Sunday, February 27, 2011

Meeting the challenge

Last week I wrote about the scale of the challenge involved if we are to succeed in making Equality and Diversity philosophy and competence part of the DNA of the new institutions which will define the landscape of Andrew Lansley's NHS.

I talked about the organisations, such as SHAs and PCTs, which are to be disbanded, and about the new bodies which will take their place: hundreds of GP consortia in charge of commissioning, and hundreds of Health and Wellbeing Boards set up by Local Authorities. I also mentioned the role of the new PCT Clusters during the transitional period.

This week I want to move on to discuss how to meet the challenge of shaping all of those.

Pathfinder Consortia

White Paper Cover

As I explained before, the North West region where I'm based already has 19 'pathfinder' consortia who've been given the Ministerial nod to proceed. The Department of Health have published a map of the picture across the whole country.

Primary Care Trusts cannot just stop what they are doing. They have statutory responsibilities which will continue until the forthcoming Health Act takes them away. The pathfinders are therefore proposed bodies which are being allowed to set themselves up, in shaddow form at first, to iron out how they will work once given statutory powers and responsibilities by the new legislation.

Health and Wellbeing Boards

Local authorities have long had statutory powers to scrutinise the management of healthcare on their own patch. Scrutiny panels have operated as subcommittees of the elected membership. Some have been very active and engaged; others less so. However, the notable point is that this has been political scrutiny of NHS bodies (the Primary Care Trusts) which are themselves publicly accountable.

Generally, because of the capacity of such subcommittees, the scrutiny has tended to be patchy - either looking at the overall picture in too little depth, or scrutinising only a few specific functions in detail.

Health and Wellbeing Boards (HWBs), as described by the White Paper, are somewhat different beasts. For starters they are possibly the first kinds of body in this area to combine both elected councillors and executive staff.

The brief is wider too, since the goal is to plan and influence a joined up local approach to both health and social care. As local authorities are being given back local responsibility for public health the HWBs operate at the interface between public health, social and health care.

No road map

If any of this sounds vague it's because nobody has much idea of the details beyond what has appeared in the White Papers that have been published.

This reorganisation is unlike any other because there is no master plan of what we are all working towards.

Instead, local stakeholders are expected to come up with their own models for how to organise all of this.

The founders of GP pathfinder consortia have to decide on the structure of their organisations, for instance. The general expectation is that these will be very lean organisations -- a small executive team, few directly employed staff, and with many functions either shared with similar bodies or outsourced to suitable independent providers.

Many of those services don't yet exist, however -- or they'll need to ramp up their scale significantly. There are organisations that specialise in purchasing, IT and human resources, for instance. Management consultancy organisations like KPMG and Tribal are also widely tipped to be lining up to bid for slices of the pie ... though they will almost certainly have to recruit from within the outgoing SHAs and PCTs to increase their capacity to do so.

The head of the new NHS Commissioning Board, David Nicholson, expects that the new clustering of PCT resources will also give rise to 'Commissioning Offers' -- groups of former PCT commissioning specialists who will be urged to separate from the mothership as social enterprises, offering to fulfil the bulk of the detailed work in specifying and contract managing services at the behest of GP consortia. They may have to compete against the private sector competition though, and it's a wonder how local knowledge, expertise and relationships can be preserved through all of this.

The picture is similarly confused about Health and Wellbeing Boards too, especially as local authorities are being expected to create these at a time of massive retrenchment, owing to the financial pressures placed upon them through savage cuts in funding from central government. It's hard to picture, for instance, how long the £20Bn promised for public health funding can remain securely ring-fenced.

All we know with any certainty about HWBs is that they are likely to be huge committees, with so many interests wanting to be involved. I'm not clear about what sort of executive resources will sit behind the public face of these vast committee meetings, or how effectively such a complex forum of interests can operate and make decisions. Nobody can say till we see the details which each set of local interests puts together.

No master plan

Given so little detail of what local structures will be like, it's not possible for anyone in the existing structure to give definitive guidance on how assure the place of Equality, Diversity and Human Rights going forwards. Also, since we at SHA level only have 13 months left to operate, we won't be around at crucial times in the future to provide guidance.

Instead, what we have to try and do is to equip the partners who'll most likely remain at the centre of these changes to produce some best practice, and to ensure that is shared with others.

Early Adopters

The North West has a strategic leadership group for Equality and Diversity, made up of leaders from across the existing landscape. It includes chief executives, workforce and commissioning specialists, clinicians, etc... When it met to discuss the challenges ahead, the conclusion was that we needed to encourage and nurture a model example of how to operate in the new landscape.

In practice, the E&D leadership group found not one but three enthusiastic organisations willing to become such 'Early Adopters'. They represent some of the best performers, measured by achievements in the Equality Performance Improvement Toolkit (EPIT). Therefore, if anyone should have a commitment and expertise to successfully embed and preserve E&D methods and outcomes it would be them.

The Early Adopter systems are:

  • Manchester
  • Liverpool
  • Blackburn with Darwen

Having a small number of these early adopter groups means that we can focus our resources on helping them to find effective ways to work in the future. Our role is then to help share what they produce with their peers ... the other 16 pathfinder systems and, ultimately, the remainder of an estimated 40 or so consortia in the region.

Setting Objectives, Aims and Means

The principal objective which we've set for the early adopters is:

To assure the embedding of E&D philosophy and competency among personnel in the new landscape at both cluster and GP Commissioning Consortium level, in conjunction with the formation of Local Authority Health & Wellbeing Boards and preparing stakeholders such as Local Health Watch.

In other words, the objective is for each group to consider how to embed a culturally competent E&D evidence-driven planning and governance approach within the whole scope of a model local system.

As we want people to own the responsibility for their success, we're not setting out to be overly prescriptive about the approach they take to achieve this outcome. However, we have suggested a few aims to get them started.

Aim 1 - To identify the appropriate levers for successful outcomes in each of the relevant domains, including (but not restricted to):

  • Meeting the statutory requirements of the Equality Act and Public Sector Equality Duty
  • Fulfilling the equality and inclusion commitments of the NHS Constitution
  • Maximising successful outcomes when measured by the Equality Delivery System
  • Ensuring Joint Strategic Needs Assessments (JSNAs) are fit for purpose in terms of relevant disaggregation to provide planning intelligence for all protected groups
  • Ensuring the commissioning is based on evidence specific to all protected characteristics
  • Contributing towards both QIPP (the Quality Innovation Productivity and Prevention programme) and AQuA (the Advancing Quality Alliance)
  • Retaining existing knowledge pools and best practice

As you will see, some of these aims are about the necessity for statutory compliance, whereas others are about improving evidence based decision making and quality in various ways, tied to programmes that continue.

Aim 2 - To develop models (and sharable templates) for operational designs (including any necessary capacity and capability development) to embed the above mentioned levers in each of the following organisations or structures:

  • GP Commissioning Consortia and their senior management teams
  • Local authority Health and Wellbeing Board (via e.g. their existing local authority E&D lead, the local Director of Public Health, etc..)
  • Commissioning support offers
  • Other stakeholders, as identified, including LINks / Local Health Watch

So, if the first aim is about establishing clarity over what drives success, the second is about where to ensure it is covered.

We also then suggest to the early adopters that they think about the means they are going to employ. Again we don't set out to be prescriptive; however we have offered them some suggestions to get them started:

  • Terms of reference / articles / memoranda / mission statements -- especially for consortia, health and wellbeing boards and health watch
  • Objectives / terms of reference for responsible and accountable officers in all of the above
  • Governance and scrutiny arrangements between the local authority and consortia
  • Commissioning strategies -- including how to utilise evidence from JSNAs, other local authority intelligence and external data to inform strategic direction and ground rules for commissioning
  • Commissioning support arrangements -- how to ensure that these (where separate) have the right information, competence and capability to advise consortia about commissioning targeted services that embody relevant evidence of specific community needs
  • Contract terms between consortia and providers (to include EDS performance goals)
  • Operating plans
  • Engagement plans
  • JSNA refresh plans
  • Monitoring arrangements
  • Recruitment strategy
  • Purchasing / outsourcing terms - particularly with commissioning support services
  • Developmental plans to ensure a strong contribution from local Health Watch

How will it work?

This, for me, is the big unknown.

