Thursday, February 03, 2011

Garbage in, Garbage out

This is the third 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 has generated.

The story so far...

In yesterday's post I introduced you to the North West's Equality Performance Improvement Toolkit (EPIT), how it links to our five year strategy, Narrowing the Gaps - Better Outcomes for All and how it is grounded in the original diagnostic research which underpins all our work, A Landscape of the Region.

EPIT was launched across the North West by the SHA's Chief Executive Mike Farrar in October 2009, and the first set of results was completed six months later. It demonstrated that, by the exacting standards we set, many organisations were still some way from the kinds of achievement we desire -- especially eight years after the first of the Public Sector Equality Duties came into effect.

On a positive note, EPIT also revealed some excellent examples of good practice and results too.

Why is this important?

Before I go on it's worth talking for a moment about why we're interested in this -- because it's not just for legal compliance. And it's certainly not because we have a bad attack of political correctness.

There is a business case for driving up the levels of professional competence and innovative working which leads to equality outcomes for everyone. And it's just what the present government says it wants to see.

Cultural competence -- understanding how different people have different needs and may experience different barriers -- is at the heart of targeting the money we spend on services more effectively.

It's about that thing people are talking about now -- achieving more for less.

Achieving more for less

Take a simple example. Breast cancer tumours in Asian women tend to appear at a younger age than for women of British and European origin. There are also barriers relating to persuading women in some communities to examine their own breasts, and to know what to do if they find any abnormal change.

If we set the threshold for routinely scanning women at age 50 then, by the time these asian women are diagnosed, their tumours are developed and have spread. The treatment costs orders of magnitude more than with early diagnosis, and the prospects for recovery are far lower.

But the response shouldn't be to blindly spend money on screening everyone earlier. A smart commissioning strategy would recognise this phenomenon and target the screening programme differently for various sectors of the population.

The new consortia also need to understand their catchment well enough to detect the groups of patients they're not seeing preventatively, and to work in innovative ways with communities to reach out to them.

You wouldn't think this is rocket science. Indeed, the (now defunct) World Class Commissioning programme referred nebulously to managers needing the competency to understand their population and commission accordingly. We measure this by seeking the evidence in EPIT. But the results tell us that, in some cases, practice falls far short of this kind of simple evidence-led planning.

This is not an isolated example. I have a long list of them. Any competent charity representing the various diversity groups can reel them off too.

Like I say, it's not rocket science. And if GP Consortia are looking for ways to make big budget savings, and are really keen to do things differently, then this is the kind of new thinking that needs to emerge.

Back to the plot...

Having run EPIT once and got the results, we are now preparing for the region's 24 PCTs and 39 NHS provider trusts to repeat the exercise ahead of the launch of the Department of Health's national Equality Delivery System (EDS).

The EDS (which has been quite openly consulted upon) is essentially a national implementation of EPIT, but with some adjustments to the language to align with the new administration's priorities. There are also significant changes to the governance approach to reflect the massive changes to the NHS structure, and the coalition's passion for localism.

If implemented well by the new NHS organisations then the EDS will provide just the kind of detailed intelligence about differential needs and poor outcomes that I've mentioned above. In turn, this knowledge can feed directly into setting the prioritised equality objectives which the new Public Sector Equality Duty requires. And the objectives should feed into changes and innovations like the kind I've suggested.

Will people understand the possibilities and seize the chance?

The theory is great. And, as an SHA we've been in a position of influence with EPIT to ensure the whole thing is done properly.

There are lots of bear traps for the unwary implementing the EDS, however. And SHA's won't be around any more by the time it's in use.

The first risk is that people may mistake the EDS for the solution, rather than understanding that it's simply a measuring tool.

Garbage in, Garbage out

The EDS measures where your strengths and weaknesses are. It points up the successes and failures.

But it doesn't create those successes. You need to have a change programme of some kind to create those better outcomes. Then EPIT or the EDS just provide an objective and consistent discipline for measuring your success.

The second point follows on. Those kinds of change can only happen if the cultural competence -- the E&D leadership and know-how -- is somehow embedded into the new organisations and the bodies that influence and scrutinise them.

Indeed the competence needs to be at the level of strategic decision making, in the hands of people who can promote and manage change.

You can't get this by outsourcing. You don't outsource strategic vision.

A central, not peripheral issue

So, the new Health and Wellbeing boards need to understand why this is important. CQC needs to understand it. The new local Health Watch organisations need to get the point. (And they will also need to develop the capability and capacity to ensure EDS assessments are realistic).

All this means that the preparation for introducing the Equality Delivery System cannot be divorced from the whole question of how to preserve collective E&D knowledge as the new organisations take shape.

If managers think that Equality and Diversity is just about statutory compliance then they'll think it's a relatively low priority that can be left till later.

"Come back when we're not so busy" is in fact the default assumption for some managers scurrying around at the moment. Fortunately there are more visionary managers too, who 'get it'

But if they don't get it then the EDS won't measure their successes. It will measure their failure.

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