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Considering equality and health inequalities is essential for STPs
The purpose of Sustainability and Transformation Plans is to help ensure health and social care services in England are built around the needs of local populations.
It is difficult to see how this can be achieved without considering the different needs within a local population.
For example, evidence suggests the reconfiguration of health and social care could improve the services for people with learning disabilities or those from Black and Minority Ethnic communities who face poorer experiences and outcomes in healthcare.
The question is: how will the STPs maximise benefits to these various groups?
At the October NHS Equality and Diversity Council meeting we considered how the needs of different groups were being considered by those developing STPs and concluded that we need to do more.
We acknowledge that STP footprints are not organisations in their own right. Some may say that the Equality Act 2010 public sector equality duty does not apply and that partner organisations will carry out the necessary equality analysis work on their own parts of the plans. A similar argument might be made about the health inequalities duties of CCGs under the Health and Social Care Act 2012. But it is important not to get too tied up in legal niceties here. If STPs are making decisions – even “in principle” – factoring equality and health inequalities into those decisions will not only fulfil the spirit and intention of these duties but will help STPs fulfil their core purpose. And this is likely to save duplication of work in STP partners.
The next period of STP development is critical for this work as STP footprints start to get into implementation plans for their priorities.
Based on the experience of the Care Quality Commission (CQC), The Race Equality Foundation and The Five Year Forward View guidance on Engaging local people, published by NHS England, this process of “equality and health inequalities analysis” should be systematic and logical – but it can be simple. For example, an STP footprint could look at the following six questions:
- For each priority or workstream, what do we know already about the access, experience and outcomes for people with each of the “protected characteristics” covered by the Equality Act 2010 – or other groups that might be facing inequalities in health access and outcomes?
- What do we know about the potential impact of STP plans on workforce equality in the local health and social care economy?
- What does this mean for targeted engagement – to fill gaps in our knowledge or because a group will be particularly affected by STP plans so need to be involved on an ongoing basis?
- What does this evidence and engagement tell us about how we can maximise opportunities to advance equality and minimise risks to equality in our plans?
- What concrete changes need to be made to implementation plans?
- What do we need to do in the future to monitor and evaluate the impact of our plans on promoting equality and tackling health inequalities?
This might seem a daunting task – but support is at hand to do this. STPs can draw on:
- Local expertise – Equality and diversity leads in partner organisations, CCGs and CSUs are skilled at carrying out this type of analysis. Engagement of local communities is vital in gathering evidence and in looking at options maximising the impact of STPs on different equality groups, so Patient and Public Involvement leads and the voluntary and community sector will also play an important role.
- Local evidence – partner organisations will have access to good area-wide evidence through the following sources: EDS2 analysis, WRES returns and previous impact analyses that will help answer these questions. You can also access information through the local Joint Strategic Needs Assessments (JSNA)s, and a range of local data sources for promoting equality and tacking health inequalities through variations in access to services and health outcomes : Commissioning for Value Packs produced for CCGs; the Atlas of Variations in Healthcare; Marmot Local Authority Profiles and Challenging Health Inequalities, which is guidance for CCGs to help identify areas of variation in emergency admissions as an indicator of inequality.
- National support – The Five Year Forward View guidance on Engaging local people is helpful. The guidance for NHS Commissioners on Equality and Health inequalities legal duties will be relevant to STPs. Some of the STP aide-memoires cover equality issues or will help in this task– not least by focussing on person-centred care which is more likely to meet the needs of a range of equality groups. The use of the new Equality and Health Inequalities Impact Analysis tools and updated legal guidance (developed by NHS England, the Race Equality Foundation, and The LGBT Foundation for internal use), would also help. Other NHS colleagues can access the documents on request, if they would find them helpful in their work. Please email the NHS England Equality and Health Inequalities Unit (EHIU) on firstname.lastname@example.org
Importantly, the NHS Equality and Diversity Council will be considering this topic again at our next meeting and welcome ideas and experiences from STPs around equality and health inequalities in your work. Please contact us at email@example.com.
One final thought, Equality Analysis may seem dry and procedural. But a good analysis – systematic, logical and yet simple – can provide valuable insight into how STP footprints can flex their plans to ensure they better meet their core purpose – to help ensure that health and social care services in England are built around the needs of local populations.
