The impact of the Workforce Race Equality Standard in our regulation since 2015

There have been longstanding concerns about racism towards staff working in the NHS. In 2014, Roger Kline published the report The 'snowy white peaks' of the NHS. This report showed the extent of the gap between representation of Black and minority ethnic people in senior positions in the NHS and the local population, the disadvantages in recruitment and promotion and disproportionate bullying and disciplinary action experienced by Black and minority ethnic NHS staff, and the impact this could have on patient care. The paper proposed better ways of holding NHS organisations to account through the use of better data on ethnicity in workforce issues.

The report was extensively discussed by the NHS Equality and Diversity Council (EDC), of which we (CQC) and NHS England (NHSE) are partners. The Workforce Race Equality Standard (WRES) was proposed, based on NHS organisations, and independent healthcare providers holding NHS contracts, publishing data about workforce race equality alongside action plans to reduce gaps in indicators between Black and minority ethnic and White staff. The EDC announced on 31 July 2014 that it had agreed action to ensure employees from Black and minority ethnic backgrounds have equal access to career opportunities and receive fair treatment in the workplace. Implementing the WRES became a requirement for NHS commissioners and NHS healthcare providers, including independent organisations who are obliged to participate in the WRES through the NHS standard contract

The WRES required NHS trusts and independent acute healthcare providers, where annual aggregated income from NHS-funded care was at least £200,000, to demonstrate progress against nine indicators of workforce equality, including a specific indicator to address the low levels of Black and minority ethnic board representation. The WRES was included in the 2015/16 Standard NHS Contract for the first time. From 2017, independent healthcare providers were required to publish their WRES data. However, this was reviewed in 2019 and the WRES indicators were adapted for independent healthcare providers.

The WRES is important to us because studies show that a motivated, included and valued workforce helps deliver high-quality patient care, increased patient satisfaction and better patient safety. At CQC, we committed in 2015 to consider race equality for staff in all NHS inspections from April 2016 onwards. This allowed NHS trusts a year to look at the issue in their organisation and plan some action to address any inequalities, before we started incorporating this into all our inspections. During 2015, we carried out a pilot to develop our approach.

To support this, we developed and implemented an equality objective to include race equality for staff (through the WRES) as a factor in our judgements about whether hospitals are well-led. Our commitment has continued and the WRES has featured in our equality objectives since 2015. Equality objectives are developed every two years and the WRES has featured in all three cycles since it was introduced: 2015-2017, 2017-2019 and 2019-2021. Each cycle has built on previous years' work on the WRES to ensure assessments are strengthened, robust and effective.

We now consider the WRES in all NHS trust and relevant independent healthcare inspections. We look at work the provider has carried out to close any gaps in experience or outcomes for Black and minority ethnic staff, compared with White staff. To do this, we have developed evidence-gathering methods and learning for inspectors. We also support a network of hospital inspection equality champions and we use external equality specialist advisors on a flexible basis on our inspections. Feedback from stakeholders has confirmed that including the WRES in our inspections has been very positive for highlighting the importance of workforce race equality in NHS trusts.

The WRES was introduced and considered as part of our inspections from April 2016, and as part of well-led inspections from 2018 onwards.

Alongside the WRES, NHS organisations use the Equality and Diversity Systems (EDS2) to help them - in discussion with local partners including local populations - review and improve their performance for people with characteristics protected by the Equality Act 2010. In 2019, the Workforce Disability Equality Standard (WDES) was launched, built on learning from implementing the WRES and from the specific experiences of disabled staff working in the NHS. By using the EDS2 and the WRES and WDES, NHS organisations can also be helped to deliver on their Public Sector Equality Duty.

Since its inception, the WRES and our approach to assessing the WRES has evolved. It is appropriate to review the impact this has had on regulation.

The purpose of this review is to:

• explore what we have accomplished to date
• establish where the gaps exist
• decide what processes we need to put in place to improve the way that the WRES is assessed
• establish how the learning from the WRES will impact on future arrangements for Equality, Diversity and Human Rights more widely.

We highlight the methodology used and our key findings, and we make recommendations on the way forward for CQC in regulating workforce race equality in NHS trusts and relevant independent healthcare providers.

The desktop research forms the baseline for each of the areas and determines the next steps.

We would like to thank Kulvinder Hira for her work on this review in 2019 and 2020, which she carried out while working for CQC. Kulvinder is now the Group Head of Equality, Diversity and Inclusion (Patients and Carers) at Royal Free London NHS Foundation Trust.

Aims of the review

The aims of the review were to take stock of our current position in regulating the WRES, explore how it has changed since its inception, and assess the evidence we have to identify the gaps in the process. It also aims to develop an improvement plan to assess the WRES and the WDES and measure how the EDS is used as a key driver to improve on equality and human rights.

The review was designed to answer the following questions:

Overall changes from 2015 to 2019

• Has the WRES implementation in regulation changed since it was introduced? Consider all hospital types including independent healthcare providers.

Monitor

• What mechanisms are in place to collate data and information to support inspections, and how effective has this been?

Inspect and Rate

• What tools and resources are available for staff, and is this enough to ensure the WRES is part of the well-led inspections?
• Does CQC use specialist advisors (SpAs) effectively and what are their views?
• Do inspection teams believe that the WRES has made a difference in regulation and what support is available to them?
• How much has the WRES featured in inspection reports since 2016?
• What has been the impact of the WRES in our reports?

Enforcement

• What are the arrangements for enforcement, and how efficient is the process?

Current approach

• What are the main concerns with the current approach?

Other research

• What other internal and external qualitative research has been conducted?

What does 'good' look like?