Everything we've done previously has provided very specific leadership to the health economy in our region. In this case, the success is really in everyone else's hands. All we can do is try and facilitate the early adopter groups to cover all these kinds of areas successfully, and to share that with the rest of the region as it comes out of their discussions.


Monday, February 21, 2011

A Media Milestone

TMW logo

A quick word of congratulations to Trans Media Watch, the educational group which sets out to help journalists, writers, editors, producers, directors and the like to manage a better job of accurately representing and portraying trans people.

The group has developed a so-called Memorandum of Understanding (MOU for short) which media organisations can sign up to, setting standards which they agree to try and maintain.

And the MOU is going to be launched in early in March, at a special reception hosted by Channel Four TV.

Great and good

The reception will be attended by an array of figures from government, media, related industries .. and, of course, the trans community. Speakers so far confirmed include:

  • Lynne Featherstone MP (Parliamentary Secretary of State for Equalities)
  • Hilary Third (Team Leader Equalities Scottish Parliament)
  • Stuart Cosgrove (Head of Programming and Creative Diversity C4)
  • David Allen Green (Media lawyer) on Human Rights and Privacy

And the guest list includes (besides myself)

  • David Abraham, Chief Exec of Channel 4
  • Tim Davie, from the BBC's executive board
  • Victoria Atkin, who plays Jason (the trans character) in Hollyoaks
  • Representatives of the Times, Independent, New Statesman, The Stage, the LGBT press, Women in Journalism and the NUJ
  • Stephen Whittle (Professor of Equalities Law)

.. plus many more figures from the media world.

Still a lot to do

It all seems a far cry from the days when used to work in this sphere and produced a report entitled "Transsexual People and the Press" [PDF], which achieved a minor change in the Editors' Code of Practice published by the Press Complaints Commission.

That was in 2004 and, certainly, it's not time to celebrate too ecstatically yet. Some tabloid newspapers still delight in publishing material which is blatantly discriminatory. TV directors and presenters still make excruciating -- basic -- errors, through laziness, arrogance or ignorance.

However, I'm full of admiration for the progress that a new generation of campaigners have made, in building bridges and creating big advances like this launch.

Thanks to their individual and collective efforts we've seen the Guardian newspaper (once heavily criticised in my 2004 report) running a groundbreaking series of fortnightly articles, in which a young trans woman, Juliet Jacques, writes thoughtfully and perceptively about her process of gender transition.

The whole series "A Transgender Journey" appears in the Life and Style Section.

Juliet also recently consented to an in-depth interview for the Just Plain Sense Podcast, where she discussed the whole issue of Trans People and the Media. You can play the show directly below.

What next

Having signed up Channel Four, the team at Trans Media Watch are now working to get other media organisations on board too. Talks are already going on with the BBC and ITV.

It's important to remember that signing these organisations up to the Memorandum is no guarantee that they won't occasionally get things horribly wrong.

Big media organisations employ thousands of people ... programmes are often commissioned from independent makers or bought in from abroad. Mistakes will be made. It may take years ... and there are dozens of major organisations to talk to and sign up.

All changes must start somewhere though, and the businesslike organisers of TransMediaWatch are to be congratulated on achieving this milestone.

I'm looking forward to being a guest to see some history being made.

Sunday, February 20, 2011

The scale of the challenge

Over the last couple of weeks I've been blogging in detail about the strategic approach and achievements of the Equality and Diversity programme at NHS North West. I covered the theory, the underlying research, the tools and approaches we developed, and the 'EPIT' performance measurement tool which has allowed us to objectively measure the outcomes which our system of 63 NHS organisations were achieving. I also introduced our work to formalise leadership competence in this field and the importance of a communications strategy.

Yesterday, I discussed the reasons why equality and diversity work is so important within the NHS -- not simply for legal compliance.

Now, as promised, I am going to move on to talk about the approach we are taking to embed some of this into the completely new commissioning and oversight structure that is already starting to take shape.

Who stays, who goes, who comes?


The change that lies ahead for the NHS is the biggest that it has ever undergone since it was established in 1948.

Unlike any previous change we also don't have a complete roadmap as we embark on it.

The White Paper: Equity and excellence: Liberating the NHS, published on 12th July 2010, provided an outline of the biggest changes. However, it also raised as many questions as it answered.

Extra details emerge from time to time. Some of the original proposals have already changed. And, overall, the Minister (Andrew Lansley) has signalled that he wants the emergent organisations, such as GP Commissioning Consortia and local Health and Wellbeing boards, to work out crucial details for themselves.

The big picture for the purposes of this discussion is about the commissioning side of the NHS. I'm not ignoring that there are big changes too for the providers. However - for the moment at least - provider trusts (which run general and specialist hospitals, mental health services and ambulances) will still be there.

The same can't be said for the organisations who manage the present system:

  • The ten regional Strategic Health Authorities (SHAs) which oversee and performance manage the NHS system in England are due to be abolished in April 2012 - barely a year from now. Some of the functions we carry out will be absorbed back to the centre (the Department of Health) for the time being and then transferred to the new NHS Commissioning Board (NHSCB). Other functions will be migrated to a new layer of distributed management called "PCT Clusters". Think of PCT Clusters as mini SHAs. There will be 50 of them in England overall, through which the Department of Health and the NHS Commissioning Board will manage the system when we are gone.
  • The 152 local Primary Care Trusts (PCTs) which currently manage commissioning, prioritisation and a raft of detailed activities will also be abolished by April 2013 (though this date may slip). The core commissioning function of the PCTs will be replaced by a much larger number of organisations called GP Commissioning Consortia (GPCCs). The name is actually a bit misleading, as we'll discuss in future -- I prefer to think of GPCCs as rebooted PCTs, carrying out many of the same functions as before, but with a wholly different structure, ethos and accountability.

There is a lot that can be said about all these changes; however I don't want to get distracted. The important thing from the perspective of this discussion is that Equality and Diversity within commissioning currently sits in PCTs - which are going - and it is overseen and performance managed by SHAs - which are also going.

No small task

If an understanding and responsibility for Equality, Diversity and Human Rights is to continue on the commissioning side of the NHS system, we therefore have to build it all over again in the new structures as they emerge. I.e. We need to embed E&D into:

  • A vast number of GP Commissioning Consortia - the final number is expected to be around 500 consortia, replacing 152 PCTs.
  • Approximately Fifty new PCT Clusters, replacing the 10 SHAs
  • Several hundred Health and Wellbeing Boards, set up by individual local authorities or clusters of them. I estimate about 250-400 of these.
  • An equivalent number of local Health Watch organisations, reborn from existing Local Involvement Networks (LINks)
  • The NHS Commissioning Board itself and
  • The Care Quality Commission (CQC), which will be the quality regulator for the new system and the home of the national Health Watch organisation

The local challenge puts this into even clearer perspective.

David, meet goliath

The NHS North West Equality, Diversity and Human Rights team consists of just five staff -- three managers, a PA and an information and policy officer who maintains our HELP database.

There is the Associate Director of Equality, Diversity and Human Rights, Shahnaz Ali; there is an Assistant Director who manages all our communications and outreach activity, including the newsletters and our consultation work; and there is myself as the team's programme manager.

The communications manager and myself both work only 3 days a week. We are a tiny team, currently managing to oversee stable operations in 24 PCTs and 39 provider organisations.

The challenge ahead of us, before the lights go out next year, is to influence the formation of all the new GP Commissioning Consortia in our region, plus the PCT Cluster which will carry the responsibility for E&D for the 5-6 Clusters that replace us.

So far, in the North West, a total of 19 "Pathfinder Consortia" have been announced, covering about half of the population. We expect that, overall, there will eventually be about 40-50 to replace the 24 PCTs.

No prospect for top down control

A glance at these overwhelming numbers makes clear that there is no prospect for our tiny team of 3 managers to influence how Equality, Diversity and Human Rights gets embedded into 40-50 new organisations, all of which are on a mission to be lean and mean, and are at risk of assuming that E&D is a compliance issue they can tackle later.

Besides, some of these organisations won't be in any position to be approached about this aspect of their responsibilities until later this year. We have just months to achieve any effect we can have.

We also need to ensure somehow that the building and influencing work goes on after we've ceased to have any statutory power and have been disbanded.

David Nicholson, who chairs the Department of Health's Equality and Diversity Council (EDC) and is the Chief Executive of the new NHS Commissioning Board, has committed to providing one important lever - by saying that participation in the new Equality Delivery System will be a mandatory registration requirement for all GP Consortia in the new system.

