the positive differences of staff attributes, rather than the traditional equal opportunities approach which is a punitive system for preventing and addressing discrimination ([59] Maxwell et al. , 2001). Indeed [21] Dickens (1994) argues that the diversity approach is actually more in keeping with the spirit, or intention, of the law because of its focus on outcomes ([81] Schneider and Ross, 1992). The development of the business case for diversity emerged largely from the observation that the laws and policies rooted in equal opportunities have failed to deliver fairness for different groups of people ([49] Kandola, 2009).
Having clarified the issue of objectives, and assuming that diversity remains the ultimate aim of the NHS, the next difficult question is what counts as diversity? Under the Equality Act 2010, the answer is fairly clear, even though, as we have pointed out the legislation does not promote diversity as its primary objective. This notwithstanding the groups covered by the act ought to frame the shape of diversity as a policy aim. Therefore, an organisation such as the NHS should use age, ethnicity, "race", national origins, sex, sexuality, marital status, religion, disability, etc. as its template. A diverse organisation would target these identity characteristics which are intrinsically linked with diverse cultural and cognitive characteristics. However, a quick examination of policy over the past 20 years indicates that gender, sex, "race", ethnicity and national origins have been prioritised. This is highlighted by the fact that "Opportunity 2000" was one of the first initiatives established in the 1980s to improve the prospects of women in management along with a dedicated women's unit (albeit disbanded in 1996) ([35] Hammond, 1994).
This does seem slightly problematic on at least two crucial grounds. First, it seems to be based on a slightly flawed assumption that by prioritising historically difficult areas for the organisation the less well-established aspects of diversity (in law) will be resolved as a result of the lessons learnt. But this ignores one of the centrally important features of diversity, which is that different groups face different barriers. The prejudice directed at one group may be, and often is, very different from that aimed at another. Furthermore, if we compare the barriers disabled people confront, they are physical and environmental as much as attitudinal (though the latter may have shaped the former) so it is hard to see how resolving the problems experienced by women and BME groups will naturally improve the situation of disabled people. To emphasise an incremental approach is in any case a very anaemic interpretation of diversity. Second, it would not be consistent with the requirements of the legislation, not only because it excludes protected groups, but also because it would undermine the public duty to promote equality (even if we only mean equality of consideration) that institutions such as the NHS are charged with. Diversity should include the full range of the protected. Targeting specific groups (like women or BME), may disadvantage other groups, as it directs resources and attention away from their plight and gives the impression that their position is somehow less worthwhile. The danger of prioritising BME, for example is that it then creates a hierarchy, which implies that those groups which are not included (e.g. gay, lesbian, disabled) are in some way less important or worthy. There is the additional problem of applying the label "BME" to groups of people assuming that they are homogenous and share common issues ([95] Wrench, 2005). Evidence suggests that in fact different ethnic groups and groups within ethnic groups (like Pakistani women) experience discrimination in different ways ([41] Hudson and Radu, 2011; [68] Parry and Tyson, 2009). Clearly institutions like the NHS are going to struggle with the intersectionality sitting at the heart of the Equality Act 2010.
Having set out the requirements of the law as far as the framework of diversity is concerned we now need, before we get into the justifications for pursuing diversity, to establish how diversity ought to be measured. This is an ongoing dilemma that requires far more consideration. If we confine ourselves to diversifying senior management, what we have previously referred to as "structural diversity" ([140] Johns, 2006), the NHS is faced with an interesting set of diverse questions. For the sake of concision and in line with an important component of NHS policy we will use ethnicity as the focus of our argument: should the NHS use its workforce or service populations as its benchmark? This is a thorny topic because as BME groups are over-represented in the general workforce this would then mean matching the "over-representation" in senior management, pleasing commentators such as [30] Fielding (1999) who claim that over-representation is required to create a critical mass large enough to genuinely challenge discrimination. However, securing support for this might conceivably prove difficult.