• Are there examples of good practice where the WRES is implemented effectively and the trust demonstrates good practice?

A series of planning tools used in CQC policy work and by the evaluation team were used to plan for this review. They incorporated elements of our usual review methodology, for example, the Problem Definition Sheet (see appendix A) and a Logic Model. These tools provided the direction that the review required for it to be meaningful and provide recommendations for us to take forward in the everchanging landscape in the healthcare sector, and consequently in regulation.

The review comprised a combination of desktop research, questionnaires sent out to inspection staff and equality and diversity specialist advisors, several interviews, and an analysis of internal and external research linked to this work that has taken place elsewhere.

The desktop research covered what currently exists in an end-to-end process across the operating model. It identified whether there are any issues in the way that the WRES is currently considered as part of well-led inspections, and how this has changed over time. This included a thorough insight into the use of equality and diversity specialist advisors, and the process followed, through analysis of data produced by our Flexible Workforce Office.

A questionnaire was developed to collate qualitative data and information, with a view to capturing the views of inspection staff and specialist advisors.

Interviews were conducted with inspection staff and specialist advisors who volunteered to be interviewed. This took the form of asking the same questions in the questionnaire and collating the responses.

This review was conducted internally and did not include providers. However, some providers participated in an independent evaluation conducted by the University of Sheffield – Evaluation of the NHS Workforce Race Equality Standard WRES. Their report focuses on the views of providers in relation to the well-led framework. The key findings are referenced in our findings and key themes section of this report.

To develop this review further, we used the following categories to facilitate the research required:

• frameworks and policy
• tools and resources
• intelligence
• qualitative research
• champions and specialist advisors.

Desktop research

Frameworks and policy

• The health assessment framework
• Well-led inspection framework
• Review of well-led inspection framework– findings (NHS England/Improvement)

Tools and resources available for inspection staff

• Technical guidance
• Interview questions
• Focus group templates
• Provider relationship management tool
• Provider handbook
• Inspector guidance
• Hospitals EDHR End to End Process
• Enforcement guidance and flowchart for the WRES

Intelligence

• NHSE briefings
• Provider Information Returns
• Evidence Appendix
• Insight dashboard
• Model Hospital

Internal qualitative research

• Reports analysis
• State of Care reports
• Inspection survey

External qualitative research

• National review of the WRES by Sheffield University
• Deloitte Review

Equality and Diversity Specialist Advisors and Champions

• Specialist advisor role, allocation and experience
• Champions’ role, allocation and experience

Interviews and questionnaires

A questionnaire was developed and circulated to all Hospitals inspection staff (including mental health and community, acute, ambulances and independent healthcare providers) for feedback, with the option to be interviewed. The response rate was very low.

• Questionnaire for inspection staff and option of interview (see appendix B).
• Questionnaire for Equality and Diversity Specialist Advisors and the option of interview – (see appendix C).

The key findings and responses to the questions presented in the aims of the review are presented here. This encompasses the analysis of both quantitative data and qualitative data from the desktop research, questionnaires, interviews, and internal and external evaluations.

Overall changes from 2015 to 2019

Has the WRES implementation in regulation changed since it was introduced? Consider all hospital types including independent healthcare providers

The desktop research and qualitative research shows that the WRES implementation in regulation has changed over the last four years and continues to evolve to align with our operating model.

When the WRES was first introduced in regulation, we developed an approach to integrate it into hospital inspections, working closely with the NHS England WRES team and other experts. The NHSE team provided inspection teams with briefings giving the data breakdown, narrative and recommended questions to further explore during inspections.

We piloted our approach in 19 inspections and recruited a small number of specialist advisors (SpAs) to assist where concerns around staff race equality were identified before inspection. After six months of pilots, a decision was made to include the WRES assessments in business as usual. From April 2016, we rolled out an approach for inspections of all NHS trusts and of independent hospitals that participated in WRES pilots. To support a ‘business as usual’ approach, further methodology was developed and published on the intranet. A further pool of equality and diversity specialist advisors were recruited and have continued to support the inspections.

The development of our hospital inspection programme (the “Next Phase”) began in 2017 at a time when the well-led inspection framework was being developed. The WRES principles continued to feature in the assessment framework for health and were strengthened to reflect the assessment of the WRES and, due to Next Phase, the changes were imported into the well-led inspection framework. The well-led framework has been the main document for implementing the WRES principles; these predominantly sit under key line of enquiry: W3 Culture.

When we first introduced the WRES it was for all types of hospitals including independent health (IH) providers that delivered NHS care. However, it soon became apparent that one size does not fit all and, in this case, it was because the IH sector did not have the tools and resources to respond to the WRES in the same way that the NHS could. This posed challenges for us to assess the WRES in the same way. As a result, the WRES has not had a large impact on the IH sector but it has triggered consideration of workforce race equality in the sector. There has, however, been engagement with the IH sector and co-production in developing new IH technical guidance and templates.

Monitor

What mechanisms are in place to collate data and information to support inspections, and how effective has this been?

Since the WRES has been introduced, we have worked jointly with the WRES implementation team at NHSE (now NHSE/I) to look at the data and have ported data from NHSE to our insight dashboard. Our intelligence team has led the analysis of WRES indicators at a trust level and developed insight dashboards under the heading of Workforce Race Equality Standard. This CQC work has now been incorporated into the Model Hospital dashboard developed by NHSE/I and accessible to trusts for quality improvement work.

Initially the NHSE WRES implementation team provided inspection teams with briefings on the WRES, which comprised of the data against the nine indicators with narrative explaining the data. To accompany this there were recommended questions for inspection teams to ask during inspections. The briefings continued for approximately a year but it was not possible to continue and sustain these due to capacity reasons.

