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In the context of the COVID-19 pandemic and the international reckoning on racial justice, there is a fundamental imperative for organisations to expose and combat racism and bias within the health-care workforce. Racism is a public health threat and there is an opportunity for individuals and institutions to identify and reverse racist policies and practices that lead to unequal treatment, outcomes, and experiences in health care.1 At present, the UK and the USA have workplaces that are increasingly diverse but are not inclusive. Here, we explore this problem in the context of these two countries and what steps need to be taken to improve inclusivity.

olicies and practices that lead to unequal treatment, outcomes, and experiences in health care.1 At present, the UK and the USA have workplaces that are increasingly diverse but are not inclusive. Here, we explore this problem in the context of these two countries and what steps need to be taken to improve inclusivity. In 1948, the UK National Health Service (NHS) was established on the back of a migrant workforce and has, over time, been sustained with crucial contributions from overseas health-care professionals.2 In 2022, 24·1% (332 102) of staff in the NHS were from minority ethnic backgrounds, a substantial increase from 16·2% 10 years ago,3 and higher than the 15·2% in the general population.4 Furthermore, as many as 30% (108 976) of NHS nurses and 45% (62 344) of doctors are from minority ethnic backgrounds.5 With the present chronic shortage of clinical staff in the NHS, and insufficient numbers of people being trained domestically,6 the NHS is likely to become more reliant on recruitment from overseas.7 Today, the largest number of new nurses being recruited to the NHS are from India, Nigeria, and the Philippines.8 But this diversity of the NHS workforce does not guarantee equality or inclusivity. The situation differs in some respects in the USA. Racism and insufficient diversity in the US health-care workforce can be partly traced to the 1910 Flexner Report, which led to the closure of all but two Black medical schools and a substantial decrease in the number of Black physicians over the years.9 A 2021 study of racial and ethnic representation in the US health-care workforce estimated that in 2019, 12·1% (17 916 227) of the workforce was Black.10 Across ten health professions studied, Black representation ranged from 3·3% for physical therapists to 11·4% for respiratory therapists.10 Latino people accounted for 18·2% (26 953 648) of the US workforce, with representation in the ten health professions ranging from 3·4% to 10·8%.10 In 2021, only 0·6% (850 074) of the US workforce were Native Americans and their representation in the ten professions ranged from 0 to 0·9%.10 Meanwhile, Black female staff are over-represented in the US health-care workforce but are heavily concentrated in low-wage jobs in the long-term care sector and in hospitals as a result of enduring sexism and racism.11

force were Native Americans and their representation in the ten professions ranged from 0 to 0·9%.10 Meanwhile, Black female staff are over-represented in the US health-care workforce but are heavily concentrated in low-wage jobs in the long-term care sector and in hospitals as a result of enduring sexism and racism.11 Nurse is using digital tablet in hospital© 2022 FS Productions/Getty Images2022

force were Native Americans and their representation in the ten professions ranged from 0 to 0·9%.10 Meanwhile, Black female staff are over-represented in the US health-care workforce but are heavily concentrated in low-wage jobs in the long-term care sector and in hospitals as a result of enduring sexism and racism.11 Nurse is using digital tablet in hospital© 2022 FS Productions/Getty Images2022 Alongside the diversity of the health-care workforce, it is important to examine whether the leadership of health-care organisations is diverse and whether minority ethnic staff have equitable experiences in the workplace compared with White staff. Data show that minority ethnic staff are less likely to progress to senior and leadership roles12 and more likely to experience discrimination, bullying, harassment, and victimisation in the workplace on the basis of race and ethnicity.13 Racism can play out in the way minority ethnic staff are less likely to be recruited or receive professional development and be promoted, and are more likely to face disciplinary processes within the workplace than their White counterparts.14 Racism also surfaces in the form of ethnicity pay gaps. In the USA, the incomes of Black physicians are substantially less than White physicians, even after the characteristics of physicians and practices are accounted for.15 Pay gaps are also evident in the UK's NHS. In May, 2020, Black NHS staff had lower monthly basic pay than White staff—Black men were paid £0·84 for every £1·00 paid to White men, and Black women were paid £0·93 for every £1·00 paid to White women.16 Across health-care organisations minority ethnic staff are under-represented in leadership roles. In the USA, Black and other racially minoritised people make up about 40% of the US population, but they hold only 16% of leadership roles in hospitals.17 In the UK, although some progress is being made, minority ethnic staff continue to be under-represented at senior levels.18

