Give staff the power to end inequality in patient care

One July evening in 1967 17-year-old Christopher Britton hurled a bottle through his local MP’s window. Around the bottle he had attached a pamphlet entitled Blacks Not Wanted Here. In his pocket he had another leaflet that asked the presumably rhetorical question: “Do you want a black grandchild?”

For this, Mr Britton was found guilty of inciting racial hatred and became the first person to be convicted under the Race Relations Act, the UK’s first equalities law.

‘Despite the importance it has been afforded by various governments, equalities law has delivered piecemeal progress at best’

Fast forward nearly 50 years and the look and scope of equalities legislation has changed considerably. It’s not just that race laws have been subsumed under a single Equality Act, or that the ambit of legislation has expanded from restaurants and hotels to cover shops, workplaces, and the provision of public services; the key change − made after the Stephen Lawrence inquiry − was to introduce new, positive duties on public sector organisations to eliminate discrimination and to foster good relations.

By building on the previous earlier prohibitions − “do not discriminate” − the new duties made public bodies legally accountable for reducing discrimination and inequality.

Indeed, the government has placed a great deal of importance on the Equality Act 2010 and its associated public sector equality duty.

Piecemeal progress

When the coalition came into office in 2010 it revised the NHS operating framework drastically, removing the scaffolding of centralised process targets (such as the 48 hour target for primary care) and introducing replacement accountability systems: patient choice, clinical commissioning and information transparency. However, it included in the framework a commitment to creating a “personal, fair and diverse” health service, explicitly using the provisions of the Equality Act.

• HSJ’s timeline of race relations and equality in the NHS

Despite the importance it has been afforded by various governments, equalities law has delivered piecemeal progress at best. London boroughs with the highest proportion of black and minority ethnic residents have poorer health outcomes compared with the areas with the highest white British population. In fact, residents in these areas, fare worse on seven out of 11 indicators (including drug use, diabetes, infant mortality, tuberculosis and early death from heart disease and stroke).

‘Too often our activities are focused on the allocation of resources, developing leadership priorities, conducting equality impact assessments’

A similar story exists on a national level. Black people are three times more likely to be mental health patients than the rest of the population. A 2009 study by the Office for National Statistics collated patient surveys from various trusts and concluded BME patients are significantly less likely to report positive experiences of care.

Being involved in treatment decisions, being talked about as if they are not there, and not being treated with dignity and respect are just some of the areas in which BME patients can expect to receive less favourable treatment.

These problems persist for a number of reasons, but they highlight two particular issues with the use of legislation:

• The things equalities duties have required organisations to do − create an equality policy, provide training, conduct equality impact assessments − have encouraged a mechanistic, “tick box” approach to promoting fairness. Given the resource pressures trusts and other healthcare providers are under, it is perhaps inevitable that many organisations only do as much or as little as necessary to satisfy the letter of the law without fully engaging with the spirit of the equality agenda.
• Without adequate scrutiny of the actions organisations take as part of their equality plans, it is difficult to ensure public bodies are undertaking activities that actually reduce unfairness.

It has been common, for example, for healthcare providers to provide “add-on” services to cater for different communities’ needs. As well meaning as such activities are, they do little to tackle long term, institutional problems. Instead, they can cause disillusionment among staff, who are asked to undertake a variety of activities that evidently have little impact on equality.

Wrong focus

One care home we worked with, for example, responded to two new Chinese residents by adding some traditional Chinese dishes to their menu. As welcome as this change was, it completely ignored the actual challenges facing the new residents. As they saw it, the problem was the way staff interacted and communicated with them.

‘Empowering staff to make a difference on equality means giving them ownership of their actions and behaviour’

Although it was not overtly discriminatory or offensive, it was clear that particular staff members spent less time with the Chinese residents, were less likely to greet them with a smile and less likely to ask them how they were. As a result, the residents were less likely to ask for help, less likely to talk about their aches and pains − in short, less likely to form friendly, human relationships with their carers.

This, in a nutshell, summarises the problem with our traditional approach to equality. Too often our activities are focused on the allocation of resources, developing leadership priorities, conducting equality impact assessments and so on. As important as these are, they do little to improve experience at the point of delivery. They do little to change the behaviour of staff when they interact with people on the frontline.

Can-do culture

Recognising this requires a culture change in many organisations. Previous approaches to monitoring staff adherence to equality law have been overly bureaucratic. Either we have told them what not to do or we have been dogmatic in telling them what they must do; both cases stifle their motivation to act positively.

Faced with the possibility of doing the wrong thing, staff often opt to do nothing at all − a kind of professional paralysis. Instead, we should focus on creating a “can-do” culture, in which people feel they have the permission to take calculated risks and innovate to improve equality at work, without feeling they will be blamed or punished for “getting things wrong”.

Legislation can be important because the information it requires us to collate can demonstrate the inequity of patient experience and outcomes. It can voice the concerns of the voiceless but, on its own, it cannot provide the motivation to tackle the challenges it highlights.

Legislation can provide the data, but not the drive to act on it. Empowering staff to make a difference on equality means giving them ownership of their actions and behaviour. This is something at which legislation has, sadly, failed.

Joy Warmington is chief executive at Brap, an equalities and human rights charity providing research, training and community engagement support to organisations