Equal access to the NHS: the next step

The creation of the new health and care system provided the opportunity to re-embed the NHS constitution throughout the service, making sure everyone counts.

It was also important to ensure that the good work promoting and advancing equality was not lost or diluted during the transition period within the NHS. At a time of great change in the NHS, the equality delivery system kept equality high on the agenda.

‘We need partnership working and co-production to ensure that we are tackling health inequalities and promoting equality for all’

The NHS should take great pride in its achievements to date on equality. However, despite much good practice, there is considerable evidence some patients and communities feel they are not as well served by the NHS as they should be.

Equality for all

The GP Patient Survey results for 2012-13 show variation by ethnicity in patients’ confidence and trust in their GP: 67 of British patients trusted their doctor, compared with 42 per cent Chinese and 52 per cent Bangladeshis.

This variance is replicated in the same survey in terms of the percentage of patients who would definitely recommend their GP surgery to someone else: 51 per cent who would were British, compared with 30 per cent Chinese and 34 per cent Pakistani.

Similarly, there is less representation in senior roles than we would like. The 2012 NHS staff survey found that harassment, bullying or abuse from staff was perceived to be experienced more by disabled staff (33 per cent) and black staff (31 per cent), than by non-disabled (21 per cent) and white British staff (22 per cent).

The survey also found such experiences were more prevalent for gay male staff (30 per cent) than for heterosexual staff (23 per cent).

To close the healthcare inequality gap, as we wrote on hsj.co.uk last year, improvements cannot be made in silos; we need partnership working and co-production to ensure that we are tackling health inequalities and promoting equality for all.

New system

Since 2009, the NHS Equality and Diversity Council has been leading the way in shaping the future of the NHS from an equality, health inequalities and human rights perspective − helping to improve the access, experiences, health outcomes and quality of care for all who use and deliver health and care services.

‘Local stakeholders must be at the heart of important decisions about the planning, developing, commissioning and delivery of health services’

One of the very first things that the council initiated was the equality delivery system, which is a tool to help NHS organisations understand how equality can drive improvements, strengthen the accountability of services to those using them, and bring about workplaces that are free from discrimination.

Launched in 2011, the EDS is being implemented by the vast majority of NHS organisations across England. In 2012, the design and implementation of the EDS was independently evaluated. Based on that evaluation and NHS England’s consultation with the NHS and the key stakeholders, a refreshed EDS − called EDS2 − was developed and rolled out to the NHS in November last year.

EDS2 is more flexible and streamlined than the original system. It is a generic tool for both NHS commissioners and providers.

Focus on outcomes

At the heart of new system are 18 outcomes, against which NHS organisations assess and grade themselves, in collaboration with patients and staff. These outcomes relate to issues that matter most to people who use, and work in, the NHS. These outcomes were identified and brought together following extensive engagement with patients, communities and the NHS.

Among other things, EDS2 outcomes support the themes of, and deliver on, the NHS outcomes framework, the NHS constitution, and the Care Quality Commission’s key inspection questions set out in Raising standards, Putting People First − Our strategy for 2013 to 2016.

Using EDS2 can help NHS organisations to respond to and the meet the specific duties of the public sector equality duty.

Meaningful engagement

Having systematic and comprehensive data and intelligence, and being able to disaggregate this data, is an important underpinning of any approach to promote equality and tackle health inequalities. Not all evidence needs to be quantitative. It can also be qualitative, and derived from meaningful and sustained engagement with local stakeholders that include patients, communities and the workforce.

Local stakeholders must be at the heart of important decisions about the planning, developing, commissioning and delivery of health services in a meaningful and sustained way. For the NHS workforce, engagement should mean helping to plan, develop and manage working environments and activities that aspire to improve working lives of the whole workforce.

The equality delivery system is not about NHS organisations assessing their own equality performance. Organisations are encouraged to assess their evidence and then set their equality objectives in collaboration with their patients, communities and staff.

As part of implementing EDS2, the South West Commissioning Support Unit, for example, is supporting a collaborative approach with peer NHS organisations in using independent third parties made up of local voluntary and community organisations and Healthwatches to help with and verify the EDS assessment and grading processes. Indeed, the use of third party verification and peer review is encouraged.

People not processes

EDS2 should be applied to people whose characteristics have been given protection under the Equality Act 2010. The nine protected characteristics are: age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race (including nationality and ethnic origin), religion or belief, sex and sexual orientation.

In partnership with patients and staff, NHS organisations are asked to assess and grade how well each protected characteristic fares compared with people overall, against the 18 EDS2 outcomes, with a view to improve NHS performance.

What about other disadvantaged groups? We know that other disadvantaged groups, some of which fall under the “inclusion health” groups, experience difficulties in accessing and benefiting from the NHS.

These groups are often socially, economically and geographically fragmented from mainstream society, and typically include the homeless, those who live in poverty, the long term unemployed, people in stigmatised occupations, those that misuse drugs and other substances and people who are geographically isolated.

‘Two years since the launch of the EDS, sustained and positive outcomes for patients and the workforce are already emerging’

Applying EDS2 to disadvantaged groups can help support organisations to deliver on aspects of their health inequalities work. As with protected groups, NHS organisations can assess and grade how well other disadvantaged groups fare compared with people overall.

There are significant overlaps here with people whose characteristics are protected by the Equality Act. These links should be kept in mind when work on either the protected or other disadvantaged groups is taken forward.

Two years since the launch of the EDS, sustained and positive outcomes for patients and the workforce are already emerging. For example, use of the system has resulted in South Devon Healthcare Foundation Trust running Project Search. The project supports young people with learning difficulties to secure meaningful paid employment. Among other positives, not only is this diversifying the workforce, it is also significantly improving the quality of life of those young people.

Merging agendas

It makes good sense for the equality and health inequalities agendas to come together. For example, improving access to chest pain clinics for South Asian patients, or increasing consultation times for women with learning difficulties attending breast screening units, is as much about reducing inequalities in access to services and outcomes for patients, as it is about eliminating discrimination, harassment and victimisation; advancing equality of opportunity and fostering good relations between groups.

‘Work on EDS2 and on the equality agenda in general will only make an impact when it is located within mainstream business’

The 2010 Marmot review, Fairer Society Healthier Lives, proposed the concept of “proportionate universalism”: universal action to reduce the steepness of the social gradient of health inequalities but with a scale and intensity that is proportionate to the level of disadvantage.

In contrast, much of the equality work in recent years has focused on positive action − action concentrated upon people from particular protected groups so that they may benefit from services to the same extent as people overall.

For a number of reasons, it may be beneficial for the concept of proportionate universalism to be applied to equality. For example, organisations may consider how learning from taking positive action can be applied to and benefit people who use the NHS or work in the NHS, as a whole.

Universal goal

In this manner, valuable lessons can be spread, improvements can be extended beyond people with protected characteristics, and a wide range of people will see something in positive action for themselves.

It is often said about marginalised and seldom heard groups that if improvements can be made to their access to, and experience of, services, then improvements can be readily achieved for many other people and groups.

Work on EDS2 and on the equality agenda in general will only make an impact when it is located within mainstream business, and when NHS boards and senior leaders lead the way through actions. Boards are encouraged to avail themselves of board leadership programmes where the emphasis is on inclusive services and inclusive workplaces.

We must make the difference that our patients, communities and the workforce need and deserve.

Dr Habib Naqvi is senior equality manager at NHS England.