Alternatively using population measures has serious drawbacks. To use a national benchmark would leave some areas under-represented, where the national BME figure is around 9 per cent and some areas have BME populations of near 50 per cent. Other areas would be significantly over-represented. In the south-west of England, for example the BME population is as low as 1 per cent, while most NHS bodies are already over-represented this does not include senior management teams and to deliberately diversify them with dedicated and explicit policy measures would undoubtedly be controversial. The Appointments Commission has set national targets for public boards, but a national BME target may not be stretching for areas such as London, but will prove more problematic for areas such as Cornwall or Northern Ireland. Similarly, there is a relatively high proportion of BME managers in London SHAs in national terms, but this figure is low in comparison with London's population ([65] NHS III, 2009). Using local population figures would have the same limitations, with over-representation in some areas and under-representation in others.
[31] Gauss and Jessmay (2007) argue that local population figures should be used where diversity is in evidence, but that a national figure should be imposed in areas of little diversity based on a moral argument. The problem with this solution, one that is all too commonly repeated, is that it mixes two quite distinct justifications for pursuing diversity as an explicit policy device. If there is little substantive evidence for the business case, and there is the problem of mirroring local populations then why has the moral case not been (re)elevated to the fore as the main justification for introducing a more diverse senior management structure?
Justifying diversity?
In essence there are two seemingly diametrically opposed justifications for prioritising diversity. On the one hand diversity is described as a matter of justice, and on the other it is seen as the product of expedience or practicality ([161] Noon, 2007). In philosophical terms we can think of the case for diversity as either principle-driven deontological justice (the moral case), or a variable form of consequentialism (the business case) ([81] Schneider and Ross, 1992; [50] Kandola and Fullerton, 1998; [3] Bagilhole, 2009). [88] Tomlinson and Schwabenland (2010) insightfully make exactly this point in relation to non-profit organisations, arguing that the context and practical realities need to be taken into account when exploring policy options. We certainly agree that to isolate a "moral" case is misleading as both have ethical reference points, but this question of organisational location/orientation needs further examination. Here we are dealing with a public sector organisation trying to negotiate between competing claims and feel that it is necessary to retain the "cases" in order to elucidate the confusion and explore potential solutions.
This section commences by setting out the business case argument first because it is the most popular argument currently in use. Indeed it has even infiltrated the human rights literature ([82] Schulz, 2002). Expedience emerged as a case for diversity in the USA during the 1980s ([81] Schneider and Ross, 1992) and it was framed in the language of business. Since 1996, a group of industry chief executives and human resource professionals have been working together under the auspices of a non-profit organisation called the Business Opportunities for Leadership Diversity initiative to help American corporations learn how to leverage their cultural diversity for competitive advantage ([53] Kochan et al. , 2003). In the UK, the [19] Department of Trade and Industry (DTI) (2003) issued Achieving Best Practice in Your Business : The Business Case for Diversity and Brighter Boards for a Brighter Future , designed to promote diversity and in particular the cause of women ([19] DTI, 2003).
The [40] Higgs (2003) review was commissioned to make recommendations for the improvement of corporate governance, with a remit to include the appointment and role of board members. Higgs and the subsequent [89] Tyson (2003) report recommended a more open appointment process, with increased diversity of directors, in particular women and those from the ethnic minorities; and increased variety of experiences and backgrounds, which might be available not just in the corporate sector, but also in the public, voluntary and enterprise sectors. More recently, Patricia Hewitt, when Secretary of State for Trade and Industry, and Minister for Women argued for more women in the boardroom: "Having more women and people from diverse backgrounds means that companies represent - and better understand - the customers they want to attract, leading to improved competitiveness and productivity" (in Spectator, 2005).