There are no equivalent levers for ensuring how E&D is integrated into Health and Wellbeing boards though. And it's one thing to commit to being measured on E&D outcomes at some future date, but that doesn't guarantee the new organisations have any kind of strategy for how to achieve those outcomes.

Working smarter, not harder

In the next post I will explain the approach which the North West is taking.

It's an approach which is designed to help distribute the challenge and to preserve as much best practice as possible into the new structures. We've dubbed it, "Building the future, maintaining the best"

Like many of the things we do, it's an innovative way of addressing the big challenges we all face. We don't know whether others will follow suit. They are almost certainly facing the same challenges though.

Saturday, February 19, 2011

One year on. The message we missed.


It's little more than a year since David Cameron promised "I'll cut the deficit, not the NHS"

The occasion was the launch of the Conservatives' draft manifesto, on 4th January 2010.

The creepily airbrushed photo at the centre of the party's new poster campaign was probably what caught our attention the most.

But perhaps we should have been paying more attention to what was said that day too, as the clues were there.

David Cameron said:

... We’re going to change the way the NHS works because it could be so much better. [..]  If we win this year's election, Andrew Lansley and his team are going to give the NHS back to who it belongs - the people. To the doctors, nurses and professionals who work in it. [..] We’ll say to doctors and nurses: "those national top-down targets you hate because they distort clinical priorities, they’re gone. Instead of answering to the people in Whitehall, you’ll be answering to the people on the ward, for the quality of service you provide and the results you achieve."

Perhaps we should have asked more closely at the time what he meant.

Of course, the flowery rhetoric from a year ago bears little resemblance to the changes now being wrought. Andrew Lansley's changes won't make the NHS directly accountable to the users in anything like the way described. However, that's not my point.

My point is that, in a sense we were told that major change would come if the Conservatives had the chance of power. It's just that the message was dressed up in such easily dismissible froth that we missed the bit we needed to have seen and challenged.

Of course there was plenty that David Cameron promised in that launch which he's failed to deliver -- the promises on Maternity services for one. The whole thing bears re-reading in the cold light of day.

But it's the full import of the bit we were distracted away from that will have the longest and most dreadful consequences.

Friday, February 18, 2011

Why Bother?

Over the last few weeks I've been writing about the 'eco-system' strategy which our team at NHS North West has employed to systematically drive up equality outcomes in the region's NHS system.

With the NHS starting to undergo the biggest structural change in its' 63 year history I plan to write next about how we preserve the advances we've achieved and the best practice that we've created.

Before that I need first to address the sceptics' challenge. Why on earth should health professionals and managers care?

Why is what we do important?

Nature loves diversity. Humans dislike it in their own species

The traditional argument for paying attention to equality law and the diversity of the population is a defensive one. It's compliance based. "We're doing this otherwise we'll be punished".

The argument goes that if organisations don't get things right then there's a direct penalty ... the threat of legal sanctions for failing to comply with the letter of the 100-plus acts of Parliament and regulations that came into force regarding discrimination between the late 1960's and the 2010.

The Equality Act 2010 has greatly simplified all that now, of course. All people really need to know is that there is one law, a handful of so-called protected characteristics, a simple list of the kinds of discrimination and harassment to avoid, and an equally simple list of where those actions are proscribed, such as employment, or providing services, housing, etc... The new Public Sector Equality Duty is equally simple to grasp.

If it was only about legal risk avoidance then you could "sheep dip" all your staff in a short "awareness" course, put the details on a laminated card to help them remember and sit back, content that the job was done.

In fact, if you take away the window dressing, this is more or less what some organisations really aim for.

Their equalities expert can tell you what the law requires and what you must or mustn't do, and a list of anecdotes of people being crass.

It's all rather depressing ... you can't defend it from those who claim it's all "political correctness gone mad" ... and usually it doesn't actually work.

Real change requires people to see the importance of equality and inclusion at a deeper, more visceral level. We need to position it in terms of bringing advantages to what they are trying to do in their work.

Only then can the majority of people see Equality, Diversity and Human Rights as a help rather than an annoying hindrance.

Smart medicine

All the language about the changes taking place in England's health economy is about doing things differently than before. GP's are said to know patient needs better and are expected to be able to commission more innovative services. We're all on the hunt for ways to achieve more with less.

The indicators aren't promising. The commissioning managers who were supposed to determine local needs, specify services, procure them and set up contracts have not scored particularly well in objective tests of how they were doing that. Health services have tended to be designed on the assumption that everyone's needs were more or less the same.

White middle class middle-age able-bodied heterosexual commissioners have tended to create a health system designed for what they know ... people like themselves.

This is why services end up being hard to access for disabled people, indifferent to gay and lesbian people, and largely ignorant of why their approaches may not work as well for black and minority ethnic people. (Collectively that's getting on for 40% of the population).

The indications are that GP's are likely to fare little better without help.

Outside of the bubble they inhabit in their own lives, GPs don't necessarily know much about the lives their patients lead. They see each patient for about nine minutes. They see only the patients they see. They may have little conception of the patients in the local population they aren't seeing ... or only see when a condition has become serious, harder and more expensive to treat.

Do GPs know why lesbian women aren't getting cervical screening? Do they know why LGBT people use alcohol and drugs, and why those factors affect the practicality of advice to 'cut down'?

Do GPs understand fully why they don't see men as much in their surgeries, and why screening women for sexually transmitted diseases is not effective unless they get to their partners too? Do they simply accept that men have lower life expectancy, or ever consider that it doesn't have to be so?

A business case for cultural competence

So, let's forget legal compliance. Let's even stop calling it "Equality and Diversity", lest people think the political correctness police are in town. Let's try for a moment to think about how to help the NHS's new breed of bright eyed commissioners learn how to do a very complex and important job in a more intelligent, evidence-based, cost effective fashion.

It's not hard. Here are some examples of the kind of basic population knowledge that people should be applying to the job. It's not a full list, but just a taster.

Black and Minority Ethnic (BME) People

Depending how you count, between 8-11% of the population have a BME background. In North West England (pop 6.8M) that's 650,000 people.

The figures are hugely variable though. In Manchester the BME population's about 30%. Up in places like Blackburn it's higher. There are parts of Leicester where over 80% of the population is BME.

And the term Black and Minority ethnic is itself made up of people from widely different backgrounds. The origins of the BME population in a place like Oldham or Rochdale are very different to Manchester.

So, the first thing you need to know is the local demographics.

Local authorities usually have quite good local demographic data - partly because of their statutory responsibility for compiling Joint Strategic Needs Assessments (JSNAs). So that's a way in which Health and Wellbeing Boards (set up by local authorities) can work intelligently with GP Commissioning Consortia.

Knowing the population makeup is one thing. Knowing its' needs is another.

Here are a few examples

  • South Asian people are 50% more likely to die prematurely from Coronary heart disease than the general population.
  • Young Asian women are more than twice as likely to commit suicide as young white women.
  • South Asian women tend to have breast tumours earlier in life than their european counterparts. Screening at age 50 won't pick them up. Cultural factors may mean that women don't present to a GP till the tumour is further advanced, harder and more expensive to treat, and with lower success rates. If you want to improve on overall mortality rates for cancer, this is one place to look.
  • The prevalence of diabetes is significantly higher in Black Caribbean, Indian, Pakistani & Bangladeshi men and women than in the general population.
  • In 2003 babies of mothers born in Pakistan had an infant mortality rate more than double that of the overall rate for England and Wales. The second highest infant mortality rate was among babies of mothers born in the Caribbean.
  • African-Caribbean men are three times more likely to be diagnosed with prostate cancer than white men.
  • Black people are six times more likely than white people to be detained under the Mental Health Act.
  • Gypsies and travellers have a significantly poorer health status than the general UK population but are less likely to access health services.
  • The average life expectancy for a male traveller or gypsy is 55 compared to 76 for the general male population.
  • Around 90% of children in the general population have visited a dentist. This contrasts with approximately 40% of Bangladeshi and 60% of Pakistani children.
  • Older ethnic minority people, especially those from Pakistani and Bangladeshi communities, face much greater poverty in retirement.

Look at that information and tell me that intelligent clinicians, given the levers of power in commissioning, can't improve those outcomes.