re under-represented in leadership roles. In the USA, Black and other racially minoritised people make up about 40% of the US population, but they hold only 16% of leadership roles in hospitals.17 In the UK, although some progress is being made, minority ethnic staff continue to be under-represented at senior levels.18 These problems hold true for usual workplace conditions but the disproportionate impact of COVID-19 on minority ethnic health-care workers has added another dimension to staff experiences. In the NHS, minority ethnic staff were more likely to work on COVID-specific wards than White staff (49·2% vs 34·7%).19 Health and social care workers from minority ethnic backgrounds were also disproportionally represented in COVID-19 deaths.20 Similarly, a study of nearly 25 000 health-care workers in the USA highlighted the impacts of structural racism (eg, Black staff working and living in places where there was higher community spread of COVID-19) and bias and discrimination (eg, Black personnel being less likely to get SARS-CoV-2 testing than White staff) during the pandemic.21 These inequalities and inequities must be tackled urgently. As we have highlighted, organisational diversity is not a precursor to progressive, compassionate, and inclusive workplace cultures. But this can be achieved if the right conditions are established within health-care organisations over time. For that to happen, organisations must take a strategic, long-term approach to create a culture of equity and inclusion.

ersity is not a precursor to progressive, compassionate, and inclusive workplace cultures. But this can be achieved if the right conditions are established within health-care organisations over time. For that to happen, organisations must take a strategic, long-term approach to create a culture of equity and inclusion. With effective leadership, embedded accountability, and concerted efforts by all members of staff, organisations can see year-on-year improvements across indicators of inclusivity, including self-reported bullying and harassment in the workplace, and on representation in senior and leadership positions within the organisation.22 However, such efforts need to be consistent and persistent over time and must be funded and embedded as strategic organisational priorities. Experience suggests that when there is a clear focus on committed leadership, data-driven accountability, effective communication, and engagement with staff actions to advance anti-racism and inclusivity benefit not only minority ethnic staff, but also the whole workforce.22 Addressing systemic bias and racism is a moral imperative and can also strengthen organisations23 and make economies stronger.24 During a time of global austerity, this is an important consideration.

f actions to advance anti-racism and inclusivity benefit not only minority ethnic staff, but also the whole workforce.22 Addressing systemic bias and racism is a moral imperative and can also strengthen organisations23 and make economies stronger.24 During a time of global austerity, this is an important consideration. There is no single fix to the structural issues we have outlined, but there are steps that organisations and policy makers need to take to begin to make the difference needed. For instance, racial bias is embedded in clinical curricula in which, for example, learning materials focus on the presentation of disease on white skin alone or flawed race-based medicine.25 Reviewing and replacing such materials can reduce the introduction of bias in the future workforce. Similarly, there is a need to address ethnicity pay gaps,26, 27 and examine not only median pay difference, but also lifetime earnings, pension inequality, and bonuses. In addition, health-care providers should consider not just how to diversify recruitment, but how they are fostering talent and creating career progression for under-represented groups to join management, executive leadership, and governing boards of health-care organisations. Training can define and spotlight the ways in which structural and institutional racism manifest in the workplace. However, organisations need to go further and embed an understanding of structural racism and inequity by interrogating and reforming workplace policies and programmes. Finally, all these actions can only be effective if built on a foundation of systematically collected and analysed data about workforces. These metrics will help guide targeted action to advance racial equity in the workforce and can also be used to hold decision makers, the organisation, and individuals to account.

s. Finally, all these actions can only be effective if built on a foundation of systematically collected and analysed data about workforces. These metrics will help guide targeted action to advance racial equity in the workforce and can also be used to hold decision makers, the organisation, and individuals to account. These interventions need to be an integral part of a broad set of initiatives that should be focused on with the same thoroughness as any other organisational strategic priority. This strategic approach must be a key leadership responsibility. It is therefore essential that leaders identify and are held accountable for how they implement transformational change to achieve racial equity in the workplace in a way that ultimately leads to equitable opportunities for all.