The WRES has formed part of the Provider Information Request, sent out to all NHS providers as part of the inspection process from 2017 to 2020. The request included the WRES report and action plan as well as the Equality Delivery System2 report and action plan and was presented in the Evidence Appendix tool, for use in planning by inspection teams. This also contained narrative explaining the data.

We have never requested workforce equality data as part of the Provider Information Request for IH providers.

Inspect and Rate

What tools and resources are available for staff, and is this enough to ensure the WRES is part of the well-led inspections?

The WRES is considered within the well-led assessment framework for NHS trusts and independent healthcare.

The well-led inspection framework was jointly reviewed by CQC and NHSE/I in the first quarter of 2020. As a result the equality and human rights content was strengthened across the key lines of enquiry (KLOEs), prompts and ratings characteristics. As already noted, the pandemic meant that these changes were not implemented.

The review proposed:

• rewording a key line of enquiry around compassionate and inclusive culture
• a reordering in this KLOE to set a stronger message about equality
• adding a prompt for the need for compassionate leaders
• all relevant prompts to focus on 'all' staff
• zero tolerance of bullying and harassment
• adding an emphasis on the health of staff.

These changes were designed to strengthen equality, diversity and human rights in the KLOEs and prompts, and to addresses the recommendations made by Deloitte in their evaluation of the well-led framework (see internal and external research). Implementation of the planned changes was brought to a halt by the impact of the pandemic; a new review is scheduled for the second half of 2021.

Turning to the tools and resources available to inspectors to carry out assessments and consider the WRES, these are available on the intranet well-led page. A series of tools was first developed in 2015 and published on the EDHR page. They have been superseded by the information on the well-led page as it worked better to integrate the WRES tools into the well-led pages rather than have them elsewhere.

However, it is difficult to ascertain how much these are used by inspection teams. The interview templates include the WRES in the scripts for both senior leaders and the operational staff responsible for equality and diversity in trusts. There is enough material available for staff to access and use during inspections, including focus group templates and questions.

The EDHR team developed an ‘Equality and human rights End to End process’ for hospital inspection teams. This tool enabled inspection staff to use the process flexibly, depending on where they required support. The provider handbook and inspector handbook have referred to some of the WRES principles. However, this is very limited in the form of reference to "compassionate and inclusive leadership including a greater focus on workforce equality".

The combined provider handbook published in 2018 does not include any equality, diversity and human rights content.

A number of equality, diversity and human rights questions have been included in the Provider Engagement Tool to further support providers and to encourage continuous dialogue with providers during engagement activity.

The NHSE WRES team have published a technical guidance on the WRES, comprising the nine WRES indicators, and they have recently adapted the technical guidance and have developed a subsequent guidance for independent healthcare (IH) providers.

One of the challenges we continue to face is that IH providers do not collate data in the same way as NHS trusts, and do not conduct NHS staff surveys. During the period where the indicators were being adapted, we published (internally) a policy statement on what the expectations are in relation to workforce race equality for IH providers. The policy statement needs revising to align with the new IH technical guidance.

Does CQC use Specialist Advisors (SpAs) effectively and what are their views?

The feedback from our survey and interviews shows that there is variability in the confidence of inspection staff assessing the WRES as part of the wider equality, diversity and human rights agenda.

Initially, in 2016 there were approximately 40 Equality and Diversity SpAs on the list. However, there are currently 14 on the list as CQC’s Flexible Workforce Office has reviewed the list over the years and SpAs have been removed for a variety of reasons including resignation, lack of availability, not responding to CQC contact or not having an up-to-date Disclosure and Barring Service check. Our data shows that, during the period from 2018 to 2020, a total of nine SpAs will not have had opportunity to attend a well-led inspection. Of the remaining five SpAs, three of them have attended more than once. All SpAs are offered assignments depending on location and speed of response to requests.

The Equality and Diversity SpAs allocation report indicates that they are not used as frequently as when first appointed. One of the reasons for this could be financial implications attached to having a SpA on site. The correlation with the mention of the WRES in reports shows this to be a likely contributing factor for not reporting on the WRES.

On a different note, not all SpAs have access to our intranet; therefore their access to the tools and resources published for CQC staff is limited, unless the inspection teams forward any of the tools and resources, SpAs are left to carry out their own research and planning prior to any inspection.

The feedback from SpAs to this review highlighted three additional issues:

• On a positive note, SpAs have reported that our regulation of the WRES has given a message to providers that workforce race equality is an important issue and that good data collection is also very important.
• Some SpAs also reported that they do not receive enough notice for an inspection, which can mean they are not properly prepared.
• They also reported that they saw a difference when NHSE/I stopped providing briefings about the WRES data ahead of an inspection. Then information about WRES was not cascaded to them in time, and they felt "out of the loop" as the WRES data and other information was discussed on the first planning day of an inspection, which SpAs do not attend. SpAs add value to inspection teams with their expertise and experience in the field, and with the outcomes that they can obtain during inspections that could be missed by inspection teams. Inspection staff told us through the review that they have learned from the SpAs.

Do inspection teams believe that the WRES has made a difference in regulation and what support is available to them?

When the WRES was first introduced, several WRES champions were recruited internally; these were a mixture of inspectors, inspection managers and heads of inspection. One head of inspection then brought the champions together in a Hospitals Equality Local Leads Group that had a wider remit, including equality for people using hospital services. This group continues to meet quarterly, providing updates on processes and acting as a platform for champions to raise any concerns or queries.