Many are instances where, by targeting resources in a specific area on the basis of the evidence, big changes can occur without spending money where it's not needed. In other words, we can achieve more with less.

Disabled People

Again, the statistics are quite easy. There are an estimated 11 million disabled adults in the United Kingdom (1 in 5 of the total population) and 770,000 disabled children. The rest of us probably know of someone with an impairment. And it's a prospect we all face as we get older.

Disabled people aren't always conveniently identifiable at a distance. They don't all have wheelchairs or white sticks. Doctors can ask themselves why disabled people may be reluctant to disclose this kind of background information if they don't have to.

Local demographic data isn't generally very good in this area -- partly because of people's reluctance to disclose their condition. This therefore means that GP commissioners will need to put pressure in the other direction on local authority colleagues to do more work on Joint Strategic Needs Assessments.

Unlike BME populations, disabled people aren't concentrated in particular geographic areas. Therefore, if clinicians are serious about addressing the needs of this sector, they need more evidence to work on.

The needs data is easy to come by though.

  • People with mental health problems have higher rates of obesity, smoking, heart disease, hypertension, respiratory disease, diabetes, stroke and breast cancer than other citizens. 61% of people with schizophrenia and 46% of those with manic depression smoke, compared to 33% in the remaining population.
  • Both people with learning disabilities and people with mental health problems experience ‘diagnostic overshadowing’: that is, reports of physical ill health being viewed as part of the mental health problem or learning disability, and so not investigated or treated.
  • The uptake for breast screening is 76% for all women in the UK, but just 17% (family care) and 52% (formal care) ‘for women with learning disabilities; for cervical screening, the rates are 85% (all women aged 20-64), but 3% (family care) and 17% (formal care) respectively.
  • Women with schizophrenia were less likely to have had a cervical smear in the previous five years (63%) compared to the remaining population (73%), but this does not apply to those with manic depressive disorder.
  • People with schizophrenia are almost twice as likely to have bowel cancer as other citizens.
  • People with mental health problems are more likely than others to get illnesses like strokes and coronary heart disease (CHD) before the age of 55. Once they have them, they are less likely to survive for more than five years.
  • People with learning disabilities who have diabetes have fewer measurements of their body mass index (BMI) than others with Diabetes. Those with stroke have fewer blood pressure checks than others with a stroke. They also have very low cervical and breast cancer screening rates.
  • 24% of deaf or hearing impaired people miss appointments and 19% miss more than five appointments due to poor communication – such as not being able to hear staff calling their name.

On the last point, I heard the other day about an audiology clinic (who you'd have thought would know better) which had a tannoy system for summoning patients from the clinic waiting area to see consultants. Imagine how it feels to be in a setting which makes your hearing impairment seem like a problem for the staff running the place, as the consultant comes out looking for you (or assumes you hadn't turned up).

Lesbian, Gay, Bisexual and Trans People

Statistics in this area are less reliable, through a combination of few reliable sources and obvious reasons why people may be reluctant to disclose their background voluntarily. Again, LGBT people aren't conveniently segregated in particular geographic areas. They live everywhere, though you will occasionally hear of GPs insisting "we don't have any of those on our list".

A lot of work needs to be done on the basic demographics ... and more could be done on health needs research. There is a serious shortage of peer reviewed research in the standard clinical research journals and databases. Our HELP database is a place to start though.

Here are some of the things we do know though:

  • Lesbian and gay young people are up to six times more likely than heterosexual young people to commit suicide.
  • 42% of gay men, 43% of lesbians and 49% of bi-sexual men and women have clinically recognised mental health problems compared with 12% and 20% for predominately heterosexual men and women.
  • The use of alcohol, tobacco and illegal drugs is higher among GLBT people
  • Gay and bisexual men are disproportionately affected by sexually transmitted diseases.
  • 15% of lesbian women over 25 have never had a cervical smear – over twice the rate for women in general
  • The Transgendered population in general feel that their trans status reduces their accessing of healthcare, because they expect prejudicial responses.
  • Between 18-31% of trans people feel that there status adversely affects the way that they are treated by healthcare professionals.

More where that came from

I could go on. I've not delved into the health issues connected with observance of particular religions or the most obvious human difference of all, gender. As I said, the examples above are only a sample too.

The point is that, without ever mentioning the expression Equality and Diversity or the need to comply with the law, these are all clinically relevant pieces of intelligence which you would imagine should be uppermost in the thinking of people charged with spending £80Bn pa of public money effectively.

Yet, because people have been so immersed in the reactionary view that all this is "political correctness" or legal compliance, the tendency of managers is to think that E&D is something they'll look at later, when all the important structural decisions about managing the new NHS system have been made.

So the real challenge facing us, as the system changes, is to alter that view.

And it starts by talking in these terms. By presenting clinicians with clinical information which captures their imagination.

Tuesday, February 15, 2011

Change Requires Communication

This is the eighth and last piece in an ongoing series of posts explaining the approach which our team at NHS North West has taken to drive up equality outcomes in one NHS region... and the spinoffs of national best practice which that work has generated.

Next time, having talked about what we've done, I'm going to move on to talk about what we are doing to preserve the advances we've made, as the NHS is restructured, and as our team prepares to enter the last 12 months before NHS North West is disbanded.

Before that, however, I've one last topic to cover regarding the programme's delivery.

The story so far (and to come)

Our monthly E&D Newsletter

In the last blog I provided quite a detailed summary of all the aspects that I've written about so far.

As I've explained, we call it an "eco-system" approach. That's because our overarching strategy has been about creating an environment conducive to change and improvement. All the components are essential for change to happen and be sustainable.

Over this series, I've described all the elements of the ecology:

  • Research, as the bedrock of deciding what's required
  • A strategy, based on research, that sets out your goals in outcome terms
  • Tools, based on the gaps which research has highlighted
  • Objective and consistent outcome measurement, to see what progress you're making on the strategy

I think people sometimes perhaps make the mistake of assuming there is a single 'silver bullet' for this kind of transformation work -- a short cut to success -- and that all you have to do is put all your efforts into the one thing, such as a particular tool.

Personally, that's one of my concerns as the rest of the country prepares to take up the  Equality Delivery System (EDS), which we now know will be mandatory for all NHS organisations when it is launched in May. My fear is that people will focus only upon implementing the EDS (a performance measurement framework) to the exclusion of thinking about how they are going to generate the performance they're going to measure.

Unless people are careful, the EDS could end up measuring their failure, as opposed to their achievements.

This is something we are looking at very closely in our plans for how to embed equality, diversity and human rights competence and philosophy into the new health economy structures over the months ahead.

However, I'm getting ahead of myself. Let's talk first about communications.

So many organisations, so many people, so much to communicate

Shahnaz Ali presenting

It's so obvious that it hardly needs to be said. You can't expect to promote and manage change without communicating with people.

My colleague Shahnaz Ali, the Associate Director for Equality, Diversity and Human Rights (for whom I work), saw this clearly at an early stage in formulating her strategy. As a result, she recruited an expert communications lead to our team, to refine and them implement a specific comms strategy for our programme. These days Loren certainly has her work cut out!

It's helpful to think about who we need to communicate with:

  • Equality and Diversity Leads and their teams in our region of 24 Primary Care Trusts and 39 Acute, Mental Health and other specialist Trusts.
  • Wider management audiences in those same organisations -- Chief Execs, Chairs, Commissioning, Public Health and Human Resource Directors, etc...
  • The strategic leads in other SHAs and civil servants at the Department of Health
  • Regional institutional stakeholders, such as Local Authority Leads (especially important in the coming transition)
  • Equality Stakeholders in every equality target group
  • Trade and general press
  • The wider general public

E&D Leads

Also, what we need to communicate about (and how often):

  • What we are doing (at all the above levels)
  • How we want people to do it
  • Core reference material, such as our published research, strategy, guides to our tools, and progress evaluations
  • Booklets, presentations, workshops, event lists, etc... to develop and inform
  • Thought pieces (blogs, newspaper articles, etc...) to explain our thinking
  • Resources to promote our message (display materials, giveaways, etc...)

From this kind of review, we established that the programme needed some core communications tools.

The E&D Newsletter

Our monthly E&D newsletter supplements day to day operational email communications with groups of people by providing a colourful, engagingly written vehicle for E&D news, timely reminders, event details and so forth.

