All posts by Lynne Carter

Creating knowledge that is good enough

This post is taken from a presentation that Susan Hampshaw and I gave at the UK Knowledge Mobilisation Forum this year.

KMB forum image

Lynne is an equality and diversity manager in the NHS.  Her NIHR funded Knowledge Mobilisation Research Fellowship is about mobilising knowledge to reduce ethnic health inequalities.  This talk is about one of her fellowship case studies – work with Susan Hampshaw from the Public Health team at Doncaster Council.

The Evidence and Ethnicity in Commissioning research project found many barriers to mobilising knowledge about ethnicity, including that people advocating for change in this area often lack skills in finding and using evidence.  Doncaster Council’s decision to assess the health needs of local Black and Minority Ethnic (BME) people gave Lynne and Susan the opportunity to work together.

Over a few months and supported by Lynne, the public health team  had brought together evidence of health needs and formally presented this at the Health and Well Being Board.  At the board, we talked about this as an on-going piece of work with work plan and that a next step would be work on this project aiming to examine inequalities for people of different ethnicities using Improving Access to Psychological Therapies (IAPT).   IAPT is national health service providing counselling to people with depression and anxiety.

We knew this was an important issue for local people and we were keen to find a way of identifying, understanding and acting on evidence about uneven access to and outcomes from services. We felt that if we could develop a simple, methodical approach we could then roll this out to other aspects of health and wellbeing.

We know, that there’s an uneven playing field in this area.  The experiential knowledge brought by BME people is generally undervalued.  Policy makers lack knowledge about inequalities linked to ethnicity and lack confidence in how to effectively intervene.  It is important to find a way to mobilise this knowledge so that everyone involved can readily understand it.  People working in public health are often the gatekeepers of this data and the way they talk about it and present it can act as a barrier to its use.  We sought out a data specialist (Laurie Mott) who could help us avoid this trap and help us use the data as a starting point for conversations about what it might mean.

Lynne worked in Sheffield and Doncaster, back and forth, gradually developing a methodology to describe and compare for local women and men of different ethnicities the need for psychological therapy, usage of those services and outcomes for people who did you use them.

picking brains

“My fellowship gave me the time and opportunities to pick the brains of professionals working in other fields.  I learnt from researchers how to think more clearly about exactly what I wanted to know and from data analysts like Laurie, how to calculate statistical significance.”

We held a workshop with local people, community organisations and staff working in the IAPT teams.   Ellie from Leeds GATE , a local Third Sector organisation, facilitated, using their roads, bridges and tunnels model to explore the community assets of local people and barriers to accessing services.

We did this as a piece of co-production work, aiming to create a level playing field where everyone’s knowledge is equally valued.  We worked on the premise that no one party has the knowledge to improve this situation.

We’re well on the way to developing a methodology to create knowledge that is “good enough” – more robust and accurate that the results of Google searches that equality and diversity practitioners often resort to; also a method that doesn’t need experienced researchers, qualified data analysts or three years’ worth of work.

We’ve brought together different types of knowledge, shared and developed skills. We’ve spanned team boundaries to do both parts of Ian Graham’s Knowledge to Action model – we’ve created knowledge as depicted in his funnel and we’re currently following his implementation cycle.  We’re making connections with a view to sharing our learning and methodology across the NHS and Public Health systems.

We held a workshop with local people, community organisations and staff working in the IAPT teams.   Ellie from Leeds GATE , a local Third Sector organisation, facilitated, using their roads, bridges and tunnels model to explore the community assets of local people and barriers to accessing services.

We did this as a piece of co-production work, aiming to create a level playing field where everyone’s knowledge is equally valued.  We worked on the premise that no one party has the knowledge to improve this situation.

We’re well on the way to developing a methodology to create knowledge that is “good enough” – more robust and accurate that the results of Google searches that equality and diversity practitioners often resort to; also a method that doesn’t need experienced researchers, qualified data analysts or three years’ worth of work.

We’ve brought together different types of knowledge, shared and developed skills. We’ve spanned team boundaries to do both parts of Ian Graham’s Knowledge to Action model – we’ve created knowledge as depicted in his funnel and we’re currently following his implementation cycle.  We’re making connections with a view to sharing our learning and methodology across the NHS and Public Health systems.


