To explore the role of senior and mid-level managers as barriers or enablers to change in tackling the discriminatory challenges experienced by Black and Minority Ethnic (BME) employees working in the National Health Service (NHS).

A multi-level, multi-sourced qualitative study of five NHS Trusts in England.

26 qualitative interviews with senior leaders and BME network chairs (27 participants) and five focus groups (37 participants) with BME employees, across five NHS Trusts in England.

Our findings revealed that discrimination, racial harassment, incivilities, lack of progression and exclusion experienced by BME employees appear to be deeply ingrained in the culture of the NHS. Despite numerous national and local initiatives aimed at promoting inclusivity and addressing discriminatory behaviours, our findings also revealed a notable disparity between what senior leaders thought was effective in addressing discriminatory behaviours and the actual lived experiences of BME employees. Finally, a key finding was the pivotal role middle managers played in setting the tone for whether discriminatory behaviours are challenged or allowed to persist, which directly impacts on the overall experiences of BME employees within the NHS.

Our results provide evidence that not only does racial discrimination continue to be experienced by NHS BME employees, but that middle managers are key to addressing and improving this situation. Despite there being national policies and initiatives addressing racial discrimination, our study found that positive change, whether at an individual or organisational level, is dependent on the actions and commitment of middle managers.