The circulation has grown with every month. The core target audience is the E&D professionals and managers in our 63 commissioning and provider trusts. However, that is now supplemented with an increasing number of subscribers from other regions, the Department of Health, stakeholders, and basically everyone who is interested in a regular update on what we are doing.

In addition to the regular monthly news, we also publish special editions on particular topics. This week we're sending out a 'special' about the new Public Sector Equality Duty. This is also one of our vehicles for launching new developments.

If you'd like to be added to the newsletter mailing list then drop an email to:

You can see a sample of the newsletter here.

The HELP News feed and blog

I've already described our Health Equality Library Portal (HELP). The blog explaining the background is here. Basically, HELP is a one-stop library and portal for finding authoritative evidence and background information about every equality target group, and the web sites of organisations with further pertinent background. It contains catalogued information about more than 1,400 documents and 300 external web sites.

However, HELP was designed to be more than just a repository. It also contains our own ad-hoc news feed, in which we editorialise relevant topics; a regularly updated events calendar; an aggregated feed of news from other organisations; and a Blog about the programme, with contributions from Shahnaz, myself and our communications lead. (The eagle eyed will notice that some of my HELP Blog items have appeared here as well and vice-versa).

External communications

Periodically we have something which we feel deserves a wider audience. That's why you'll sometimes see articles like this, featuring Shahnaz Ali, in the mainstream press: The Guardian: A Partnership of Equals ... or this: We know diversity work saves cash, but does George Osborne?

We also sponsor and contribute to key events in the calendar for various communities. For instance, we regularly sponsor and appear at the Pride Parade in Manchester. The 2010 parade included a huge turn out of NHS staff all walking together. We also sponsor various Disability and awards events around the region too.

The Timeline Exhibitions

Our first exhibition resource was produced in 2008 to mark the 60th Anniversary of the NHS. It was a carefully researched and professionally designed series of static display panels charting the contribution which Black and Minority Ethnic people have made to the National Health Service in that time.

The "BME Timeline" has been extensively booked out since we launched it at a big gala event in the 60th Anniversary week. NHS organisations and other interested organisations book it from a company that organises the transport and setup. Since it was launched it has seldom been out of use.

The timeline was also accompanied by a professional 20 minute film covering the 60 year history, and interspersed with interviews from half a dozen NHS staff describing their own careers in that time. To make the resources even more widely accessible, the film and all the timeline details have also been made into a permanent online exhibition.

The success of the BME Timeline has since led us to commission a similar exhibition about the history of LGBT people in medicine and the NHS. This, again, consists of 20 large display panels which can be set up in any suitable indoor public space.

The LGBT Timeline exhibition was launched at the offices of the Lesbian and Gay Foundation in Manchester on February 1st 2011, to coincide with the start of LGBT History Month (of which I'm a patron). A film, a 20 page booklet and an online web display are also in preparation as I write, and I'll obviously blog about those when they are launched.

Pulling it all together

I've not described everything we produce, as it's a long list. However, I've hopefully picked out enough to underscore the point that it's not enough to have a strategy. You also have to have various ways of communicating about it and being seen by all the stakeholders.

Anyway, as promised, next time I'll be turning my attention to the challenges of ensuring that all this doesn't turn to dust as the NHS completely reinvents itself over the next couple of years...



Friday, February 11, 2011

Competent Change Management is Key to Achieving Equality Outcomes


This is the seventh in an ongoing series of posts explaining the approach which our team at NHS North West has taken to drive up equality outcomes in one NHS region... and the spinoffs of national best practice which that work has generated.

The story so far

I've previously described the idea of an all-round evidence-based strategy for driving up equality outcomes as an 'Eco-system' approach. That's because many aspects of the environment need to be right for a successful equalities approach to be seeded, take root, grow and flourish.

So far, in the first part of this series I've talked about the importance of understanding the crucial difference between measuring the work you put in and the tangible outcomes which you can show for it.

After establishing what it is we need to measure, part two described the approach we devised for measuring outcomes consistently and objectively - our Equality Performance Improvement Toolkit (EPIT). Our success with EPIT means that the design principles lie at the heart of the forthcoming Equality Delivery System (EDS), which will be launched by the Department of Health in the Spring.

In part three I took a step back to discuss why all this stuff is important to embed in the culture of a system like the NHS.

Then, in part four, I introduced the research and findings which pointed to the things we concluded we must do to facilitate the necessary change.

I followed this with descriptions of two of the tools we realised we needed - the Health Equality Library Portal (HELP) and our sustainable consultation methodology, the Health Equality Stakeholder Engagement (HESE) approach.

In all of this, so far, I've barely mentioned the role of leadership -- and whether the managers tasked to lead change like this in the NHS have the competencies and backing to succeed.

The people factor

If you go back to our Landscape of the Region research and conclusions then you'll find that quite a lot of the conclusions are about people, their skills, experience and the support that's provided for them to succeed in leading an E&D change agenda.

I should stress, of course, that although the research was conducted across NHS organisations in North West England, the issues are the same everywhere. Indeed, more recent research carried out to test the design of our Competency Framework across several Strategic Health Authority regions underlined that, if anything, the constant development we've given in the North West has resulted in a better picture than in other parts of the country.

The research found several weaknesses:

  • A lack of consistency in how E&D leadership roles are graded. In terms of the NHS's Agenda for Change framework, people managing this area for their organisations ranged from junior levels (grade 6 or less) to the associate director level (grade 9). Much of this pointed to serious lack of clarity about what an E&D leadership role entails -- especially how much of it is about strategic thinking and influencing, and matrix working with directorate managers across the organisation. Typically, organisations are confused between a leadership role like this and the supporting practitioner roles which a lead might line manage to carry out their programme of work.
  • No senior manager or board would appoint a Finance lead without knowing what the job and person specification entails. Other senior roles like this in the NHS are extremely well documented within either the Knowledge and Skills Framework (KSF) and/or the Leadership Qualities Framework (LQF). Evaluated job roles are also then incorporated into the Agenda for Change grading framework, so there is very tight consistency over the level at which roles are graded, and hence the level at which managers are paid. None of this has existed until now, however, for E&D roles. This reflects the historical way in which organisations found they suddenly needed to employ such managers in response to equalities legislation. Nobody thought it through nationally.
  • Likewise there was inconsistency over where the E&D leadership role sat within organisations. Some leads reported to the Human Resources Director, reflecting the presumption that E&D is only about workforce issues and not service provision. Other organisations had their E&D leads reporting to Quality / Governance Directors, Organisational Development Directors or Directors of Nursing. Few organisations had grasped that the scope of the challenge was such that they might need to think of having their E&D lead report to the Chief Executive (even if they are line managed by another executive director).

These are not the only weaknesses or inconsistencies, however I'll leave you to read the rest in A Landscape of the Region.

Why is leadership so important in this area?

The purpose of measuring equality outcomes is to identify areas where the organisation is weak and to put those right. In doing that effectively, you also contribute towards higher level quality and effectiveness goals.

It's not just about complying with the law. And it's not just about being ethical or touchy-feely with people. The kind of outcomes we are talking about improve clinical results, allow us to do more with the same level of resources, and to save the human waste of losing staff unnecessarily, or dealing with complaints.

The challenges for each organisation will be specific to them. Therefore we can't just say to everyone, "do this and the problem's solved". Leads have to work it out for themselves.

Successful Equality, Diversity and Human Rights leadership therefore combines strategic vision, diagnostic, analysis and change management skills.

Some organisations make the mistake of thinking that just because their managers have all been on a 'diversity awareness' course they've done all that needs to be done. However, those also turn out to be among the weakest in terms of tangible results.

An E&D Competency Framework for the NHS

All of these factors pointed towards the need for a national level NHS E&D Competency Framework, which is now in the final stages of development.

We are hoping that the framework, jointly funded by the Department of Health and NHS North West, and developed by experts in the field, will be launched at the same time as the Equality Delivery System (EDS), as one of the essential tools that organisations will need to improve their measured performance.