So, in short this was a project this was a project about transformation! We aimed to transform the data we had on mental health, ethnicity and gender and turn it into usable knowledge that we could act upon.

John Barnes and the Iceberg

I first told this story at an action learning set meeting with other Knowledge Mobilisation Research Fellows (KMRFs). Most recently I told it at a workshop at the Health Services Research UK symposium in Nottingham.  Another KMRF Vicky Ward has blogged about this workshop.

Something I’ve been trying to do as part of my fellowship is to find a simple way to explain the links between ethnicity and health.  The links are complex and contested with people working in this field, be they academics, NHS staff or activists, having many different perspectives on these links.

I was attracted to the creative means used by some of the other KMRFs in their projects, for example serious play with Lego, forum theatre and the use of images to describe themes from qualitative data.  But I couldn’t work out how to use such methods to portray the complicated ideas I’m interested in.   Nevertheless, the idea of trying to do something along these lines stayed at the back of mind.

Then I was at a conference where someone from Leeds GATE (a third sector organisation working with people from Gypsy and Traveller communities) talked about and shared a map they have produced to depict the ways in which many people from Gypsy and Traveller communities access NHS services.  They used the metaphor of roads, bridges and tunnels and these were depicted clearly and engagingly in their illustrated map: an illustration that seems to work as a way of describing a complex inequality in a way that people actually experiencing that inequality, NHS staff and policy makers can all relate to.

So maybe I could do something similar around ethnicity and health?

Later I was delivering a new equality and diversity training session I’ve developed for CCG staff.  One of the teaching resources I use is an article that John Barnes (a black football player) wrote for the Guardian newspaper in 2013. In it he argues that the overt racism in football that was much reported on at the time (Russian fans throwing bananas at a Black British player and the much debated case of a White British footballer who’d been heard verbally abusing a Black British player on the pitch and whether he should be fined or not) is only the tip of the iceberg and that the real problem is the hidden, systemic discrimination that contributes to reduced opportunities for Black British people, the lack of Black football players who go on to become top coaches or managers and the fact that many Black British people don’t reach their intellectual or professional potential.  He also describes the more subtle, and often not talked about, stereotyping of Black people and the disproportionate numbers of Black British people who are runners, footballers or singers.

Barnes’ argument seems to me very relevant to the situation in the NHS where the focus of much Equality and Diversity training and work has been on “tip of the iceberg” individual acts of discrimination rather than on reducing the effects of less obvious and more multi-faceted systemic inequalities. The first time I’d led this training session it became clear in the discussion that some participants hadn’t understood the points Barnes was making.  So, I found myself standing at the flipchart having drawn an iceberg with its tip showing above the waves, eliciting from the group what is above and what is below the water line and writing phrases like verbal abuse and deliberate discrimination on the tip of the iceberg and then on the much larger part of the iceberg below the water, writing poverty, lack of interpreters, stereotyping, organisational culture, inconsistent application of processes and mistrust.

I was able to return back to this drawing throughout the session, explaining that the Public Sector Equality Duty requires us to reduce the inequalities that are caused by many of the factors that are hidden beneath the sea and that to identify those inequalities we need to gather together and consider various pieces of information, for example service usage data, demographic information, feedback from patients and research evidence.

So this metaphor has actually helped me to introduce the concept and practice of knowledge mobilisation too.

Effective knowledge mobilisation to improve race equality – a case study

In July 2014 the NHS introduced a Workforce Race Equality Standard, now affectionately known as WRES, and to my mind, this is a great example of using knowledge of an inequality to actually do something to remove that inequality. And not just doing a little something but requiring the whole NHS to measure how unequal their organisation is and to take steps to reduce that inequality year on year.

Some BME (Black and Minority Ethnic) staff networks have been talking about some of these issues for years – the glass ceiling round about bands 5 or 6 that most BME staff don’t get through into more senior jobs and that if you’re BME you are often less likely to find out about those chances for secondment that can lead to promotion, for example. Yet staff networks were generally seen to be about providing mutual support for individual BME staff rather than helping an organisation to identify a systemic issue and then do something about it.

Some of us working in equality and diversity in the NHS were pleased to discover robust statistical evidence of this inequality in the NHS staff survey reports, freely available on the internet and including tables that showed differences in the reported experiences of BME staff and White staff and that these differences persisted across organisations and from one year to the next. We dutifully included this data in our EDS (Equality Delivery System) reports but generally struggled to get colleagues and senior management teams to show an interest, let alone take action.

