By Mojisola Green, Equality, Inclusion and Human Rights Senior Manager, NHS Arden & GEM CSU
The three shifts set out in the 10 Year Health Plan – hospital to community, analogue to digital and sickness to prevention – aim to create a more sustainable and patient-focused health service. But how can we ensure these changes reduce health inequalities and improve outcomes for our most vulnerable communities?
Equality Impact Assessments (EIAs) may seem just another task to tick off the growing list of processes involved with transforming healthcare but when completed robustly and embedded in decision making, EIAs provide the understanding needed to deliver sustainable services which meet population needs and deliver more consistent benefits for diverse communities.
Why EIAs matter
We know inequalities exist in healthcare. As Wes Streeting told the Health Select Committee in July, “inequality can be a matter of life and death. It should be the NHS’s core business to tackle health inequalities”. The latest MBRRACE-UK report into maternal deaths and morbidity showed that Black women are three times more likely to die during or up to one year after pregnancy than White women, while Asian women face twice the risk. Prostate Cancer Research states that 1 in 4 Black men will be diagnosed with prostate cancer, compared with 1 in 8 White men, while LGBTQ+ communities and those with disabilities are more likely to experience mental ill health. These examples highlight the importance of tackling inequity as we transform health services, and EIAs are a key tool in helping us achieve this.
EIAs assess the potential impact of policies, decisions and practices on people within protected characteristic and health inclusion groups ensuring fairness and preventing discrimination. They differ from, but are informed by, health needs assessments which are broader assessments of the health needs of a population to improve health outcomes and guide resource allocation.
A robust EIA requires teams to consider:
- Positive and negative impacts of a change
- Voices from across the communities impacted
- Mitigations to minimise negative impacts
- Opportunities to deliver positive impacts
- Proportionality – prioritising which changes will have the most impact
- The needs of people from different protected characteristic and health inclusion groups
- Alignment with health needs assessments and health equity assessment methodologies.
When we think about enabling the three shifts, we need to be mindful of how these changes might impact the more vulnerable members of our community. The EIA process combines research, impact analysis, consultation, action planning and monitoring to guide decision making and ensure changes tackle rather than increase health inequalities.
Right first time transformation
Transformation is hard work, time-consuming and often costly, so it’s essential to have the information needed to make choices that deliver positive, equitable outcomes. A robust EIA builds a detailed understanding of your local population demographics and highlights the, often complex, barriers to access, including where multiple factors intersect. This enables you to identify potential risks and opportunities associated with service changes. For example, in transferring services from hospital to community, understanding which settings would feel more comfortable or convenient for different groups, existing access to public transport, parking, proximity to other facilities etc. can all have a bearing on whether a target cohort will use the service in the way you’re expecting. Doing the detailed work to understand potential impacts helps avoid costly delays or underutilised services.
EIAs also help meet a number of legal obligations. All NHS organisations are subject to the Public Sector Equality Duty, under the Equality Act 2010, to consider how their decisions and policies affect people with protected characteristics. While the Health and Social Care Act 2012 established specific legal duties on NHS organisations to have regard to the need to reduce inequalities between patients. EIAs help organisations demonstrate due regard for the needs of those protected under the Equality Act as well as other vulnerable communities, for example, health inclusion groups. Failing to account for these needs can lead to legal challenge, with significant financial and reputational consequences.
Critical success factors
How you engage in the process and what you do with the outputs are critical to the strategic value of your EIA. In our experience, there are two critical success factors.
- Stakeholder engagement: EIAs can only be robustly completed by actively engaging with the communities and stakeholders that will be affected by the change. This includes patient engagement, specifically with health inclusion groups and those with protected characteristics, as well as your workforce and partners. This engagement adds qualitative information to existing population data to provide a richer and more accurate picture of health needs and barriers.
As integrated neighbourhood teams emerge, partnership working across organisational and geographic boundaries is becoming more common. Engaging more widely with health and care providers and the voluntary sector helps to inform transformation plans, minimise duplication and ensure limited resources are used effectively to meet population needs. - Review and refinement: EIAs should not be a single snapshot in time but living documents that you come back to regularly to review impact and refine your approach. Are the mitigations you planned working in practice? Are you successfully realising the opportunities you envisaged? Is further engagement needed? Regularly reviewing and updating your EIA helps monitor progress and enable continuous improvement.
Whether we’re shifting analogue processes to digital or moving services from hospital to community, simply doing the same tasks but in a different place or through a different channel risks maintaining or even entrenching existing inequalities. The EIA process encourages us to rethink existing practices based on a deeper understanding of community needs. While EIAs rightly focus on those with protected characteristics to prevent discrimination, the benefits of this process extend more broadly. If we can use this level of stakeholder engagement and community understanding to address some of the barriers and inequalities faced by our more vulnerable communities, we will be delivering a better, more sustainable health service fit for all.
This article was originally published in Healthcare Leader.
Find out more about our Equality, Diversity and Inclusion support for the public and voluntary sectors.