Initially, support sessions were made available for all champions, for them to be able to raise concerns and queries and for the EDHR team to give them updates. This continued up until mid-2018 when, due to poor attendance, they were discontinued and instead the Hospitals Equality Local Leads Group convened to bring all Hospitals colleagues interested in equality into one group. This brought together inspectors to consider equality and human rights for both the workforce and people using hospital services, and in doing so did increase the attendance.

A series of webinars were delivered to inspection staff and to specialist advisors at the start of the rollout of the WRES in our inspections, after the pilot phase.

Feedback from inspection staff demonstrates that there is a lot of variation in the approach to assessing the WRES outcomes and in the way that inspections are conducted and then reported. There are inconsistencies in the way that WRES has been considered on inspections, but feedback through questionnaires and interviews demonstrates there are pockets of good practice and levels of confidence in staff in bringing up this agenda in discussions with providers. It is disappointing, despite the communications and support available over the last four years, that some inspection staff have witnessed inspections in which this agenda does not get addressed unless they raise it.

How much has the WRES featured in inspection reports since 2016?

Since the WRES featured as part of business as usual in 2016, the metrics have been included in the evidence appendices of our reports. Data shows that up until 2018, the number of reports that cited WRES as a factor in our assessment was stable. However, the number of narrative sections of our reports specifically citing WRES fell from an average of 133 in the previous 3 years to 88 reports in 2019. This was balanced by evidence about WRES being consistently included in the report evidence appendices. The reason for this change was the ‘lightening the load’ project which aimed to streamline inspection reporting, so there was a smaller time lag between inspections and published reports. This project changed inspection reporting, including introducing standard statements and the concept of reporting by risk. This meant that there was less detail in the narrative section about workforce race equality. The positive side to this is that the WRES data that covers the nine indicators then featured as an integral part of the evidence appendix published alongside the main inspection report, so there was standardisation of the coverage of WRES in our published reports.

Inspectors have reported that having the WRES indicators embedded in the evidence appendix has prompted discussion on the WRES and the wider equality and diversity agenda. The evidence then prompted the discussion in well-led reports. However, some inspectors said that covering the WRES in a main report has become increasingly difficult, as they are reporting by exception and are therefore having to report on equality and diversity in the evidence appendix only, unless the evidence had an impact on the rating. For example, if a trust was going to be rated as good and the WRES evidence was not of particular concern, it would not be included in the narrative report.

This was seen by some colleagues and external bodies as a ’downgrading’ of the use of WRES evidence, although the evidence appendix was central to our ratings and our engagement with trusts.

We have analysed reports published in 2018/19 for their content on workforce race equality and explored:

• What went well?
• What needed to improve?

All published report/evidence appendices were extracted from the public CQC website and assigned to analysts for coding. Coding was completed using MAXQDA, a qualitative coding program.

Material for analysis was defined as any references to equality and diversity found within the well-led section of the inspection report/evidence appendix. Any reference to the WRES outside of this section was excluded from analysis.

Qualitative analysis of this data was carried out against a framework which featured the nine specific indicators (see below for details) set out in the assessment framework specifically developed to assess the WRES.

We published a report/evidence appendix in the 2018/19 year for 144 trusts (out of a total of 227). Of these, 137 contained information relevant to the WRES in their inspection reports and/or evidence appendices. The analysis shows that our reporting on the WRES has picked up trusts with positive practice and outcomes. The 2018/19 report shows that overall, 126 trusts (out of 137) demonstrated positive practice regarding the WRES.

Four key themes of good practice were reported on across trusts of all ratings, including those rated as inadequate: staff representation, career progression and opportunities, bullying and harassment, and leadership and culture.

Despite this positive practice, in the analysis of reports/evidence appendices in 2018/19 we also found that most trusts (130 of 137) had areas where they could improve when implementing the WRES. This included trusts rated as good and outstanding. The same four key themes for improvement were identified: staff representation, career progression and opportunities, bullying and harassment, and leadership and culture.

The table below shows the number of reports covering these themes – the evidence in the reports was sometimes based on WRES indicators alone and sometimes on qualitative findings – for example interviews with Black and minority ethnic staff on inspections or good practice examples given by the management of trusts.

Figure 2: Themes across 137 inspection reports/evidence appendices, 2018/19

Theme	Number of trusts where positive practice was identified	Number of reports where a need for improvement was identified
Staff representation	81	97
Career progression and opportunities	75	95
Bullying and harassment	70	85
Leadership and culture	116	83

Note: Though the report noted that sometimes positive comments about representation were made, even when the representation did not reach the percentage of black and minority ethnic people in the population.

This shows that the inspection reports were more likely to report a need for improvement rather than positive practice in the three themes where there are WRES indicators, but more likely to report positive practice than a need for improvement in the theme where there are no WRES indicators but evidence is drawn from qualitative findings (leadership and culture). Bearing in mind the central role of leadership and culture in addressing workforce equality, this may indicate that inspection teams are more confident about stating where improvement is needed if there are indicators to use as evidence.

What has been the impact of the WRES in our reports?

Internal analysis of inspection reports over a period of three years suggests that a trust being rated as good or outstanding is not an indicator of its WRES performance also being at that level. This could be due to two factors. Firstly, the WRES is only one of 47 questions within our well-led key lines of enquiry (KLOEs) and no single KLOE is a ratings limiter. Therefore, a trust may be performing well in other areas sufficient to receive a rating of good or outstanding, even if it is a poorer performance on the WRES. Secondly, and more problematically, it may be because we are missing evidence that indicates poor progress in race equality for staff which would be sufficient to impact the trust’s rating. In our initial inspections, we were mainly checking that trusts had an action plan and had engaged Black and minority ethnic staff in this. In later inspections, we needed to focus on whether the action plan was taking place and making a difference, which was harder to check in the limited time on an on-site inspection.