The framework is based on a combination of in-depth research followed by testing with professionals who already lead the Equality and Diversity brief at a senior level in their organisations. Extensive field research identified five core competency areas that successful leads must possess in equal measure:

  1. Operate from a Human Rights, equality and inclusion context
  2. Apply a robust equalities analysis to service planning and improvement
  3. Build capacity to respond to diverse and changing community needs
  4. Communicate a compelling business case for Equality, Diversity and Human Rights and influence strategically
  5. Influence and lead change to improve equality outcomes

There is obviously a great deal in the detail behind each of these five core areas; each comprises many individual standard competencies. However our extensive field testing confirmed that the top level headings and the assessed levels of individual competencies and leadership qualities which they comprise reflected, very well, the profiles of E&D leads who are demonstrably successful in their work.

Notice how the first two competencies are the only ones that require specific equalities knowledge. The other three are far more generic competencies that should be possessed to varying degrees by any senior manager.

The top level headings are defined in terms of generic competencies, making the first part of the toolkit independent of the NHS context. It can be used anywhere. Those generic competencies are then mapped back onto the NHS's Knowledge and Skills Framework (KSF) and Leadership Qualities Framework (LQF) and assessed in terms of the levels of these abilities and experience that are required.

In turn this mapping also allows managers to compare the E&D leadership role with other evaluated NHS functions. It means that staff and managers can both understand what development a manager would need to move into E&D leadership, or what they would need to go onwards to other responsibilities as part of a managed career. This has never been done before. It means, potentially, the end of seeing Equality and Diversity roles as a career cul-de-sac or graveyard.

The work has also been important in establishing a firm case for how senior and experienced an E&D lead needs to be. Again, there was no standardisation to this before, as I've mentioned already. The analysis points very firmly to the need for E&D leadership to be seen as one of the Agenda for Change Grade 8 roles, with the possibility for entry at grade 7 (subject to having the right development plan, mentoring and line management in place).

A development framework

The competency framework doesn't stop at defining in detail what competencies a manager in this role should have. The toolkit also includes fully worked job descriptions and person specifications for recruiting, plus tools for extensively evaluating where existing staff stand against each of the competency areas.

The training needs analysis toolkit was extensively tested with volunteers from three Strategic Health Authorities, covering a wide range of organisations (PCTs, acute, mental health and other specialist provider trusts). Volunteers were also selected from a range of existing pay bands as well.

The pilot results were interesting in that, although they revealed a typical spread of capabilities (and a correlation between success and competence), each individual had particular weaknesses. Some tended to be stronger in competencies 1 and 2; others in 3,4 and 5. The results underlined the importance of us providing suitable developmental approaches that could target the weaknesses and produce stronger, more effective, managers. Again, we don't think that anyone has done this in such a systematic way before within the sector.

A tool for organisations

The competency framework will do several things for organisations:

  • It will enable any senior management team to understand the nature of leadership for Equality, Diversity and Human Rights, the seniority and oversight required, and to differentiate between strategic and change management skills (which must be in-house) and supportive practitioner / delivery functions which could easily be shared or bought in from outside. Many of the competencies of an effective E&D lead will be found in other senior managers, so the framework enables chief executives and board members to understand what they are missing and whether they need to recruit a specialist or develop an existing manager.
  • It provides clear job descriptions and person specifications to ensure that organisations consistently recruit personnel of the right standard, at the appropriate grade to be effective -- just as in any other NHS profession. The national standardisation in this area will also lead to more and more training providers developing training and accreditation to prepare candidates for such roles.
  • The framework also enables an organisation to accurately assess the competence of existing E&D leads against the five competency areas, so as to identify gaps that need to be addressed by professional development and/or mentoring. The framework also makes it easy to compare the competencies for other evaluated Agenda for Change roles and therefore plan career development for all managers, so that elements of E&D leadership qualities can be embedded into the experience of directorate leads, in areas such as commissioning, organisational development, governance and human resources. The clear identification of comparable KSF and LQF competencies means that Equality and Diversity can be a senior leadership role that individuals can move into and out of, like any other, as part of a planned career development.
  • Finally, the framework provides tools that have hitherto been unavailable, to address identified competency weaknesses in this area, and provide an accredited qualification that can will make it easier to gauge an individual's suitability at a glance.
A tool for individuals
The framework is also valuable for individuals wanting to develop a more successful career:
  • It provides the same clarity and consistency of job description as for any other defined professional role in the NHS Agenda for Change system. Staff in the role can be confident that their leadership team understand exactly what they bring to the table, and what is expected from line managers to support the lead in being effective.
  • The framework clearly defines the range of Agenda for Change bands in which effective E&D leads should operate. Staff below the required standard can clearly see what skills and experience they need to develop in order to advance into an E&D leadership role at an entry level, and how they can develop to be more proficient and effective. The comparison between KSF and LQF competencies for other comparable senior roles also allows E&D leads to be able to consider other management areas that they could move into as part of a long term career portfolio development

The future

Not surprisingly, we are excited about the ability of the new Competency Framework to address all the structural weaknesses in E&D Leadership that I described above. For the NHS to improve its' equality outcomes requires some fundamental change leadership in every organisation -- so getting the right people properly equipped to lead on this is a crucial part of achieving success.

Wednesday, February 09, 2011

When Rights Conflict

How do you reconcile a conflict between someone’s right to their religion and beliefs and the rights of others?


This is a question I first posed in one of my early Podcasts, about three years ago. The show was based on some advice I had needed to write for some public sector managers, who were trying to understand how to balance the wishes of staff with religious convictions against other concerns.

Today people are discussing this same topic on Twitter. However, as I appreciate that not everyone can listen to a Podcast (especially on a computer at work) I thought it was worthwhile digging out the script for this Blog.

In the process of dusting off the script I've done some small amendments to take into account the advances in the law that have occurred since this was first written.

Protections for all of us

The increased level of legal entitlements and protections in Britain over the last few years has provided most people in our society with the tools to be able to insist on fair and equal treatment, and to live their lives without the fear of harassment or violence.

There is hardly anyone left these days whose right to live in their own way is not covered in some shape or form.

  • For women there has been substantial legislation dealing with discrimination in work, training, and the supply of services; the right to equal pay; protections during pregnancy and, of course, rights to contraception, fertility treatment and abortion. There is now also a positive duty on public bodies to promote gender equality
  • Other provisions outlaw discrimination on grounds of race, disability, age and sexual orientation. In some of these instances hate crimes is also specifically dealt with and there are positive duties for public bodies relating to race and disability.
  • The right to thought, conscience and religion is also protected, along with the right to change one’s religion, and to manifest one’s religion or beliefs, along the lines required by article 9 of the European Convention on Human Rights.

In fact, since I wrote this piece, all the above protections and more have been consolidated into a single, more consistent, Equality Act and public sector equality duty embracing all of the so-called protected characteristics.

Exemptions extend privileges for some

Rights regarding religion or belief are not just reflected in direct form, but also indirectly, through the special exemptions that have been written into the laws protecting other groups. This means, for instance, that laws protecting gay and lesbian people’s rights have included clauses that withhold those protections in certain contexts, such as applying for teaching posts in faith schools.

The question of whether each of these exceptions is reasonable, and the circumstances in which they can be claimed to apply, has naturally been a hot topic – especially during the time when these Acts and Regulations have been open for consultation and debated in Parliament.

I’m not going to deal with the detailed ins and outs of the specific exemptions. Suffice to say that when they clearly apply then everyone knows where they stand and the rights and wrongs can be settled by what the law actually says.

Dealing with grey areas and ambiguity

Nevertheless, there are also going to be circumstances where the position isn’t so clear, or where someone misunderstands the limits of what the law protects on either side. In those cases it’s important to be aware of exactly what the Human Rights say – and, just as importantly, -- what they don’t mandate.

Let’s consider some examples first. I’m going to do that by considering the kinds of situations that could arise in health and social care. However, the same could well apply in other settings too:

In a hospital or clinic some staff may inevitably voice objections towards treating certain service users or working with particular colleagues on the grounds of their religion or beliefs.

This could arise, for instance, where the situation involves people who are known to be lesbian, gay, bisexual or transgender, or where the individual concerned belongs to a another religion or expresses very different beliefs.

Similar conflicts might also arise the other way around, such as a patient saying that, on the grounds of their personal religion or belief, they don’t wish to be treated by an openly gay man, a member of staff from a particular race or religion, or even a member of staff of a particular gender.

Indeed it‘s conceivable that a conflict might arise between an individual’s religion or beliefs and just about every form of legislated protection for individual rights.

