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Breaking the inequality reproduction circle in the NHS: the importance of senior management team's actions (SMTA)

Wen Wang (School of Business, University of Leicester, Leicester, UK)
Roger Seifert (Wolverhampton Business School, University of Wolverhampton, Wolverhampton, UK)
Matthew Bamber (Schulich School of Business, York University, Toronto, Canada)

Employee Relations

ISSN: 0142-5455

Article publication date: 18 April 2024




This study examines potential ways to break the inequality reproduction circle faced by ethnic minority health workers and sustained by key performance indicators (KPIs)-centred management in the National Health Service (NHS) in England. It does so through the lens of signalling theory.


Three years panel data for 2018–2020 covering 207 hospitals was compiled from the annual NHS staff survey and matched with relevant administrative records. Structural equation modelling was used to test the proposed hypotheses at the organisational level.


The moderated mediating model reveals that persistent racial discrimination by managers and coworkers can disadvantage the career progression of ethnic minority health workers, which in turn reinforces and reproduces economic and health inequalities among them. More importantly, we show how the collective agreement that the senior management team acts (SMTA) on staff feedback can break this vicious circle.

Research limitations/implications

While our research focuses on the not-for-profit health care sector, it opens important opportunities to extend the proposed model to understand organisational inequality and how to address it.

Practical implications

Perceived SMTA can send strong signals to reduce deep-rooted discrimination (race, gender, age, etc.) through resource allocations and instrumental functions. This is also a way to address the current staff burnout and shortage issues in the healthcare sector.

Social implications

This article reveals why the purpose of organisations that provide public service to reduce social inequality was comprised during their business-like operations and more importantly, how to reflect their foundational purpose through management practice.


This study offers a way forward to resolve one of the unintended consequences of KPI-centred management in the not-for-profit sector through unpacking the process of inequality reproduction and, more importantly, how it is possible to break this vicious circle.



We thank financial support from the University of Leicester (Research Development Fund 2022-2023) and the British Academy [No. IF2223\230023] to compile various data set that was used in the article; we thank the excellent research assistance by Dr (Med) Hussein Lubbad, Mr. Precious Reuben and Ms. Mariya Yeldhos.


Wang, W., Seifert, R. and Bamber, M. (2024), "Breaking the inequality reproduction circle in the NHS: the importance of senior management team's actions (SMTA)", Employee Relations, Vol. ahead-of-print No. ahead-of-print.



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