Even in cases where there may be identified gaps or areas for improvement that are required, they may be insufficient to affect the rating of the trust. While there are examples of this for which we have faced national criticism, it remains difficult to use performance against the WRES indicators as an aggregated factor for rating. We have considered a ratings limiter, but this did not go ahead as it did not seem viable for two reasons:

• We do not use any specific factor as a ratings limiter, other than enforcement action. As explained above, the coverage of the well-led key question is very large.
• It is difficult to get an overall measure of the WRES, which is made up of nine indicators, because, for example, one trust may be performing relatively well on some indicators but not others and another trust may have a mixed picture of performance, but in different indicators. We carried out work with NHSE on whether an aggregated WRES indicator was possible. The WRES Strategic Advisory Group led by NHSE decided against this approach. A 'ratings limiter' is a piece of evidence that stops a regulated organisation receiving a particular rating. Ratings limiters work when there is a clear "yes" or "no" answer – for example “are we taking enforcement action?" The WRES composite indicator would give a spectrum of how well a trust was performing rather than a clear cut "yes" or "no" answer. We also need to consider the feedback that we receive from staff about workforce equality. This will not be a binary answer of "yes, it is a good place to work" or "no, it is not a good place to work"; there will be a range of viewpoints. While the overall evidence can be considered in ratings, it is hard to apply a ratings limiter to something that is not clear cut. A composite measure of risk to workforce race equality is therefore achievable but using this as a ratings limiter rather than a risk measure for further investigation is not easily achieved.

However, despite not having a ratings limiter, poor workforce race equality has been cited in several inspection reports as a factor in the well-led rating for the trust.

The inclusion of the WRES in trust-level inspection reports has also enabled us to report nationally on the WRES in our State of Care publications, for example using the analysis covered in the section on the WRES in inspection reports above.

Enforcement

What are the arrangements for enforcement, and how efficient is the process?

Enforcement should always be a last resort, as our aim is to promote equality and to encourage providers to engage positively with the diversity and inclusion agenda for their staff, through recognising the benefits that this brings to the workforce and to people who use services.

We are limited in the enforcement action we can take by the scope of the Health and Social Care Act 2008 regulations. The only time that workforce equality may come into the scope of regulations is where a direct link to the quality of care for people can be established. Therefore, we do not regulate the WRES; instead we assess the outcomes of progress against the WRES through reviewing WRES reports and action plans and undertaking interviews during inspections. This helps inspection teams to gather evidence on how trusts have implemented the WRES and made improvements year on year. So, the leverage that CQC can bring to bear is mainly in terms of ratings rather than enforcement.

As it is rarely possible to enforce the WRES, we have developed a flowchart that is used if trusts are found to be non-compliant with WRES requirements. The flowchart identifies where there might be potential breaches or non-compliance with WRES requirements and outlines the options of for CQC to refer a trust to NHSE/I’s WRES team.

There has been one instance of a trust where we were able to establish a direct link between workforce inequality on the grounds of race and risk of an impact on patient care. In this case, we issued a s29 Warning Notice, requiring the trust to improve their support to Black midwives.

If there is a potential breach of equality law (again an area we do not enforce), we have an arrangement in place to make a referral to the Equality and Human Rights Commission.

We have adopted a supportive role in respect of trusts compliance with the WRES, based on encouraging improvement by having conversations and making suggestions for actions, rather than referring to NHSE/I. This report has not identified any trusts that have been referred to NHSE/I.

Current approach

What are the main concerns with the current approach?

In theory, the way that the WRES has been positioned in the regulatory model should provide a consistent approach. However, this review has highlighted that there has been an inconsistent approach over the last four years. A contributing factor may be that we have continued to make changes to our approach to inspections. For example, in our ‘Next Phase’ project we introduced the well-led inspection framework, which emphasised the importance of the WRES principles and data collated through provider information returns and presented in the evidence appendix. However, the data being available did not necessarily result in inspections exploring matters further or that teams had the confidence to explore further. Some inspection staff feel that they do not have the confidence to interpret or use the data provided to them.

This latest approach still emphasises the WRES but in a different way and reports by exception only. While the information is still available, it is in a different format and lacks consistency. Furthermore, our resourcing of inspections has changed over time. The number of SpAs, instrumental in the focus groups for Black and minority ethnic staff, has reduced considerably. Alongside that reduction has been a reduction in the numbers of these focus groups. There is also some variation in how inspection staff view these changes, with some being comfortable running focus groups by themselves, while others were unaware that SpAs were still available. Unfortunately, our research does not identify any clear reasons for these views.

The well-led inspection framework underwent a review jointly by NHSE/I and CQC in March 2020. This has resulted in proposals to strengthen some KLOEs, prompts and ratings characteristics around equality, diversity and human rights. (Due to the pandemic these changes were not implemented and the assessment framework is now being reviewed again.)

Through the analysis of the reports and feedback from staff and some of the practices that have changed over the four years, it is evident that there is lack of consistency in the approaches to assessing the WRES outcomes leading to the following inconsistencies:

• focus groups for Black and minority ethnic staff not always conducted
• equality and diversity SpA not always recruited to the team where it is necessary
• the WRES varies in the way it is mentioned in reports
• standard tools in which WRES is embedded are not used consistently
• trust equality and diversity leads not always interviewed as a standard approach.

It is imperative that these areas are addressed, albeit within the new regulatory model that will come into effect from 2021 onwards.

Other research

What other internal and external qualitative research has been conducted?

