About this report

About this report

This report was commissioned by the NHS Alliance as a follow-up to Shattered Hopes (2022). It explores how opportunities for individuals from ethnic minority backgrounds seeking leadership positions within the NHS have changed over the last three years and examines the factors that continue to influence progression, representation, retention and organisational culture within NHS leadership environments. 

The research had five key aims:

1. Understand the experiences of ethnic minority staff working in, or aspiring towards, NHS leadership roles.
2. Explore barriers and enablers relating to leadership progression, representation and retention.
3. Identify gaps in current approaches to improving leadership diversity. 
4. Highlight examples of positive practice and opportunities for improvement. 
5. Provide recommendations to support meaningful and sustained change across NHS organisations. 

The findings presented within this report are based on the BME Leadership in the NHS survey undertaken between 12 November and 1 December 2025, alongside qualitative interviews carried out in May 2026. The survey explored experiences relating to racism, leadership diversity, career progression and organisational culture. Qualitative interviews were undertaken to provide greater insight into the lived experiences behind the survey findings and to better understand the factors influencing leadership opportunities, workplace experiences and career decisions. 

The findings are presented across four interconnected themes:

• Progression.
• Representation.
• Retention.
• Organisational culture.

The development of this report was informed by the views of Lord Victor Adebowale CBE, chair of the NHS Alliance and founder of the NHS Race and Health Observatory, who described four forms of racism that have helped shape wider discussions about race inequality within the NHS:

• Racism by omission, where inequity is reinforced through inaction, silence or a failure to address known issues. 
• Racism by fear, where individuals feel unable to challenge, report or discuss racism due to concerns about consequences or repercussions. 
• Racism by belief, where assumptions, stereotypes and biases influence perceptions, opportunities and decision-making. 
• Racism straight, no chaser, where racism is overt, explicit and directly experienced. 

These concepts provide a useful way of understanding the different ways in which racism may be experienced within organisations.

However, the analysis presented within this report draws upon the NHS Race and Health Observatory’s understanding of racism as operating at interpersonal, structural and institutional levels, recognising that many of the barriers relating to progression, representation, retention and organisational culture are shaped by organisational systems, leadership practices and workplace cultures. 

Interpersonal racism. This refers to racism experienced between individuals and includes discriminatory behaviours, exclusion, stereotypes, microaggressions and unequal treatment. 

Structural racism. This refers to the policies, processes and practices that create or perpetuate unequal outcomes for different ethnic groups, including barriers relating to recruitment, progression and access to opportunities. 

Institutional racism. This refers to the ways in which organisational cultures, systems and leadership practices can reinforce and sustain inequity, even where there is no explicit intention to discriminate.

While experiences of interpersonal racism remain important, the findings suggest that many of the challenges experienced by ethnic minority staff and leaders are rooted in structural and institutional factors. The report therefore places particular emphasis on the role of leadership, organisational culture and system transformation in creating more equitable experiences and outcomes. 

This framework is used throughout the report to explore how racism influences leadership experiences, opportunities and organisational culture. Participants frequently described experiences that reflected more than one level of racism, highlighting the interconnected nature of race inequality within NHS organisations. 

Quantitative survey findings and qualitative interview data are presented within the report to provide both statistical insight and lived experience perspectives. 

References to overt and covert racism are intended as descriptive rather than legal terms. In legal terms, experiences described by participants may reflect both direct and indirect unlawful race discrimination. 

The report is intended to support NHS organisations, board leaders and staff to better understand the experiences of ethnic minority employees working within the NHS and to inform practical actions that strengthen progression, representation, retention and inclusion within NHS leadership. It seeks not only to describe ongoing challenges, but also to identify actions that support meaningful and sustained change across the NHS.

How the research was undertaken

• The research was informed by a literature review undertaken by NHS England’s knowledge and information team, together with a separate literature review undertaken by the NHS Race and Health Observatory. 
• The BME Leadership in the NHS survey was conducted online via Qualtrics between 12 November and 1 December 2025. The survey was distributed through the NHS Confederation’s communication channels, including LinkedIn, member bulletins and member meetings. The NHS Confederation subsequently merged with NHS Providers to form the NHS Alliance in April 2026. To participate, respondents were required to:

• identify as being from an ethnic minority background
• be NHS staff currently working in, or aspiring towards, leadership roles.

• A total of 950 survey responses were received, which included 55 board, VSM and band 9 respondents. Questions within the survey were not mandatory and therefore response numbers vary across individual questions. 
• Five qualitative interviews with senior NHS board leaders from ethnic minorities were undertaken in May 2026 to explore in greater depth the lived experiences behind the survey findings. 
• A workshop was also held at NHS ConfedExpo in June 2026, during which 139 participants took part in table discussions exploring anti-racist interventions and actions required to improve race equality within the NHS.