Konrad (2003, in [43] Jayne and Dipboye 2004) has stated three primary arguments in the business case for diversity. First, competition for the best talent requires organisations to reach out and embrace an increasingly diverse labour pool. Second, a global economy requires that organisations have a diverse workforce so that they can effectively deal with an increasingly diverse customer base. A third argument is that demographic diversity unleashes creativity, innovation and improved group problem solving, which in turn enhances the competitiveness of the organisation. [43] Jayne and Dipboye (2004) state that in addition to these arguments, one could add that in the context of the debate and controversy surrounding affirmative action programmes, diversity is a more palatable and "socially acceptable" way to address "race" and gender issues.
Increasing diversity in the workforce is therefore regarded as in the interests of those organisations that embrace it rather than of unilateral benefit to minority communities (Noon, 2007). One of the problems with this was the lack of clarity about the parameters of ethnic diversity in particular and how this could be translated into unambiguous policy ([45] Johns, 2004; [47] Johns and Green, 2009). Additionally there is a fundamental lack of evidence to support the business case argument. In fact the evidence is very mixed, and it has been almost impossible to find evidence where diversity is linked to measurable outcomes like reduced absenteeism, improved financial performance, turnover or job satisfaction (see [29] Esmail et al. , 2005; [23] Dreachslin et al. , 2004; [95] Wrench, 2005). Therefore, [29] Esmail et al. (2005), admit that the business case alone is not a sufficient rationale to support the case for diversity.
Indeed when we look at the impact of diversity for measurable performance indicators the evidence is sparse ([94] Wise and Tschirhart, 2000). The number of studies using robust empirical evidence to measure the effect of ethnic diversity on performance is even more limited ([1] Andrews et al. , 2005; [71] Pitts and Jarry, 2007). In fact the evidence for the negative effects of ethnic diversity on performance is perhaps more compelling ([72] Pitts and Jarry, 2009). Much of this is based upon social identification theory, which emphasises self-categorisation of personal characteristics to locate oneself in relation to others. Thus those with similar characteristics, such as gender and ethnicity will be seen favourably, whereas those who are "different" are perceived negatively ([87] Tajfel, 1982; [4] Brewer, 1979; [85] Stephan, 1985). Empirical research on ethnic diversity and performance has shown that employees in fact suffer less motivation and job satisfaction ([34] Greenhaus et al. , 1990; [79] Sackett et al. , 1991). Diversity has also been linked to greater absenteeism ([70] Pelled et al. , 1999) and greater emotional conflict at work ([52] Kizilos et al. , 1996). Although there are studies showing positive outcomes for ethnic diversity ([92] Watson et al. , 1993; [56] McLeod and Lobel, 1992; [66] O'Reilley et al. , 1997; [61] Mullen and Cooper, 1994), [72] Pitts and Jarry (2009) argue that on balance the literature indicates that greater ethnic diversity leads to lower performance outcomes.
Despite this the "business case" for diversity has been embraced in the NHS along with other public sector institutions ([22] Dickens, 1999; [93] Wilson and Iles, 1999; [39] Hicks-Clarke and Iles, 2000; [24] Edwards and Robinson, 2004; [84] Squires, 2008). However, applying arguments for the business case which are based on private sector evidence (albeit weak) are flawed because the NHS is not a business in any meaningful sense, even taking the quasi-market features that were introduced during the late 1980s. In recognition of this the [12] CRE (1995) created a "quality case" as a viable alternative. Whereas the core of the business case was the bottom-line, namely, the positive effect diversity would have in maximising profitability, the quality case emphasised the importance of increasing the quality of care that the NHS could provide. The main assumption was that a diverse society requires diverse health providers in order to fully appreciate the diverse needs manifested by the service population. Two key dimensions here would be cultural needs and lingual needs. In distinguishing between the business and quality cases the CRE was moving the expedience argument back towards a more ethical position as would befit a public service; forming a bridge between consequentialism (providing a good service to the maximum number) and deontology (because this is at the heart of the public service ethos). The quality case would therefore seem to be the best defence available for increasing diversity in the NHS.