An evaluation carried out by the University of Sheffield in conjunction with Lancaster University reported mixed findings on the role of the WRES in improving culture. On the positive side the report highlighted CQC as being a driver for change:

The WRES metrics, combined with criticism from CQC, were reported to have been a 'wake-up call' to address race inequalities and cultural difficulties within the trust.

 

However, the report also identified a lack of real impact for staff, with only surface changes being made by trusts in respect of CQC activity:

Staff felt the response to WRES had been inadequate, with focus group participants reporting a complete lack of action from the board until 'tokenistic' consultations took place during the week of CQC inspections.

 

Other relevant findings included:

• It is important that the WRES continues with the same commitment and momentum.
• It is vital to retain the same indicators and methodology so that trusts can learn as much as possible from their data, by monitoring change over time, and to help them embed the culture change that is needed to ensure greater race equality within the NHS.
• To maintain positive views of the WRES, steps should be taken to ensure that ‘monitoring fatigue’ is kept to a minimum by allowing greater use of existing data and procedures.
• It is essential that the future leadership of the WRES is considered a priority, both in ensuring continuity at the national level and in decentralised leadership so there is more expertise at a local level.
• There was universal agreement from all data sources that the WRES was helpful in opening eyes and putting race equality on the board agenda.

The report evaluated the WRES as a catalyst for change. One of the fundamental issues relating to impact is that there is a danger that the WRES is seen as a standalone item, when it should be a key part of the wider equality, diversity and human rights agenda. It has been argued that the introduction of the WRES led to the equality and human rights agenda becoming skewed into considering only one equality issue in regulation. Conversely providers have said that incorporating the WRES in regulation has been a catalyst for change. Although this is contradictory, the University of Sheffield report highlighted that where the WRES has made a difference, our reports have also highlighted where this can be improved.

Another evaluation has been conducted by University of Manchester and Deloitte on the well-led framework. A key recommendation from the report in respect of the WRES is to refine the culture and leadership elements of the well-led framework to include greater levels of detail on:

• measures and prompts for assessing organisational culture(s), including signs and symbols, and patient and staff experiences, that indicate displayed and enacted values, attitudes, beliefs and behaviours (examples: existence and embeddedness of Schwartz rounds; Arnstein levels of patient involvement)
• evidence of the encouragement and management of talent pipeline and succession planning for key leadership roles
• assessment of capacity, capability, empowerment and development of middle managers
• development of further lines of enquiry around equality, diversity and inclusion (example: existence of reverse mentoring
• the extent and penetration of clinical and, specifically, medical leadership engagement.

Other areas identified as warranting greater emphasis relating to equality, diversity and inclusion included: ; unconscious bias training; and insights into the different experiences of black and minority ethnic staff, patient and carer groups.

The importance of our approach to equality, diversity and how it contributes to the culture of organisations, is evident from this evaluation. It will be important to continue to improve the narrative and importance of workforce equality and how it can assist in identifying the root causes of equality and diversity challenges facing health and care organisations.

What does ‘good’ look like?

Are there examples of good practice where the WRES is implemented effectively and the trust demonstrates good practice?

The last four years have seen many examples of both good and poor performance in respect of the WRES. We have continued to monitor the progress and improvement that trusts make year on year. This is vital in order to check on continued improvement and aspiration, and to demonstrate that the culture is shifting, leaders are committed to this agenda, and staff feel valued and respected as part of an inclusive culture.

A clear example of good practice during that timeframe is provided by our case study of Northamptonshire Healthcare NHS Foundation Trust (NHFT). The trust was rated as outstanding overall and in well-led, and featured in our State of Care Report 2019. A key area was the work to improve equality within the workforce, which was demonstrably making a real difference in the working environment and the quality of care they provided. The trust reported improvement against six of the nine WRES indicators in one year, and demonstrated a commitment across leadership, culture and engagement to promote workforce equality.

You can read the full case study on the CQC Medium account.

Including the WRES in regulation has made a positive impact over the last four years, but there is much more work to be done.

We achieved what we set out to do, in that we have developed and supported intelligence, methodology and policy to promote, implement and embed the WRES in well-led assessments. In terms of the process, the WRES principles have been incorporated into the KLOEs, prompts and ratings characteristics in the well-led framework. And they have consequently been strengthened through the recent review carried out by CQC and NHSE/I, albeit this has not been implemented yet due to the pandemic. Supplementary tools are available for inspection teams to access. Our intelligence work around the WRES data has been recognised nationally and incorporated into the Model Hospital dashboard.

The outcome from this development work has been evident in the results of the analysis of inspection reports over a period of three years and in the level of detail included in the information collated and reported as an integral element in the Evidence Appendix and policy development. This has also enabled us to report nationally on the WRES in State of Care.

Overall, the awareness of the WRES among inspection staff is apparent and is demonstrable. However, this can be improved. There are variations in the approach and levels of intervention with providers, as a consequence of differences in approaches being taken by individual inspection teams and the frequency of change in inspection methodology and guidance. This finding highlights a pressing need to develop a more streamlined, cohesive and a systematic approach, which considers equality and human rights across CQC’s regulatory activities and ensures a focus on the outcomes of those activities and their impact on both the workforce and people using services.

Performance on workforce race equality has had an impact on the ratings of several NHS trusts. However, there is still work to do, most importantly on ensuring consistency and the reporting of outcomes. Our next step is to explore how trusts can best demonstrate improvement on the WRES, and identify the reasons for their chosen actions.

External evaluations have also identified CQC as a catalyst for change in the implementation of the WRES.