That is, it’s possible for conflicts to arise involving religion or belief and someone else’s gender (or gender presentation), racial / ethnic background, disability, sexual orientation, age or another religion.

Some working principles

Whatever the circumstances, managers must be prepared to deal with these potential conflicts of rights in a consistent, firm and confident manner.

It’s also vital to draw a distinction between conflicts that really do arise from a firmly held religious teaching or belief, and the more general case of someone expressing a discriminatory attitude.

This means we need clear ground rules, and a logic that’s simple enough to explain to all concerned. You’re more likely to be successful if the rule can be seen to be consistent and transparently applied.

The required outcome is the same in all circumstances, of course...

I.e. The legislated rights of all parties need to be upheld.

However, there is a necessary difference to the approach where the issue arises from a potential conflict of the rights rather than simply the exercise of a prejudice on the part of one party.

The essential difference is that in instances where a conflict of two people’s legal rights are concerned a solution must be found, through compromise, which satisfies the rights of both parties.

Prejudice or a genuine issue?

Let’s consider a pair of examples:

  • A practice nurse in a health centre is not willing to give sex education leaflets to a young woman on the grounds of her religion’s position on these issues. This involves a conflict of legislated rights and a means must be found to satisfy the legitimate rights of both parties.
  • A male service user is abusive towards a hospital worker whom he perceives to be gay or lesbian. There is no conflict between rights; the matter is clearly about unacceptable discriminatory behaviour and the required course of action is clear.

Conflicting rights

So, what happens when rights appear to conflict?

In the case of apparently conflicting rights managers must be very clear about what the law protects and what it doesn’t protect.

Clearly, none of the anti-discrimination laws that have been enacted give anyone a right to use their position to impinge on others.

I.e. The fact that all groups in society now have roughly equivalent degrees of protection against direct or indirect discrimination or harassment in employment, training, and the provision of goods, services and housing does not allow anyone to use their protected status as a means of disadvantaging someone else in another group.

To be clear: Nobody has any form of legalised mandate to disadvantage others in order to enjoy their own protection.

Qualified vs unqualified rights

This idea has been embodied into the European Convention on Human Rights since these principles were drafted and endorsed over fifty years ago.

The same concepts are part of the Human Rights Act too.

Some rights are considered to be “unqualified” – i.e. nothing can water down the principles involved. A good example is the provision which says that no one shall be subjected to torture or to inhuman or degrading treatment or punishment (Article 3).

Other rights are referred to as so-called “qualified rights” however. That means that they must be balanced against other competing rights. A good example of a qualified right is the second part of Article 9.

The first part is unqualified:

Everyone has the right to freedom of thought, conscience and religion; this right includes freedom to change his religion or belief and freedom, either alone or in community with others and in public or private, to manifest his religion or belief, in worship, teaching, practice and observance.

The second part comes with a qualification though:

Freedom to manifest one’s religion or beliefs shall be subject only to such limitations as are prescribed by law and are necessary in a democratic society in the interests of public safety, for the protection of public order, health or morals, or for the protection of the rights and freedoms of others.

Thus it’s clear that managers can only accommodate the requirements and beliefs associated with membership of a particular religion to the extent that this does not impinge on someone else’s rights.

Putting it all together

How do you put this to use?

A good working approach is to start from the right that everyone has, under the law, to belong to a particular religion, to worship according to its provisions and to hold the beliefs which followers of the religion are expected to have.

This is what the law actually sets out to protect, in accordance with Human Rights Article 9, and the European Community Employment Equality Directive 2000/78/EC.

Insofar as that aspect of religion or belief is concerned, there is little likelihood that belonging, worshipping in a particular fashion or holding particular beliefs will impinge on someone else.

In these circumstances there should not therefore be any conflict to resolve and managers should be able to concentrate on respecting and upholding those rights in an unfettered way. I.e. If someone or something is discriminatory towards a person’s religion then the law is clear that that is wrong.

Difficulties are only likely to arise when the issues move from an individual’s passive observance of their religion to an active status. That’s when you may find that their actions begin to impinge on others.

Of course, the activity may still be alright so long as the result is not discriminatory towards the other person or is perceived by them as harassment.

If that other person’s own rights to be free of direct or indirect discrimination and harassment are impinged upon, however, this is where the right to religion or belief becomes qualified and limited.

Thus (to stay with our health examples) an NHS employee may not use their religion or belief as a mandate to deny treatment to someone else, or to refuse to work with them, or to proselytise or condemn, since any of these are most likely to impinge on the other individual’s rights, which must be balanced.

The challenge in a multicultural society is to be able to live together in harmony in spite of the fact that we all have such different backgrounds and beliefs.

The law reminds us that rights are a shield to defend us. Not a cudgel to impose ourselves on others.

Tuesday, February 08, 2011

Effective and Sustainable Engagement with Equality Stakeholders

This is the sixth in an ongoing series of posts explaining the approach which our team at NHS North West has taken to drive up equality outcomes in one NHS region... and the spinoffs of national best practice which that work has generated.

The story so far

Front cover - An Equal Partnership

In part four of this series I explained how our research pointed to the need to develop certain tools for improving equality outcomes in the NHS. Earlier parts also described how we measure those outcomes objectively.

In the last post I described the evidence library and portal which we developed to address one of the identified gaps.

In this post I want to go on and describe another of the innovations we realised we needed: the Health Equality Stakeholder Engagement Approach.

You can read more about what I'm about to describe in our publication about this, An Equal Partnership. However, I'll summarise it here.

Consultation and Involvement that lasts

Consultation and involvement with stakeholders is just as important to successful planning as having good research. Indeed the two overlap, as stakeholders are often the best source of the information needed to make good decisions.

The problem with engagement of this kind is that it's often not very well done. Our research told us that there was a need to establish some best practice and point the way.

We also needed effective and sustainable strategic consultation partners of our own. The project to establish those relationships was a way of proving the theory in practice.

And the word 'sustainable' isn't an idle throwaway. We wanted to develop long term relationships that would last -- by being good for all sides.

The bear traps

Firstly, we were aware of what can go wrong with consultation and involvement

The first mistake, often made, is to assume that organising a big public consultation event with hundreds of people is all that you need to do. There are several problems with this:

  • It is pure luck whether an event of this type attracts people from all of the diverse communities in society. I.e. Both men and women, of all ages; representatives of all the local black and minority communities; disabled people; lesbian, gay bisexual and trans people; people with different religious beliefs (or none) and people with caring responsibilities, gypsies, travellers, homeless people and so forth. The list will depend on the makeup of your local population.
  • Not everyone in these categories wants to be recognised as such. For instance, there may be many lesbian and gay people in the audience, but they won't necessarily wish to 'out' themselves publicly to express their experiences
  • Even if you DO identify people from all these groups in a public consultation (the obvious example is a person in a wheelchair), there is no guarantee that that person knows about the wider needs and experiences of other people like themselves or, for example, people with other forms of impairments. The answers you get may not be representative.
  • Lastly, of course, the needs of small communities can easily be drowned out by bigger and more insistent voices.

All this points to the need to seek out more specialist organisations who should have the depth and breadth of experience to give authoritative input.

Again, however, it is very easy to get this wrong too.

  • Firstly, how do you know that the group you've chosen is properly representative? Is consulting with them going to upset other parts of that community?
  • Lack of forethought can also mean that managers seeking input don't get the full picture. How do you plan for the people you are engaging with to give of their best? How much time do they need to prepare or follow-up? How much time can they actually afford to give, without you supporting them in practical ways to do that?
  • Lack of insight into the stakeholder's view of the process can also mean that organisations fail to appreciate the burden they're imposing on people with limited resources. The result can be 'consultation fatigue' and disengagement. We've spoken to organisations who've said they just couldn't respond to every 100 page consultation document which plops through the door. In the North West alone there are well over 100 organisations who might be wanting to consult the same small charity. Yet, if they don't reply, are the people at the other end simply assuming that everything is fine?

The Health Equality Stakeholder Approach

The methodology we created addresses all of this and more. It's a complete philosophy for how to engage with third sector equality stakeholder organisations in a way that recognises the needs of both sides.

At the heart of the approach is the almost radical commitment to commission this work on a financially viable basis from the best organisations in class, and to embody everything required for a full year's committed engagement in a formal Service Level Agreement with each one.