The major flaw in the argument for diversity though, is this lack of evidence to support the business case. If we are to accept the quality case as the best defence it cannot simply be taken at face value and the first question that needs to be addressed is the relationship between workforce and performance in terms of service delivery. While these elements were once separated out in equality thinking ([11] Collier, 1998) this is no longer the case. Equality of opportunity in employment is connected to service delivery through the medium of diversity. The essence of this is that the "best person" for a job or promotion is the person who is best able to recognise the diversity of needs they are facing ([45] Johns, 2004). Having established this the next question is: what impact has diversity made where it has been achieved? The difficulty with this is that the most convincing evidence about positive impact seems to come from the private sector, and interestingly it shows the inconsistency in the work of key diversity advocates such as [51] Kandola et al. (1995), [50] Kandola and Fullerton (1998), [49] Kandola (2009). One of the primary benefits of diversity according to Kandola and colleagues has been in selling commodities more effectively to ethnically diverse communities, which invalidates the whole basis of individualistic diversity. With great insight [55] Liff (1999) has distinguished between the "dissolving differences" and the "valuing differences" approach that accounts for this, but we would argue that many commentators ([51] Kandola et al. , 1995; [50] Kandola and Fullerton, 1998) simply flip flop between them trying to provide employers/managers with the most flexible tool for their particular needs (or prejudices). (Interestingly - and perhaps appropriately - for diversity claims the primary benefits can vary according to the commentators referred to, see [13] Cox and Blake, 1991 and [22] Dickens, 1999). Elsewhere the motives of diversity consultants have been subjected to closer scrutiny and this is something that requires further investigation, particularly given the resources that have been used in contracting their services by public agencies such as the NHS ([95] Wrench, 2005; Johns, 2006; Noon, 2007).
Specific evidence about the positive impact of diversity for health service delivery is extremely sparse. A few studies have produced evidence, for example, Johns (2006) reports that a sickle cell service in the south of England saw a greater up-take when a black nurse was appointed, but this was based on the testimony of the nurse in question. Thus it is difficult to say with any authority that ethnically diverse health providers provide more sensitive services than non-ethnically diverse providers. Nor does it recognise the possible costs for those appointed, are they being set up as "ethnic specialists" with prescribed and restricted career prospects; something that has been observed since the passage of the Local Government Act 1966 ([83] Somerville and Steele, 1998; [45], [144] Johns, 2004, 1999). Furthermore, this operates on the assumption that increasing uptake is a positive outcome, which would reflect the philosophy of the NHS (underlined in the constitution), but would inevitably place an additional strain on finite resources. The private sector generates extra income from new customers, but in the NHS more "customers" may meet organisational objectives, but at higher short-term costs. There are in-built conflicts that need to be acknowledged.
Even if some positive effect could be evidenced it presents us with a significant problem to overcome. Do areas that are not ethnically diverse require services that are not diverse? This has been a claim made by far-right extremists ([86] Swain and Nieli, 2003) and it is hard to counter. To deny largely white communities (ignoring less visible aspects of diversity) from having a predominantly white workforce would be more than simply unfair, it would be to actively subject them to a less sensitive and effective service. Fortunately (or unfortunately depending on one's perspective) it is a moot point as the evidence to substantiate the expedience as public service ethos claim does not currently exist. There are writers who try to obscure this issue by merging the boundaries between the moral case and the "good service" case by arguing that ethnic diversity should be implemented where populations are diverse because of their enhanced sensitivity ([31] Gauss and Jessmay, 2007), but that diversity should also be imposed on apparently non-ethnically diverse areas because it is the right thing to do. But to do so is either to confuse two incompatible cases, or, to attempt a con trick albeit with the best of intentions. Our object next is to consider the position that diversity is a matter of justice regardless of its impact, and at a later date to reflect on the best available policy mechanism for its achievement.
