In February 2021, ADPH London released a position statement supporting Black, Asian and minority ethnic communities during and beyond the COVID-19 pandemic. This statement highlights racism as a public health issue, and outlines five themes for action.  One of these themes is Diversifying The Workforce And Encouraging Systems Leadership – and is led by Dr Natalie Daley,  Consultant in Public Health at Barnardo’s and Dr Nike Arowobusoye, Consultant in Public Health, Richmond and Wandsworth Council.

This blog is based on a conversation between Natalie, Nike and the programme’s Communications and Engagement Officer, Lee Pinkerton. 

Lee Pinkerton: What attracted you both to this particular work stream, as opposed to any of the four others?

Nike: I think it’s more a case of what attracted me to the work that ADPH were doing around tackling racism as a public health issue. At the point I became involved, we didn’t have the workstreams we now have – this is work we’ve all done together.

It started off with some of the London Directors of Public Health having a meeting where they were talking about the ethnic minority groups and felt that the conversation should also be had with them. I think at that point they started to work on the position statement and then that started to evolve. 

I was interested in the whole ‘racism as a public health issue’. It was new, it was innovative, it was ground-breaking and it was evidence based. I was interested in inclusiveness, thinking about the diverse public health workforce and through my work as a UKPHR assessor, understanding the issues that people were having.

When we narrowed it down to five workstreams, given my special interest, it made sense to me to lead the one that was about diversifying the workforce, and adding system leadership to it as part of the conversation.

Natalie: The workstream had already been set up when I came into it. The Diversifying The Workforce workstream appealed to me because of my existing interest in that area. I was already interested in representation in the workforce, as I had been volunteering with an organisation called African Caribbean Medical Mentors that supports young people from Black African and Black Caribbean backgrounds into medical school and into dentistry. 

Nike: I had also been doing mentoring. Having been a consultant in public health for the last 15 years, I’d heard many stories and supported people trying to understand how to go through the programme and formalising their public health career.  A recurring theme that really got me thinking was that they felt there was nobody to mentor them. Nobody who had their life experience or looked like them to give them opportunities. 

So I decided to go back to my colleagues to see if I could get some Black African and Black Caribbean mentors. But I struggled to get colleagues to come in and offer their support. 

It really showed me how challenging it is for people to get in. And that’s medicine, not to talk about when you want to do Public Health – that appeared to be a total closed shop for them.

LP: So why does the ethnic make-up and the racial diversity of the workforce matter? We’ve heard about the importance of diversity in the police force and why it’s important that the police force represents the people they are policing, but is it important in Public Health? Is medicine not colour blind?

Natalie: When I was studying medicine, when you looked inside a medical textbook, pretty much all of the conditions were presented on white skin. That has massive implications when it comes to trying to diagnose illness, because many diseases can present very differently in Black and Asian people compared to White people.

And it’s the same with some of the equipment used, like the equipment we use to look at someone’s oxygen levels. There’s research to show that’s not as effective on people with darker skin. I think when you have a workforce that is predominantly of one ethnic background, it’s a lot easier to not consider those kinds of things because those issues don’t affect them.

When you’re studying medicine, it is really helpful to see people who are like you and that was my motivation for becoming a mentor.  In medical school  I saw very few Black doctors and even fewer Black Caribbean doctors. I think that representation is really important, because for people who want to get into that field, it gives them something to aspire to and think , ‘I can do that too’. 

The other aspect for me is around cultural competence and being able to engage with people from different backgrounds. There is evidence showing that having health care professionals who are from the same ethnic backgrounds as their patients have a positive impact on patient outcomes. 

Nike: When you think of race and skin colour, it’s a very big thing in the UK.  If you were in Nigeria, and you train there, you live there, and you’re practising there, everybody’s going to be Black. So when you say medicine is meant to be colour blind – it could be,  but what it is, is diverse and inclusive. We treat everybody. There’s a whole range of different people and even though we’re all one human race, some communities have sickle cell, some have Thalassemia, some have cystic fibrosis. So when you look at medicine through those lenses, then you begin to see that we do have to ensure that people are able to deal with all of the differences inherent in being in the human race. 

But I know for a fact you don’t think of race in terms of colour and power until you actually come and live and work in the UK. Race becomes a thing, it’s part of how you have to navigate the world. 

LP: So if we’re starting from the premise that the workforce needs to be more diverse, historically what have been the obstacles to that, and what things are now being put in place to make that happen?

Natalie: You can start all the way back at school. You’ll see that certain ethnic groups don’t achieve as good GCSEs and A levels. To be able to do certain university courses you need the A levels. If you can’t even get to do the university course that you want,  whether that’s medicine or some other kind of science that might set you on the path to Public Health, then that’s already a barrier.

Some people aren’t even aware of these careers as an option to them. And I think if you’re not seeing people in that field who are like you, you may think that that’s not an option for you. Public Health was not a career I was particularly aware of. In medical school, no-one spoke about it as a specialty. It’s only as a junior doctor that I became aware of it as a career. 