Now WRES lists the indicators where nationally the inequalities are starkest and requires all NHS provider organisations to measure their progress on workforce race equality and to publish an action plan showing how they are going to tackle the most significant inequalities in their organisation. Clinical Commissioning Groups should be monitoring how well NHS organisations are doing this and the CQC (Care Quality Commission) is picking it up in their inspections. Nationally WRES performance is being monitored and benchmarked.

What has made the difference? I think the following have all contributed:

the dogged determination of some individual people like Roger Kline and Yvonne Coghill

bringing together different types of knowledge

  • research evidence like the Snowy White Peaks of the NHS which showed how few BME people there are employed in senior positions in the NHS and NHS Staff Management and Health Service Quality which showed that patients (of all ethnicities) have a better experience in organisations where race equality is good
  • individual BME members of staff sharing their experiences of working in the NHS
  • statistical data gathered in the NHS staff survey
  • pulling together that evidence into a compelling narrative about why action to improve workforce race equality in the NHS is urgently needed. Making it clear that better race equality will ensure we have the best possible staff working in the NHS and will improve patient care for everyone

using WRES data for problem sensing rather than comfort seeking purposes as Mary Dixon Woods describes in her research about NHS culture. Her description of how NHS managers and boards often use data for assurance purposes rather than to identify issues and opportunities for improvement reminded me of how many NHS organisations have approached the publication of data to meet the requirements of equalities legislation. A great example of complying with the letter but not the spirit of the law.

Roger Kline has just blogged about much of this

To summarise,

  • bringing together different sorts of knowledge,
  • framing that knowledge to show why it is important to act on it
  • using knowledge to identify issues that need addressing rather than for reassurance


These are key principles to effectively moving knowledge about ethnicity and health to action.

Knowledge mobilisation can improve equality impact assessments

Acas (the UK advisory, conciliation and arbitration service) describes an equality impact assessment (EIA) as “a practical tool to identify discrimination.”  Its managers’ guide to EIAs describes how carrying out an EIA can identify and reduce unintended discrimination and promote equality by removing barriers and improving participation.

Yet all too often an equality impact assessment ends up being a bureaucratic, box-ticking exercise that doesn’t lead to any change.  A quick google search just took me to newspaper articles decrying the waste of tax payers’ money on bureaucratic nonsense and box ticking along with government briefing papers and Local Authority guidance documents which aim to ensure that EIAs are not just about ticking boxes.

So the danger that carrying out an equality impact assessment won’t actually lead to improved services and reduced inequalities is well recognised but, in my experience at least, support to actually do EIAs better is a bit thin on the ground.

That’s why we’ve just produced a briefing paper on how thinking about an equality impact assessment as a process of gathering together what we know to:

  1. Describe an inequality
  2. Understand why the inequality has happened
  3. Prescribe action to tackle that inequality.

The briefing paper shows how our Evidence and Ethnicity in Commissioning knowledge mobilisation tools can help to generate knowledge not only to describe an inequality but also to understand it and to identify effective interventions.  They can also help to ensure an appropriate range of stakeholders are involved.

Do have a look at the briefing paper and if you’re interested in discussing anything in it and in learning with me about how to better move knowledge about ethnicity and health to action, please join my new Community-of-Practice

So what exactly is knowledge mobilisation and how can it help to reduce ethnic health inequalities?

To put it simply, knowledge mobilisation is about closing the gap between what we know and what we do.  In a health context, it aims to make sure that research evidence and other types of knowledge lead to benefits for patients and populations.

In my last blog post I wrote about what I learnt from being involved in the Evidence and Ethnicity in Commissioning research project.  It became clear to me that evidence generated through academic research, about any subject, often doesn’t make any difference to policy or practice or if it does, it can take a very long time.  Other sorts of knowledge like the experiences of people using services or of the staff providing them is also often not used to develop and improve those services.

I particularly like this definition of knowledge mobilisation that was coined in Canada:

“a dynamic and iterative process that includes the synthesis, dissemination, exchange and ethically sound application of knowledge to improve the health of Canadians, provide more effective health services and products and strengthen the healthcare system.”

Over the last year, I’ve looked at lots of different ways of describing the knowledge mobilisation process and the one the works best for me at the moment is Ian Graham’s map.