This blog was written by Lucy Wilkinson, Equality, Diversity and Human Rights Manager, Care Quality Commission – lead author of the blog. Lucy would like to acknowledge Jabeer Butt from the Race Equality Foundation and Anu Singh, Director Patient and Public Participation and Insight, Nursing Directorate, NHS England for their help with writing this blog.
I am an equality lead for a CCG and I would like to know of any good practice or link into any STP level work across England relating to health and social care.
Thank you for your interest. To discuss this further, may I suggest contact the team directly at: firstname.lastname@example.org.
Hi Lucy . I read your blog and found it fascinating. My family and I have worked in the NHS for over 200. We are black. The situation is so bleak in Doncaster that for over 13 years the NHS, Public Health and Statutory partners have neglected the production of a BME Health Needs Assessment and Action Plan. Putting to one side the mortality and morbidity implications there does not appear to be any mechanism for the STP process to intervene ? I am therefore grateful to a Professor Fenton for having the decency to articulate the case for non discriminatory HNA . And whilst it is my understanding that HNA is fundamental for commissioning personal , diverse and fair STP. There is no where I can find any evidence base for a Health and Wellbeing Board to neglect carrying out a cogent needs assessment for a protected characteristic . There is the sense of racism being played out in Doncaster? I would welcome your observation on whether the STP PMO should safeguard our basic rights?
Thank you for your comment. We welcome your feedback, and suffice to say that the very idea of STPs is to better address the specific needs of the local populations they serve.
You raise some important points about the need for joint partnerships arrangements in local areas to consider equality in their work, which is a key point in the blog. However we are not in a position to comment on how well this is done in specific local areas.
I have a rare illness but cannot get care, CHC or a personal health budget, I also have a number of long-term illnesses and I also have a powered wheelchair my main illness is inclusion body myositis
Hi John, thank you for your comment. Can we suggest that you contact our customer contact centre, who will be able to discuss this in more detail with you.
I’m very worried about the STP for North Devon and the impact on my Learning Disabled daughter. She has frequent medical needs requiring hospital admission. Paediatric services at our local hospital are threatened and we would be forced to drive 70 miles to get her the help she needs. The STP proposal to relocate services to South Devon would be disastrous for us and for anyone else in the Learning Disabled community who have medical problems.
Thanks for your comments Kristina. Some STPs have specifically looked at the impact of service changes on transport to services for different groups, as part of an equality/health inequalities impact analysis. If you want to raise any issues with your local STP, you can comment through http://www.northdevonhealth.nhs.uk/have-your-say
A focus on the impact of proposals on different groups is to be welcomed. However, the ‘protected characteristics’, a worthwhile basis for general purposes, does not always cover the needs within a local population. I am especially concerned about rurality, which can have a massive impact on individuals and communities, as we have been energetically pointing out in relation to the Success Regime proposals in Cumbria. Also, carers need to be explicitly considered, and the combination of rurality and the needs of carers requires careful thought. Equalities Impact Analysis must not be a tick-box exercise based on standardised criteria if it is to truly reflect the reality of local populations’ healthcare needs, which do not exist in a vacuum but are part of a web of people and relationships.
Thank you Alice. We agree with your point about the importance of considering a wide range of needs within a local population. This is why carrying out a Health inequalities Impact analysis, alongside an Equality Impact Analysis is helpful. Health inequalities impact analysis is not restricted to particular groups. In the first question that we suggested for STPs, we included the point about “other groups that might be facing inequalities in health access or outcomes” – this could include a wide range of groups such as people living in rural areas and people with caring responsibilities. As you also say, it is important to look at how these factors work together, as well as separately.
Would like to send you email.
Can you provide email address please
You have made a very important point in saying:
‘But it is important not to get too tied up in legal niceties here. If STPs are making decisions – even “in principle” – factoring equality and health inequalities into those decisions will not only fulfil the spirit and intention of these duties but will help STPs fulfil their core purpose. And this is likely to save duplication of work in STP partners.’
We now need to ensure that STPs take account of your views. I am pleased the EDC will be considering this issue further at your next meeting and hopefully meaningful actions will follow from it. I will also cvontact you separately on email@example.com.
Dr Anil Jain
Thanks for your support, Anil. We look forward to hearing from you.