Nike: All of these obstacles start off with the opportunities you have, and your chances in life. I was fortunate coming from a very well off background and I’ve always wanted to be a doctor.  I didn’t grow up understanding that there is a level of disadvantage for many. 

Then there’s the self limiting beliefs, there’s the possibility of limited knowledge of some families. There’s this idea about aspiration. That if your dad didn’t do it and your grandfather didn’t do it, why would you assume you’re going to do it? 

So, in its broadest sense, it’s that whole thing about power,  about income, and about who has a right to be at the table, who has a right to go to that school,  who do you expect to see there and what you do if you come across someone who you don’t expect to see there?  

That’s what we’re looking at. How can we mitigate those barriers? How can we make people become allies and see that we need to make it more of an equitable playing field? Not an equal playing field but an equitable one.

What we are doing in our work now, is to feel comfortable to ask the question, ‘who’s missing in this room?’ and ‘have we done everything to enable them to be part of it?’ How do we systemise the acceptance that it is okay to have seven Black Directors of Public Health or five Asian Directors in a group of 20?

Natalie: Like Nike I was lucky. I went to a private school where if you were predicted three ‘A’s, they tell you you’re applying to Oxbridge, no matter what. But I was not represented in that school. I could have counted on one hand the number of black or mixed race girls there. I’m not from a middle class family. I don’t have parents, grandparents, uncles or aunties who went to medical school. So it wasn’t that I’d come from that background, and I was very lucky to have the opportunities that I had. But not everyone is in that position, and they may end up in a school where they look at the Black kid and say, ‘I’m not gonna talk to you about medicine, that’s not an option for you’. 

Nike: Another one of the reasons I am doing this, is also to get people like me to understand that they need to show up. We can’t say ‘the system will look after it’ and step away and do nothing. There’s the responsibility for the system not to be racist, but there’s responsibilities for all of us.

So I think there are many sides to it, and hopefully people will now speak up, because part of the work we’re doing is giving people the language, helping them feel comfortable dealing with the discomfort of naming what they think they’re seeing that is wrong.

LP: So we’ve talked about the obstacles that are in place. What kind of assistance are you hoping will redress the balance? Do you want to give a bit more detail about the training course, why it was created and what you hope to achieve with it?

Natalie: We rolled out an initial program of training with five different modules,  a mixture of online and in person.  We kicked that off with an in-conversation event with Kevin Fenton, Sandra Husbands, Catherine Mbema, and Anna Raleigh as our panellists, chaired by Meera Spillett from the Staff College, just having an initial discussion about their experiences as leaders in public health.  The first cohort of participants were consultants and Directors of Public Health in London local authorities. We went through a very iterative process with the Staff College to get the sessions right.  We took on board a lot of feedback and it became a very good learning experience.  We developed a really good relationship with the Staff College and we’ve recently launched the second cohort of training. 

We’ve tried to capture the consultants and directors in London who we didn’t get the first time around, but we’ve opened it up to a wider London Public Health Workforce. So, to the NHS UKHSA, OHID, – to capture more people. 

Nike: And we have a report that came out in January 2024 called the Workstream Review. It’s the report of cycle one of the EDIE training we commissioned. We set out on a journey to improve population health and promote equity in the public health workforce by empowering conversations about race and multicultural staffing at all levels. We wanted to share good practice and to develop cultural competence and cultural humility, encourage dialogue and curiosity. 

Natalie:  One of the people who went through the training is looking to work with the Staff College to deliver training tailored to his team, which I think is a really good example of the impact.

Nike: What I think we could also cover is the learning that we’ve had. We were intentional, but we can’t say we knew what we were going to meet when we started doing it. This has been a journey of learning for myself as joint lead with Natalie – my understanding of the different ethnic groups, including White has grown, and how I measure whether we’re being diverse and equitable has changed.  I think that’s translated itself into having more confidence in picking up conversation topics that relate to race that I would never have before.

So when we are interacting in the same workspace with people of the same colour as us but of different cultures, we don’t necessarily understand that there are differences in the culture until it is brought home to us. And this work has opened my eyes to that a lot more than if I wasn’t doing this role. 

Natalie: One good thing for me has just been working with Nike, because I’ve learned from her and her experiences. As she alluded to, we may both be Black but we have very different backgrounds – she is Black African, Nigerian and I’m Black Caribbean, Jamaican. So, we sometimes have different perspectives on things that’s influenced by our cultural backgrounds. 

I also think being able to work in this space as a Black person is really exciting. The kind of conversations that we have started to have over the last few years are ones that I’ve had with family members for a long time, but now having the opportunity to be able to have those conversations with a wide range of people is a great privilege and opportunity, because we couldn’t do that as much before.  It’s really fantastic to have the opportunity to learn and share with other people, and to listen to people’s stories. I really value that and I think that’s what this workstream has given us.