The model outlined by Kandola et al. is flawed in respect that the business case is essentially functional in nature (Noon, 2007). This means that it stands or falls on empirical outcomes - either diversity is valuable or it is not. This elbowing aside of moral concerns means that if the situation changes, or, there is no evidence for the practical value of diversity it will (and should) be cast aside ([78] Ryan et al. , 2002; [95] Wrench, 2005). As Noon (2007) stresses, diversity claims are inherently short term and even if evidence can be accrued it is likely that managerial patience will run out before it can be presented and correctly interpreted. Furthermore, the business case can and has been used to justify racist policies and decision making and this reflects its indifference to moral concerns (Noon, 2007).
[76] Richards (1980) argues that using the business case alone weakens the case for increasing diversity. She argues that identity has a strong relationship to how we perform in a wide range of tasks. The example she used involved gender and clinicians. Women perform differently as doctors and therefore the gender-specific skills they provide are needed in medical practice. What she was trying to get away from was the idea that taking identity into account was simply positive discrimination, and that, implicitly, the idea contained in the legislative ideal of genuine occupational qualifications, where employment opportunities can be offered on the basis of identity when it is relevant to the task at hand (e.g. female carers may be required to provide personal care to female patients), should be extended. Of course, such an adaptation of merit criteria risks essentialising aspects of identity with potentially negative consequences for "minority" groups as set out above.
Nevertheless, this focus on identity and merit has been picked up and adapted by others with regards to "race" and ethnicity (see e.g. [26] Edwards, 1995; [32] Glazer, 1998; [30] Fielding, 1999; Law and Harrison, 2001). [45], [46] Johns (2004, 2005, 2006) found that there is support for increasing diversity regarding BME groups amongst different groups both inside and outside the NHS. The international evidence about the efficacy of this will be discussed below, but it is worth pointing out at this stage that it has been adopted in comparable public sectors such as policing, but with mixed results ([80] Sardar, 1999; Law and Harrison, 2001; [91] Walker et al. , 2003). Ironically the principal obstacle to expanding the notion of merit to incorporate diverse identity-related factors on justice rather than functional grounds appears to be the continued emphasis on the business case.
Conclusions
What has emerged is that there is both too much and too little evidence. While there is a huge literature on the impact of diversity, drawing relevant conclusions for the NHS is problematic for a number of reasons. First, much of the evidence relates to group performance rather than organisational performance. Second, the vast majority of the evidence relates to business in the USA and generalising to the NHS is inappropriate. Third, much of the evidence relates to diverse workforces (which the NHS has already largely achieved) but much less relates to diversity at senior management or board level. Fourth, much of the evidence - even the best evidence - has conceptual and methodological problems.
We strongly argue - echoing the social justice claims of Noon (2007) - that the only consistent and coherent argument must therefore rest upon the moral case for pursuing greater ethnic diversity (as well as other relevant forms), and the fact that it is the "right" thing to do. As the NHS has relied so heavily on BME labour (and of course that of women) to exist and function so cheaply and efficiently from the point of its conception ([54] Law, 1996), maybe a fairer share of the highest positions is a just reward? While [25] Edwards (1988) convincingly disposed of the case for compensation as a basis for positive discrimination, there appears much stronger potential for combining such a claim with carefully refining merit to take into account aspects of identity. Indeed [2] Bagilhole (1997) maintains that the very development of equality of opportunity policies in the 1940s was essentially about this kind of compensatory morality. The 1944 Disabled Person's (Employment) Act (amended 1958) was designed to assist war veterans who had suffered impairment into employment, using various measures including registration and a quota of 3 per cent disabled employees in organisations with workforces >20. Bagilhole (citing Oliver, 1990) suggests this emerged from a combination of collective guilt and moral obligation.
The use of a moral argument has been successfully used in the past to implement policy and cultural change and is still a relevant strategy. It is not the case that discrimination has "disappeared" and that there is no need for these types of measures. Since the publication of the [58] Macpherson (1999) report which was produced as a result of a public inquiry into police investigations of the racist murder of Stephen Lawrence in 1993 formally stated that institutional racism exists, other reports have confirmed it ([67] Parekh, 2000; [77] Roberts et al. , 2009).