Graham's map

A piece of knowledge is created using the funnel process shown in the middle of the diagram and then that knowledge is applied or moved into action. The action cycle is similar to the plan, do, study, act cycle that you might already be familiar with.  This diagram is taken from Ian Graham’s paper which describes and brings together developments in the field of knowledge mobilisation.

In the Evidence and Ethnicity in Commissioning research project we used our findings to identify the key barriers to moving knowledge about ethnicity and health into action and developed some tools to help overcome those barriers.  Some of the tools can be used in a training workshop or by a team carrying out service improvement or commissioning work.  Others can be used by a team or individual while they are doing the service improvement work.

The tools are all available on our EEiC website and link to the different stages of knowledge mobilisation as in this diagram.

During my fellowship I am going to try out some of the tools in different contexts – more on that in future blog posts and do get in touch if you think any of the tools could be useful in your work.  I’m happy to discuss and help if I can.

I am a knowledge mobilisation research fellow

In my first blog post I described how I came to be an equality and diversity manager in the NHS and now I’m going to tell you why I decided to become a knowledge mobilisation research fellow.  I’m aiming to reflect on what I learn during my fellowship in this blog and I hope if you want to reduce institutional racism, particularly in the NHS, that you’ll come along with me on a journey, or the bits of the journey you find interesting anyway, to find out how knowledge mobilisation can help with this.

So a few years back, I was looking for a way to make the equality and diversity work I was doing in NHS commissioning more effective, so that I was actually making a difference.  So that my work contributed to increased access to health services, better experience of using those services and better health outcomes for black and minority ethnic people and communities, and for other groups of people who experience discrimination.

By chance (well, it was a piece of work a colleague was going to do but by the time it started we’d been through a restructure and he had left the organisation) I got involved in the Evidence and Ethnicity in Commissioning (EEiC) research project.  I was one of three co-researchers working in three different NHS commissioning organisations in Yorkshire who linked up with researchers working in Yorkshire universities to find out how people involved in NHS commissioning were making use of evidence about ethnicity to improve services.

Despite some initial misgivings along the lines of “I don’t understand this academic stuff and I really don’t have time for it when it won’t help me do my job better,” being involved in this research turned out to be a great experience for me.  I became part of a team of people who all want to work out how to reduce ethnic health inequalities.  It turned out that whether we were employed by the NHS in equality and diversity roles, in public health or in research jobs or whether we worked in universities leading and carrying out research projects we shared a sense of frustration at how our work was not influencing change in policy or practice.

I began to develop some new skills – carrying out qualitative interviews and analysing the data that comes from them. I got to listen to senior figures in the NHS locally and nationally sharing their views and experiences of how evidence is used in commissioning and in particular evidence about health inequalities linked to ethnicity.  I got the chance to step back, see the big picture and reflect on what exactly was making my job so hard.  Most importantly for me, it left me even more confident in my view that I needed do my job differently if I wanted to get results.

If you’re interested, we wrote two briefing papers summarising what we found out.  Briefing paper one describes why race equality should be at the heart of healthcare commissioning and briefing paper two describes steps that can be taken at an operational level to improve healthcare for black and ethnic minority communities.

So, when the research funding and therefore the project ended, I’d learnt a lot. I wanted to be able to learn more and use that learning to change the way we approach equality and diversity in the NHS.  And then Sarah Salway who works at Sheffield University and led the EEiC project told me about the chance to apply for a Knowledge Mobilisation Research Fellowship.

I applied and was successful. Here are some of the reasons why I decided to apply.

  • Knowledge Mobilisation is sometimes called “Knowledge to Action” and it’s about making change happen. One important thing I learnt from being part of the EEiC research team is that making sure that policy and practice in the NHS (and indeed in many institutions) is based on sound evidence is difficult and often doesn’t happen. So some of the barriers to making progress on race equality in the NHS are general difficulties in moving from evidence of any problem to making improvements that will solve that problem.
  • Doing research when you’re not employed full time as a researcher gives you the opportunity to get off the hamster wheel of your day job and work out how to do things better.
  • As I began reading about knowledge mobilisation, I discovered that successful knowledge mobilisers are boundary spanners and realised that boundary spanning is what I’d been doing in my most successful pieces of equality and diversity work. Forming partnerships between healthcare providers, commissioners and users.  Leading project teams that encouraged colleagues to work with people they wouldn’t normally.  Bridging the gap between academics and practitioners.
  • I want to learn more about what works and then share that learning. I remember when I was fairly new in the NHS and in response to the deputy chief executive asking me how I was getting on, I told her that I was making it up as I went along. This was completely true but as soon as I said it I was kicking myself for being too frank.  To my surprise, and relief, she smiled and said “You keep on doing just that.” Of course there is a freedom to develop your own practice with this approach.  But it also means that sometimes it works and sometimes it doesn’t.  And the trouble with everyone making it up as we go along is that opportunities for learning are lost and professional practice does not improve.

