Breaking the inequality reproduction circle in the NHS: the importance of senior management team's actions (SMTA)
| Date | 18 April 2024 |
| Pages | 817-832 |
| DOI | https://doi.org/10.1108/ER-09-2023-0470 |
| Published date | 18 April 2024 |
| Subject Matter | HR & organizational behaviour,Industrial/labour relations,Employment law |
| Author | Wen Wang,Roger Seifert,Matthew Bamber |
Breaking the inequality
reproduction circle in the NHS:
the importance of senior
management team’s
actions (SMTA)
Wen Wang
School of Business, University of Leicester, Leicester, UK
Roger Seifert
Wolverhampton Business School, University of Wolverhampton,
Wolverhampton, UK, and
Matthew Bamber
Schulich School of Business, York University, Toronto, Canada
Abstract
Purpose –This study examines potential ways to break the inequality reproduction circle faced by ethnic
minority health workers and sustained by key performance indicators (KPIs)-centred management in the
National Health Service (NHS) in England. It does so through the lens of signalling theory.
Design/methodology/approach –Three years panel data for 2018–2020 covering 207 hospitals was
compiled from the annual NHS staff survey and matched with relevant administrative records. Structural
equation modelling was used to test the proposed hypotheses at the organisational level.
Findings –The moderated mediating model reveals that persistent racial discrimination by managers and
coworkers can disadvantage the career progression of ethnic minority health workers, which in turn reinforces
and reproduces economic and health inequalities among them. More importantly, we show how the collective
agreement that the senior management team acts (SMTA) on staff feedback can break this vicious circle.
Research limitations/implications –While our research focuses on the not-for-profit health care sector, it
opens important opportunities to extend the proposed model to understand organisational inequality and how
to address it.
Practical implications –Perceived SMTA can send strong signals to reduce deep-rooted discrimination
(race, gender, age, etc.) through resource allocations and instrumental functions. This is also a way to address
the current staff burnout and shortage issues in the healthcare sector.
Social implications –This article reveals why the purpose of organisations that provide public service to
reduce social inequality was comprised during their business-like operations and more importantly, how to
reflect their foundational purpose through management practice.
Originality/value –This study offers a way forward to resolve one of the unintended consequences of KPI-
centred management in the not-for-profit sector through unpacking the process of inequality reproduction and,
more importantly, how it is possible to break this vicious circle.
Keywords Racial discrimination, Inequality, Signalling theory, Staff retention, NHS
Paper type Research paper
Introduction
There is a growing awarenessthat the business model adopted by corporationsplays a role in
normalising, reinforcingand worsening social inequality (Bapuji et al., 2020;Currieet al., 2022;
Inequality
reproduction
circle in NHS
817
We thank financial support from the University of Leicester (Research Development Fund 2022-2023)
and the British Academy [No. IF2223\230023] to compile various data set that was used in the article; we
thank the excellent research assistance by Dr (Med) Hussein Lubbad, Mr. Precious Reuben and Ms.
Mariya Yeldhos.
The current issue and full text archive of this journal is available on Emerald Insight at:
https://www.emerald.com/insight/0142-5455.htm
Received 15 September 2023
Revised 19 March 2024
Accepted 19 March 2024
Employee Relations: The
International Journal
Vol. 46 No. 4, 2024
pp. 817-832
© Emerald Publishing Limited
0142-5455
DOI 10.1108/ER-09-2023-0470
Mayer, 2021;Sadeh and Mair, 2023). This is typically processed through the lens of
organisational inequality (OI), denoted as individuals and groups being exposed to unequal
opportunities, risks, and rewards by virtue of their social group position in the workplace
(Bapuji et al., 2020; Bermudez-Figueroaand Roca, 2022). Meanwhile, since the 1990s, the UK’s
not-for-profit sector (public services and charities) has gone through a business-like
transformation as part of the New Public Management (NPM) agenda. This reproduces
corporate problemsin a non-corporate setting. For example, there is recent evidence of greater
disparity in pay and promotionfor employees due to characteristics such as ethnicity,gender
and age (Salamon and Newhouse, 2020;Wang and Seifert, 2022). These issues are clearly
visible in the NationalHealth Service (NHS) in the UK (Applebe, 2019;Woodhams et al., 2023).
Given that thenot-for-profit sector was set up to redress societalinequality, such contradictory
consequences are damaging to boththe reputation and the operational effectiveness of these
vital services. The aim of this article is to unpack this paradox by critically addressing the
following research questions:(1) what is the mechanism through which career inequality (the
main source of income distribution) among ethnic minoritygroups persists in the NHS? And
(2) whether it is possible to breakout of this vicious circle? Answering these questions is both
theoretically and practically important, given the innate prosocial agenda of not-for-profit
organisationsand their pursuit of fairness. Hence, we shine light on the somewhat paradoxical
persistent high levelsof racial discrimination in the NHS (NHS England, 2023;UKParliament,
2022a) as well as the acute NHS staff shortages (UK Parliament, 2022b).
The challenge of implementing equality, diversity and inclusion (EDI) in the workplace
has been well documented, but remains a Sisyphean task in an organisation the sizeand scale
of the NHS. The organisation comprises 215 hospitals and –at the time of writing –employs
approximately 1.25m full-time equivalent (FTE) staff (The King’s Fund, 2023;Rhead et al.,
2021). Nonetheless, a variety of studies have shown that signs of change from organisational
signallers –such as senior managers, human resource departments and line managers –are
crucial, especially when the signals denote strong commitment to EDI (Bergh et al., 2014;
Connelly et al., 2011;Guest et al., 2021). In this study, we consider the role of the senior
management team (SMT) in the NHS Trusts as the signallers-in-chief (Nishii and Paluch,
2018) to reverse OI. Under the current NPM regime, they are both pushed and pulled,
pressurised and incentivised to meet service-user-centred KPIs (Bevan and Hood, 2006;
Fearfull and Kamenou, 2007). Using large national panel data, we aim to unpack the
association between perceived discrimination, fair career opportunity and ways to attenuate
this association. This then contributes to a better understanding of OI and how to address it.
KPI-centred management and the reinforcement of organisational inequality
The purposeof NPM was to make public servicesbetter value for money by adoptingso-called
“best practices”from the private sector (Ham, 2014;Hood, 1995). Inspired by the well-
documentedsuccess betweenbusiness goal-settingand organisational achievement(Locke and
Latham, 2002,2006;Ogbonnaya and Babalola, 2021), KPIs were developed and managed
through top-down goal-setting (Ellwood, 2009;Mason and Araujo, 2021;Munir, 2021). NHS
SMTs must meet a comprehensive patient-centred KPI matrix to secure state funding. These
includeperformance measuressuch as patient waitingtimes, the numberof medical procedures
performed and patient safety (Mason and Araujo, 2021). For example, in the Accident and
EmergencyDepartment, a well-publicisedKPI target is that 95% of patients shouldbe treated,
transferred, or discharged within four hours. To meet this politically (and professionally)
sensitive target, management has been pressurised to adopt a tunnel-vision approach.
This creates fertile ground in which discrimination, bullying and harassment are allowed
and tolerated.To illustrate the depth andbreadth of the problem, one in threefemale surgeons
in the NHS has been assaulted by a colleague in thepast five years (Gallagher et al., 2023).
ER
46,4
818
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