We are therefore not in a position to pursue a diversity strategy based on business imperatives and individualism. What is more the moral case used as the justification for seeking greater diversity, actually better reflects the core values of the NHS as set out in the NHS constitution and in its published NHS values, a general point raised by Law and Harrison (2001). If this position is widely accepted perhaps the next stage is to outline the centrality of morality for the quality case; arguably the service ethos that underpins the quality case goes beyond the simple consequentialism of the parallel business case. This is a debate we hope to contribute to in follow-up publications.
The Guardian
Society
The Independent
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Further reading
1. Brown, C. and Gay, P. (1985), Racial Discrimination 17 Years After the Act, Policy Studies Institute, London.

2. Dhami, R., Squires, J. and Modood, T. (2006), "Developing positive action policies: learning from the experiences of Europe and North America", Research Report No. 406, Department of Work and Pensions, HSMo, London, available at: http://research.dwp.gov.uk/asd5/rports2005-2006/rrep406.pdf (accessed 13 April 2004).

3. Hasnain, R., Shaikh, L.C. and Shanawani, H. (2008), Disability and the Muslim Perspective: An Introduction for Rehabilitation and Health Care Providers, Center for International Rehabilitation Research Information and Exchange, Cornell University, New York, NY.

4. Healthcare Commission (2009), Tackling the Challenge: Promoting Race Equality in the NHS in England, HCC, London.

5. Hussain, Y., Atkin, K. and Ahmad, W. (2002), South Asian Disabled Young People and their Families, Joseph Rowntree Foundation, York.

6. Jones, A. (2006), Rising to the Challenge of Diversity, The Work Foundation, London.

7. Ministry of Justice (2010), "Employment Tribunal and EAT Statistics 2009-10 (GB)", Tribunals Service, London, 1 April 2009 to 31 March 2010.

8. Paul, K. (1997), Whitewashing Britain: Race and Citizenship in the Postwar Era, Cornell University Press, New York, NY.

9. Simpson Caird, J. (2009), "Is positive discrimination a 'very blunt solution to a complex problem', and does it fight 'unfairness with unfairness'?", Human Rights Review, Vol. 1, pp. 240-57.

10. Vernon, A. and Swain, J. (2002), "Theorizing divisions and hierarchies: towards a commonality or diversity?", in Barnes, C., Oliver, M. and Barton, L. (Eds), Disability Studies Today, Polity Press, Cambridge, pp. 77-97.

Appendix
Corresponding author
Nick Johns can be contacted at: JohnsNR@cardiff.ac.uk
AuthorAffiliation
Nick Johns, School of Social Sciences, Cardiff University, Cardiff, UK
Alison Green, Faculty of Health, Education and Society, Plymouth University, Plymouth, UK
Martin Powell, School of Social Policy, HSMC, University of Birmingham, Birmingham, UK
Word count: 8679
Copyright Emerald Group Publishing Limited 2012
Indexing (details)
Cite
Subject
Morality;
Multiculturalism & pluralism;
Cultural change;
Race relations;
Disabled workers;
Coalition governments;
Equality;
Public sector
Location
United Kingdom--UK
Title
Diversity in the British NHS: the business versus the "moral" case
Author
Johns, Nick; Green, Alison; Powell, Martin
Publication title
Equality, Diversity and Inclusion: An International Journal
Volume
31
Issue
8
Pages
768-783
Publication year
2012
Publication date
2012
Publisher
Emerald Group Publishing, Limited
Place of publication
Birmingham
Country of publication
United Kingdom
Publication subject
Business And Economics--Labor And Industrial Relations, Women's Interests
ISSN
20407149
Source type
Scholarly Journals
Language of publication
English
Document type
Feature
DOI http://dx.doi.org/10.1108/02610151211277626 ProQuest document ID
1125558065
Document URL http://search.proquest.com/docview/1125558065?accountid=14205 Copyright
Copyright Emerald Group Publishing Limited 2012
Last updated
2012-11-15
Database
ProQuest Central
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