Now that I am a knowledge mobilisation research fellow, NIHR pay 0.7 of my salary to release me for three and half days a week to do some knowledge mobilisation research, to do some knowledge mobilisation work and to take up learning and development opportunities about how to do this well.

The latest round of these fellowships will open for applications on 20th July 2016.  If you’re interested, details are available here.

During my fellowship I am going to try out and develop some knowledge mobilisation tools that were designed at the end of the EEiC project.  They will, I hope, help us work out what works and provide us with some better ways of working that will make sure that knowledge about health and ethnicity leads to action that will improve services and reduce inequalities.

More on the process of knowledge mobilisation and the tools in my next blog post.

About me – how I came to work in equality and diversity

I am a Knowledge Mobilisation Research Fellow.  When I tell NHS colleagues, and anyone else for that matter, they generally look quite mystified.   As mystified as the woman next to me in my Pilates class looked the other evening when I told her I was an Equality and Diversity manager.  Hopefully if you read my first two blog posts, you’ll know what they both are – well what I think they both are, at least.

In 2008 I got my first job in the NHS and my first job as an Equality and Diversity manager.

Before then I’d worked for further education colleges, teaching ESOL (English for Speakers of Other Languages).  My students were initially adults who had come to live in this country from Pakistan and Bangladesh.  Later I taught people who were born in Poland, Egypt, Thailand and Russia, amongst other places, and I taught Kurdish and Iraqi asylum seekers.  Listening to the difficulties they experienced navigating public services in this country taught me a lot, as did the experiences some learners shared with me of racism, sometimes subtle, sometimes not so subtle.

In April 1993, I was pregnant with my mixed race son (his father is of Nigerian heritage) when Stephen Lawrence was murdered.  Eventually, in 1999, following the campaign led by Stephen’s parents, the government asked the Macpherson Committee to look into why the investigation into his murder was of such poor quality and the resulting definition of institutional racism encapsulated for me the systemic unfairness and inequality many of my students found themselves up against.

Institutional racism is: “The collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture, or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantage minority ethnic people.”

Replacing the words “colour, culture or ethnic origin” in this definition with “sex or gender” produces for me an accurate description of the institutional sexism which affects me.  Making connections with my personal understanding and experience of sexism helps me to understand how racism and other forms of oppression operate.

I hadn’t believed that legislation could help to remove the systemic, institutional unfairness that reduces the life chances of black and ethnic minority people, of women, of disabled people and of lesbian, gay, bisexual and trans people.  But the Public Sector Equality Duty, introduced following the Macpherson report in 2001, and at that initial stage focusing only on race, aimed to do just that.

In 2008, following what was for me a disastrous college merger (but that’s another story) I was made redundant and became an NHS Equality and Diversity Manager.   I was so pleased that I’d landed a paid job that was about reducing institutional discrimination.  And I’m pretty certain that without equalities legislation that job wouldn’t exist.

Fast forward a few years and I was feeling very frustrated at how little I seemed to be able to achieve in what had at first seemed like the perfect job for me.  In my commissioning organisation (now there’s another mystifying concept) I felt quite distant to work that was actually improving services.  I often bumped up against the thick silo walls that seemed to mean different teams and different local NHS organisations didn’t even communicate with each other, let alone work together. On my bad days I felt like my only function was to cover my organisation’s back and protect its reputation.

But then I became a knowledge mobilisation research fellow!  Find out about that in my next blog.

This blog is about my experiences as a Knowledge Mobilisation Research Fellow, funded by the National Institute of Health Research (NIHR).  The views are my own and not necessarily those of the NHS, the NIHR or the Department of Health.