However, the analyses underpinning this review clearly identify the need for CQC to revise its approach, systems and methodology in respect of the WRES in order to improve delivery on both the WRES and wider equality objectives within our new regulatory model. A more streamlined approach would support consideration of workforce equality in the round in our regulation, including the WDES and the refreshed EDS. Learning from the WRES could then form the basis of improvements that address how we could best assess outcomes of the WDES and EDS. The next section provides a list of actions that we will take to address the issues raised in this report and to create an improvement plan to generate strategic change.

High-level actions

1. Aligning with our strategic ambition to be a smarter regulator, we should take a differentiated approach to workforce race equality in the NHS, based on risk of poor workforce race equality in an NHS trust – with clear expectations about our engagement with trusts and our actions for different levels of risk.
2. These risk decisions should be made in collaboration with other national partners, including professional regulators and NHSE/I national teams responsible for workforce equality.
3. Recognising the adverse impact of the pandemic on Black and minority ethnic staff working in the NHS, we should develop some short-term focused work around workforce race equality in NHS trusts that enables us to encourage improvement in workforce equality and to test our future approaches. This would include engaging an external expert to lead this work, We are in contact with the following organisations and groups, who will be invited to participate: NHSE/I national teams responsible for workforce equality, professional regulators, the Race and Health Observatory, Equality, Diversity and Inclusion leads in NHS trusts, national organisations representing NHS staff in particular equality groups and equality leads in relevant Trades Unions. It will also involve considering how we look at workforce equality at a ‘core service’ level within a trust at different levels of risk.
4. Over time, use this learning to develop and implement a seamless approach and systems to assess the workforce equality overall, by considering the WRES, WDES and EDS as well as considering differences between workforce groupings, for example the forthcoming Medical WRES and EHRC inquiry findings on low-paid Black and minority ethnic people working in health and social care. This would also include developing our approach to workforce equality in independent health care providers.

Areas to consider for the improvement plan:

A flexible and targeted approach to assessing risk to workforce equality on an ongoing basis

1. An annual analysis of WRES and WDES data along with qualitative data, such as feedback from staff working in trusts, will give an indication of the risk to inequality for staff in a trust. This will drive different levels of regulatory activity around the WRES and workforce equality more generally. Our findings from this annual analysis will be brought to a Workforce Equality risk summit, involving the national NHSE/I WRES and WDES teams, professional regulators and the National Guardian’s Office, to agree in which trusts there are the highest apparent risks. We will test this approach in our short-term focused work.
2. We will strengthen the equality and human rights elements in provider engagement activity, including additional engagement for trusts deemed to be at higher risk of workforce inequality. This would form a clear set of actions for inspection teams to undertake depending on risk.
3. In higher risk trusts, this will involve proactively seeking the views of staff, for example Black and minority ethnic staff or disabled staff, and regular engagement with the trust with an expectation that this will lever improvement action in trusts. A SpA will be allocated to advise the inspection team for each high-risk trust and the local team will determine how to use the SpA in their activities. We will build on work developed during the pandemic to engage with Black and minority ethnic staff through online focus groups, which attracted high numbers of participants, and also our recent work on developing bespoke staff surveys to gather evidence on specific topics. We will also look at how we can engage with staff who have been through the WRES experts programme and with Trust Equality, Diversity and Inclusion leads.
4. For lower risk trusts, we will strengthen the dialogue between CQC and the trust. We will ensure workforce equality and equality and human rights for people using services is on the agenda for our provider engagement activity at least once a year. We will ensure that some engagement activity is undertaken with NHS trust staff around equality and inclusion in each trust at least once a year, for example through focus groups.
5. In trusts where there are indications of good practice around workforce equality, engagement activity will focus around this, to develop improvement case studies that can be shared and to help in ratings decision-making for example the boundary between good and outstanding.
6. Risk levels would be kept under review during the year, for example new feedback from staff, from providers and from other regulators or potentially from data analysis between annual WRES collections, if possible, to develop this.
7. The results of this information from ongoing risk assessment will drive further actions, in line with the new regulatory model.

On-site activity

8. We will ensure equality and human rights for both workforce and people using services is integrated into planning meetings for on-site activity.
9. Where, in the lead up to on-site work, we have current concerns about workforce equality in a trust, or alternatively where we could gather on-site information about good practice, workforce equality may be a focus for on-site activity.
10. In these cases, an assessment will be made about whether a SpA should be allocated to work with a lead inspector, for example to interview the trust EDI lead, Freedom to Speak Up Guardian, responsible NED and Patient Experience lead as it is important to be consistent and to corroborate between these roles.
11. If we do not have up-to-date information from staff about workforce equality, we will undertake focus groups or develop mechanisms to capture staff views about organisational culture, so that our decisions about workforce equality include up to date views of staff, alongside data and the view of the leadership of the trust.
12. Where core service inspections are due to be carried out in trusts where there is a known workforce equality issue in the core service, workforce equality should be considered at a core service level. This may include allocating a SpA or a lead inspector for this. Where core service inspections are due to be carried out in trusts where there is high risk to workforce equality at a trust level, then we will use tools that enable inspectors to gather information from staff and managers of the service about workforce equality, to add to trust-wide monitoring of the issues. We will develop our approach to workforce equality at core service level in our short-term focussed work.