Hi Lucy. It would be useful to talk to you further about this? Although I think you’ve mapped out a useful set of questions for STPs to think about I worry that they are unlikely to go anywhere for several reasons, including: the lack of skills, motivation, or awareness to carry out meaningful equality analyses at organisational level (let alone for STP footprints); the persistent relegation of equality and diversity issues amid all the other priorities (there always seems to be a reason not to do it); the marginalisation of E&D to someone who does not carry the authoritative clout required to elevate its importance; and the disinclination to systematise equality analyses as part of service planning, service reconfiguration, or in contracting and procurement. The EDC is well-meaning but in practice where is the evidence that it is taken seriously outside the EDC? If the EDC know this, it should be pulling the levers to make it happen. If it doesn’t know this then it lacks credibility.
Thanks Steve. This blog is only the first step in EDC engagement with STPs. As we say, we know we need to do more and we will be considering this topic again at our next meeting. Yes, there are challenges to STPs carrying out meaningful equality analysis but there are also opportunities to be gained if they do this well. We hope that the blog will encourage those leading STPs to see the opportunities and also to assist people at a local level to make the case to STPs for good equality analysis – knowing that the national EDC are supporting this. We also hope that any STPs doing good work on this will come forward to share their approaches. But we know that may need to do more and we will consider this at our next meeting and as work on STPs develops.
I agree that putting equality at the heart of the STP agenda is fundamentally important. I worry that our current policy approaches to addressing inequality places too much emphasis on the choosing individual and the proximal factors (like diet, exercise, and other health related behaviours) and too little emphasis on the more contextual factors shaping choices (despite overwhelming evidence that purely choice-oriented policies have limited purchase on inequality). This should include but go well beyond nudging, and should address the imbalances between communities and available transport, food availability, perceived safety, and routes into health and social care. These are often closely bound to historical and economic experiences of places and transmitted not simply by culture but also by cognitive and biological mechanisms. Providing locally focused approaches that draw upon existing community assets, and build on locally articulated priorities, could be powerful (but hard to do).
Thanks for your comments Tom. In the EDC we are aware that there are many factors which cause health inequalities – as well as needing to tackle equality barriers within health services. By publishing this blog, we hope that it helps STPs to think about the causes of inequality in a systematic and considered way. Some work in the Five Year Forward View emphasizes asset-based approaches to tackling health issues and locally articulated solutions – particularly the work of the People and Communities Board. By including the Guidance on Engaging Local People in the blog, we hope to make the connections between the equality, health inequalities and engagement agendas which are vital to ensure that STPs result in health care changes that benefit everyone.
2/2. Another questionable idea is triage by other ‘health professionals’. My CCG has even suggested using receptionists to carry out Practice triage! All these proposals are purely cost saving measures and have nothing to do with patient care. We are turning the NHS into a pile ‘em high and treat ‘em cheap production line for the convenience of the system and not the patient.
The purpose of STPs is to help ensure health and social care services in England are built around the needs of local populations. There are many aspects to this for example increased integration of care and a focus on prevention and reducing inequalities. We hope that the publication of this blog will help STPs to consider in more depth how to ensure patient care is good for everyone.
Lucy, STPs have the potential to make access to health services even worse for those with disabilities and others who are frail and unable to travel easily. The centralising and rationalisation ‘doing things at scale’ thing is likely to place ‘local’ services further away as Practices close and merge and some hospital services move out into communities where it is questionable if standards will be maintained or even if passenger transport will operate. How will someone who finds it difficult to travel get to another Practice or support further away?
As you know a relationship with your own GP is also very important especially for those with complex health needs. Our records are being computerised so any tom dick or harry can have a butchers and treat us anywhere, this is just the opposite of what should happen. The opt-out consent system is also going to infringe the rights of patients who haven’t been told about this and no equality impact assessments have been done either.
Thanks Ian. Your point about service reconfiguration and transport issues is well-made. This is just one of the reasons why EDC is encouraging STPs to carry out equality impact assessments, even if they are not legally obliged to do so – as we say in the blog, doing so will help STPs fulfil their purpose.
The issues about access to records are complex – there are also many advantages for people with complex conditions in having shared records but as you say, this should be an individual choice.
I think a good starting point would be to tap into you minority staff support groups if you have them in place… they can provide you not only with valuable first hand information on what is based on their own first hand experiences as service users but also can share the feedback they may well have received by those they have provided care for as service providers.
Thanks Rifat. Yes, we agree that engagement of staff diversity and equality networks are a great way of gaining insight into equality aspects of STP plans – for both staff and patients. This would be very helpful alongside direct engagement of patients and the public through local Healthwatch and other voluntary and community sector groups that reach a diverse range of people.