Sunday, January 30, 2011

Equality Impact Assessment and the BIG system changes

Having raised the topic of Equality Impact Assessment, I'm going to recycle some guidance which I wrote a few months ago for NHS Trusts in the North West. This was originally published on the Equality and Diversity Blog that my colleagues and I have created there...

The Bigger it is, the more vital it is to Impact Assess

A terrible fuss? Political Correctness gone mad? Or a discipline that goes to the heart of rigorous change management, quality assurance and the pursuit of public value for money? Why do we insist on effective Equality Impact Assessment of big system changes?

One of the most important functions of a Strategic Health Authority within the existing NHS structure is to performance manage and carry out assurance on the NHS system in our respective regions.

This is why we pioneered the Equality Performance Improvement Toolkit (EPIT) in the North West. It's also why, as an Equality and Diversity team, we've long been involved in other big mainstream assurance processes, such as the annual review of Commissioning Strategic Plans, World Class Commissioning, Operating Plans, Reconfiguration proposals and changes that take place under the banner of Transforming Community Services (TCS).

Scrutiny isn't unusual

When these commissioning, resourcing and structural plans are scrutinised by the SHA, each specialist team in the relevant directorates looks at the plans with their own hat.

The finance team will assure themselves that proposals are financially sound and represent best public value. Clinical specialists and commissioners will look at the governance and contractual arrangements to ensure that proposals are safe and effective.

As Equality and Diversity specialists our assurance usually focuses on ensuring that proposals have been (or are in the process of being) cogently assessed.

Basic tests

Our first test is to check that the organisations putting forward major plans have undertaken an Equality Impact Assessment. This is something that is backed by the Chief Executive and the board.

It's not just because the failure to check this would be a breach of statutory obligations for which they'd be accountable. The whole organisation recognises that Equality Impact Assessment is a vital management tool to ensure the NHS meets its fundamental goals of serving the whole community and valuing and respecting our workforce.

Our second test is to verify that the Equality Impact Assessment, where it has been undertaken, has been a properly rigorous process.

That means we check to see that the organisation has followed a logical process, considering available evidence (and the lack of evidence), consulting or involving stakeholders as appropriate, and looking for opportunities to promote equal outcomes, as well as identifying adverse effects and planning how best to mitigate these.

Not academic

The approach isn't academic. If we feel that the process hasn't been conducted in a sufficiently robust fashion then, just like our colleagues, we can require that it is done properly as a caveat for signing off the proposals at regional level. In extreme cases we could also argue that the proposals shouldn't proceed at all.

This is what every other department does, so it's not unusual .. just a matter of ensuring that compliance with equality legislation, quality, effectiveness and adherence to NHS principles are at the centre of what the system does.

Sometimes managers may have difficulty visualising what equality impacts may arise from the proposals in question -- and in those instances we explain our reasoning and try to provide as much practical guidance to managers as we can.

For instance, when we carried out assurance on the Commissioning Strategic Plans prepared by the region's 24 PCTs earlier this year, we not only looked at the Equality Impact Assessments but also scrutinised the structure of those plans to ensure the evidence-based reasoning that underpins good commissioning was considering all sectors of the population, and not just those that are geographically distinct.

We wanted to see that commissioners were disaggregating the available population and health data and research to fully recognise who they are serving, and the tweaks that may be needed in delivery by their providers to produce uniformly good outcomes for all. We were also able to look at wider evidence about both the commissioners and their providers through EPIT too.

Scrutinising the transfer of community services

Similarly, we've just completed the first phase in a major assurance process on plans to transfer management and delivery of community services from the Primary Care Trusts to local acute and mental health providers.

Again, we were not just looking to see that the impact assessment paperwork was complete, but that organisations had thought objectively about what the impacts may be on different equality target groups: on men, women, black and minority ethnic people, disabled people, LGBT patients / staff, different age groups and people of different religions or beliefs.

Some organisations advanced the view that transferring every aspect of existing community services into new hands would have zero equality impact because they felt it was just a contractual transaction. Anyone who has had a change of manager would probably disagree with that conclusion though.

The whole point of the reconfiguration is to achieve financial and operational benefits. The new provider management may have medium and long term plans to change services. They may or may not be better or worse at understanding diverse needs than the original PCT. There may be existing adverse outcomes in the services which could be aggravated or simply be less likely to be addressed by the new organisation. Services may be relocated or merged. These possibilities require more than just cursory dismissal.

Don't assume zero impact without checking

It's also a principle of Equality Impact Assessment that you mustn't just assume that there is no effect on part of the population. You need evidence either way.

That evidence can come from consultation with stakeholders, by looking for existing published research indicating the likelihood of particular problems, or by doing some digging and analysis yourself (including looking at what other similar organisations have concluded).

To some managers this may all sound like a terrible fuss. Some may label it political correctness gone mad. However, which other aspects of a multi-million pound system change would managers contemplate doing without answering fundamental questions like these properly?

Why we do it

The NHS is a service for everyone -- not just those whose needs we know best because they are most like ourselves. We wouldn't contemplate changing services in ways that would hurt us or our families. Quite apart from the equality law implications it would be just plain negligent, and a betrayal of the principles of the NHS, to reconfigure the system without checking properly that others aren't negatively affected.

This also underlines the point that Equality Impact Assessment isn't supposed to be an annoying paperwork exercise that you do in haste after the big decisions have already been made.

When conducted well, it's an essential part of the change planning process, which serves to ensure that all managers think about the impact of what they are changing before finalising their proposals. To think that this was optional would be an admission of negligence in my view.

So, as with other assurance processes, our feedback to PCTs transferring their community services has probed the thoroughness of their reasoning.

We've asked some PCTs to consider what they already know about adverse outcomes in their services.

We've asked them to consider how they are going to ensure that the new providers have the capability to address those issues and to question how, contractually, they are going to ensure it happens.

In some cases we've also asked organisations to think more widely about the vulnerability of some groups to change.

Who would be affected if services moved to new locations or were available at different hours? Armed with that knowledge we expect PCTs to ensure that the new providers take those factors into account.

So, as you'll see, scrutiny involving Equality Impact Assessment is far from an academic exercise.

When it's done properly the process goes to the very heart of what public sector change management needs to be about. Ultimately it supports broader questions about quality, innovation, best practice and public value for money .. ensuring that the NHS serves everyone and produces better outcomes for all and not just some.

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