Equality and Diversity Specialist Advisors (SpAs)

13. We will assess the overall requirement for SpAs based on this differentiated approach, including the experience levels required to be a SpA.
14. We will implement a fair and transparent allocation of SpAs.
15. We will provide SpAs with access to the most up-to-date tools that we use on inspections.
16. We will allocate a SpA for our work with each trust where there is a high risk of workforce inequality, to provide advice to our local team.
17. We will ensure SpAs are included in planning stages and meetings.
18. Provide SpAs with learning on this new approach

Policy

21. We will develop thematic work to start with, in order to test some of the future concepts, for example risk rating, risk summits, approaching trusts with higher perceived risks through engagement activity and gathering good practice through engagement activity.
22. The positive changes proposed before the pandemic to the well-led assessment framework should be considered in any review of the framework undertaken by NHSE/I and CQC.
23. We will strengthen the equality and human rights elements in future provider and inspector handbooks.
24. We will develop our approach to the WRES for the independent health sector.
25. We will work with CQC’s Academy to develop solutions to learning needs arising from this new approach.
26. We will re-run the questionnaires to inspectors and SpAs after introducing changes, so we can iteratively improve.

Enforcement

27. Using our MOU with the EHRC and learning from a recent success in referring workforce equality issues to EHRC, we will develop a more formal referral strategy if trusts may also be in breach of equality law and we view that an EHRC referral may be better use of our respective powers. For example, if a trust is not taking action to address workforce inequality despite our engagement with them on the issues. This would enable the EHRC to consider using its powers under the Equality Act 2006 to enter into a formal agreement with the trust on the basis that it will not use its other enforcement powers, provided that the trust undertakes not to commit an unlawful act and to take (or stop taking) specific actions, which can be laid out in an action plan. EHRC cannot take every case that is referred to it and we will need to discuss and agree the referral strategy with them.

This sets out the fundamental problem to be resolved and not the solution.

1. Basic question to be resolved: What impact has the WRES had in regulation since its implementation and what improvements are required?
2. Scope of the work:
   • CQC’s remit and commitment to the WRES
   • Analysis of published reports
   • Analysis of our processes
   • Published external reviews
   • Views of inspectors and SpAs
3. Out of scope:
   • New external engagement work
4. Desired outputs and success criteria
   • A review of current processes and achievements
   • Identification of gaps
   • Report containing recommendations for improvement of regulating the WRES
   • Lessons learned enable future regulatory work on the WDES and refreshed EDS
     • Outline timings and milestones
     • Scoping: May to July 2019
     • Project plan: August 2019
     • Establish task and finish group: Sept 2019
     • Desktop research/ questionnaires: Sept-Dec 2019
     • Report writing and sign off by Equality Objective 3 working group: Jan-March 2020
   • Context:
     • The WRES has been considered as part of our regulation and the ‘well-led’ key question since 2015. As we have at least three full years of data and reports, we can measure the impact of including the WRES in regulation
   • Constraints and dependencies
     • Changes in methodology over the period – e.g. shift from ‘inspect and rate’ to monitor and introduction of standard statements may make longitudinal analysis difficult
     • Analytical capacity to analyse impact beyond the three annual qualitative analysis reports on the WRES that have already been produced

WRES Review

Questionnaire for Hospitals inspection staff

As part of our work on Equality Objective 3 – ‘Equality and Well-led Provider’, I am currently exploring the impact that the Workforce Race Equality Standard implementation has had since we have included this as part of our well-led inspections. I would really welcome your general and would be grateful if you could complete the questionnaire below.

Name:

Job role:

Hospital type:

Region:

1. In your view how do you think that looking at WRES in the regulation of hospitals, what has worked well and what can be improved?
2. Is there any variation in how well it is working in the regulation of NHS trusts compared to Independent hospitals?
3. Do you feel that you have enough data and information about WRES in Monitor including for inspection planning? For example, do you use the WRES information in Insight in inspection planning?
4. How often do you use equality and diversity specialist advisors for well-led inspections and in your view what value did they add to the inspection? If yes, how and if not, why do you think this could be?
5. Do you feel confident in asking questions – either on inspections or in engagement activities - based on the data and information available to you?
6. Do you hold BME staff focus groups, if so, do you hold these at every inspection and when in the process do you hold them? Do you ever hold BME staff focus groups outside the inspection period, for example as part of ongoing engagement?
7. Do you feel confident in holding BME staff focus groups? If not, what could help you feel more confident?
8. How do you think that WRES related findings influence ratings? Provide examples of where this has been demonstrated.
9. Do you feel that the WRES sustained its importance in well-led inspections and what are your reasons for this?
10. Have you faced resistance from internal colleagues and or providers when assessing the WRES? If so, what happened?
11. Is there anything you would like from the EDHR team i.e. further training, tools, guidance?
12. Any other comments/observations?

Many thanks for completing this form.

As part of our work on Equality Objective 3 – ‘Equality and Well-led Provider’, we are currently exploring the level of impact the Workforce Race Equality Standard implementation since we have included this as part of our well-led inspections. I would really welcome your views and would be grateful if you could complete the questionnaire below.

Name:

Number of inspections attended:

1. In your view how do you think that looking at the WRES in regulation has been, what has worked well and what can be improved?
2. Is there any variation in how well it is working in the regulation of NHS trusts compared to Independent hospitals?
3. Do you feel that you have had access to enough data and information about WRES in Monitor including for inspection planning?
4. Do you feel confident in asking questions – either on inspections or in engagement activities - based on the data and information available to you?
5. Do you feel you had access to the relevant documentation and tools to provide advice and guidance to the inspection teams?
6. Do you feel confident in holding BME staff focus groups? If not, what could help you feel more confident?
7. How have WRES related findings influenced ratings? Provide examples of where this has been demonstrated.
8. Do you feel that the WRES sustained its importance in well-led inspections and what are your reasons for this?
9. Have you faced resistance from internal colleagues and or providers when assessing the WRES? If so, what happened?
10. Is there anything you would like from the EDHR team i.e. further training, tools, guidance?
11. Any other comments/observations?

Many thanks for completing this form.