The approach embodies seven easy steps for public sector organisations like NHS Trusts to follow:

  1. Decide on which kinds of expertise you need to cover all the diverse groups in your area (including the ones sometimes referred to mistakenly as 'hard to reach')
  2. Decide on some sensible selection criteria. (We supply a complete set to adapt)
  3. Decide how much work is involved ... how many days of time you want to buy over the life of the agreement
  4. Work out a fair going rate for that time
  5. Conduct a fair and objective procurement exercise to locate possible partners, shortlist and select one of each type
  6. Set up an SLA with each partner
  7. Design the engagement activities in a way that develops the expertise of the partners. That way, over time, they give even better advice. The methodology contains advice on how to structure engagements to do this.

A complete success

We developed our approach in the autumn of 2008 and issued the first set of agreements in time to begin consultation exercises in January 2009. Now, in 2011, we are about to embark on a third year of operation.

In the first year we consulted with our partners on a wide range of topics - a dozen in all - kicking off with the SHA's ten year workforce and education strategy.

The methodology paid off straight away, through allowing the preparation time, in-depth face to face discussions, and written follow-up and evidence submission that our 3 day 'set piece' format allowed.

Over the course of time we also noticed how stakeholders who were essentially activists with very specific issues on their minds began to provide ideas in a more strategic way. As they began to understand how the health economy works, they tended to present thought through practical solutions, rather than simply lists of problems.

The SLA doesn't just provide for big 'set-piece' consultations. It also has time built in to fund ad-hoc telephone support. This means nobody feels guilty or imposed upon unfairly by contacting our expert stakeholders for quick advice on a policy matter. Time was also built in for each stakeholder partner to carry out a specific piece of research for us in their own specialist area. We also used everyone's resources to provide the research to stock our 'HELP' library.

Success is judged from two perspectives: whether we felt it worked for us, and whether the stakeholders felt it worked for them. At the end of the first year we carried out a thorough audit on the value for money and effectiveness of the approach. The returns were excellent. And both our own managers and (just as importantly) the stakeholders gave glowing feedback.

How to set up your own HESE

As I explained at the outset, the goal in setting up our own Health Equality Stakeholder Engagement arrangements wasn't just to meet our own needs. The project (designed by me) included detailed documentation on every step. The publication "An Equal Partnership" is therefore a complete 'How to' manual for anyone who wishes to repeat our success.

Sunday, February 06, 2011

The Health Equality Library Portal (HELP)

This is the fifth in an ongoing series of posts explaining the approach which our team at NHS North West has taken to driving up equality outcomes in one NHS region... and the spinoffs of national best practice which that work has generated.

Making research easy

The HELP home page

Today I'm writing about our creation of this public resource:

In the last few posts I've concentrated on the theory and strategy for equality outcomes improvement. In part four I explained how all this needs to be grounded in evidence.

In previous posts I've been talking about the need for research and evidence to inform an overarching strategy. However, the same obviously then applies when commissioners and providers are analysing the effects of policy decisions in the way they organise services and staff them.

Our Landscape of the Region research at NHS North West found that organisations were typically weak in finding and using the appropriate kinds of evidence to inform their decision making. To quote the report:

Without accurate and up-to-date data, any Equality Impact Assessment or Action Plan is questionable. Not only must actions be based on appropriate research findings and/or numerical evidence but that same data is also necessary in order to provide a baseline for subsequent measurement of results. (2.5.8)

Regionally and nationally all the indications point to the fact that even where data is unquestionably available for some of the ETGs, many organisations, particularly PCTs, are nationally failing to demonstrate the use of disaggregated data in order to drive strategic planning. Therefore plans are vague, rather than focussed, and provide no measures for outcomes. [..] Trusts were asked what data sources they use to inform operational and strategic planning, and whether they use other sources such as the Census, national / regional market analysis reports or Local Authority data. (3.6)

Following this we did some more specific survey work on the kinds of external information sources which organisations were using and (just as importantly) which ones they were missing. We did this across a wide range of managers and organisation types besides Equality and Diversity practitioners and leads.

What we discovered confirmed what we already suspected. Most people used only a relatively small set of sources for information in this area. They tended towards 'official' sources, such as Medical Journals, the Census, Local Authority statistics or the Public Health Observatories.

However, many of these sources they relied on were themselves poor in covering needs and experiences related to diversity. Managers were particularly unaware of so-called 'grey research' -- the kind of studies which only get published by advocacy and support charities, filling gaps that are not being addressed by mainstream peer-reviewed journals.

Improving access to evidence

All our research pointed towards one conclusion. There was a desperate need for an authoritative and easy to use resource that E&D teams and managers could refer to as a one-stop-shop to find the kind of information which they hitherto regarded as hard to access. Something that pulled it all together.

We found a need to satisfy two primary requirements:

  • A well catalogued library of published documents - either pointing to where the publishers' web sites or (where not available elsewhere) holding the documents itself
  • A similarly indexed portal to help managers find entire web sites for organisations where they could make contacts or find more information directly.

Whilst we were at it, we saw that this service could also sensibly include:

  • An up to date calendar of diversity-related events -- a listing to remind people of community specific dates when it would not be a good idea to organise meetings, and also to signpost interesting courses, meetings, etc..
  • An editorialised news feed, where we could raise the profile of anything relevant (later supplemented by a blog too)

Cataloguing is Key

As I personally come from a consulting background in document management and retrieval, I was keen that the new service should pay particular attention to what we call the information 'taxonomy'. A taxonomy is a system for classifying things.

Online libraries succeed or fail on the simple test of whether they help you find what you want.

Google is successful as a general search tool because most users are able to find just what they want on the first page of results. However, it is poor at finding the kinds of information we are talking about here, without a lot of extraneous material as well.

None of the existing software we looked at could categorise information in the way that Equality and Diversity research is naturally classified.

In the end we came up with a bespoke scheme which simultaneously satisfied two overlapping requirements

  • A formal hierarchic classification system representing the major diversity categories (gender, race, disability, etc...) and the unique ways in which each of those are then broken down. The sub-categories for race and ethnicity are completely different from those for disability, for instance
  • An open ended system for describing what kind of subject matter the document or web site is concerned with. This saves having to rely on guessing which words a document might contain if it was talking about a particular topic.

It's also vital that everyone uploading information into the system should catalogue the same document in a consistent way. This is always a tricky problem, since different people will see a document and the cataloguing options in different ways. The key, however, is to strike a balance between providing enough terms to distinguish subjects sensibly, but not so many as to encourage ambiguities.

Introducing HELP

The name 'HELP' was my idea. We needed something snappy that summed up what we were trying to achieve. The name also says exactly what the service provides. It is both a library (a place cataloguing and storing documents) and a portal (a system pointing you to web based information which we don't ourselves control).

Getting the custom software developed was only a small part of having something ready for people to use. The bigger challenge was to stock the system with authoritative information from day one.

We knew that if we launched the service and people couldn't find what they wanted on their very first visit then they would be unlikely to return.

In the end we launched HELP in the late summer of 2009 with around 1,400 documents fully catalogued, and with the portal section listing almost 300 web sites.

Stocking the system with all this information was a massive undertaking -- helped immensely by the Service Level Agreements we have with a set of third sector organisations who are expert in each Equality Target Group.

The task we set for each stakeholder organisation was to supply us with all the resources which they thought NHS managers should be able to find in order to research the needs of their communities. This had the advantage that they automatically provided only the most up to date and most relevant resources.

Maintaining HELP

A resource like HELP cannot stay still. Its' usefulness and reputation is only ever as good as the last successful search.

To build HELP we brought in our stakeholders to do the research and some temporary staff to do the inputting and checking.

But the knowledge base and the world wide web are both constantly changing.

On a simple level, if you point a catalogue entry at someone else's web site then you have to keep periodically checking that it hasn't moved. This has proven to be a task that's a bit like painting the Forth Railway Bridge. The moment you've completed it, you have to start again from the beginning.

New documents are always being published too, and some others cease to be so relevant or are superceded. For this we've built a requirement into our SLAs with our third sector equality stakeholder partners to keep us supplied with new content.

Open to all

We never wanted HELP to be a closed resource. One of our earliest design decisions was that it should be accessible to everyone -- not just the NHS managers in our own region, whose needs were the original driver, but other public, private and third sector staff, who are basically all needing the same kind of information.

What HELP strives to achieve is to ensure all those people only need ONE place to go and look.