Monday, January 31, 2011

Announcing a new historical timeline exhibition for LGBT History Month and beyond

Tomorrow, 1st February 2011, I'll be popping in to the offices of the Lesbian and Gay Foundation in Manchester, where my colleagues and I from NHS North West will be launching a newly commissioned exhibition resource in time for the start of LGBT History Month.

As a patron of LGBT History Month and as NHS NW's Equality and Diversity team's programme manager, I'll be saying a few words to the assembled audience.

A brand new resource

The new LGBT History timeline has been funded and produced by NHS North West in partnership with the Lesbian and Gay Foundation (LGF) and the Trans Resource and Empowerment Centre (TREC) -- who carried out most of the research.

NHS North West is the Strategic Health Authority for North West England. The North West has a population of around 6.8 million people, of whom an estimated 420,000 are LGB or T. That's a number equivalent to the entire population of a city the size of Liverpool!

The whole of England's LGBT population would equate to ten such cities, of course.

Celebrating, Remembering

The timeline celebrates the history and achievements of LGB&T people, particularly those that have contributed to healthcare over the years, and the development of a vibrant and active community in the North West.

The timeline also documents the way in which the medical view of sexual orientation and gender identity have altered through the ages, showing the landmark decision points where changes occurred.

Key figures who are celebrated, include the gay rights campaigner Alan Horsfall, who in 1959 tabled a motion to his local Labour party in Lancashire to back the decriminalisation of homosexuality. Dr. Louisa Martindale is also celebrated, who became the first woman GP when she set up a practice in Brighton in 1906. Prominent trans campaigner Professor Stephen Whittle is also recognised for his role in trans activism and equality.

The latest in a line

The new timeline is not the first that my colleagues have produced. In 2008 the team commissioned a similar resource documenting the contributions made by Black and Minority Ethnic People to the NHS since it was founded in 1948.

The 'NHS BME Timeline' has been an overwhelming success since it was launched to mark the 60th anniversary of the NHS's foundation in the summer of 2008. We also produced an informative video and interviews and combined these into an online version of resource.

You can view the online version of the BME timeline here.

We plan to make a similar online version of the LGBT timeline as well. Filming for this is already underway. Meanwhile both timeline exhibitions, each consisting of around 20 large mounted panels, can be booked by contacting my colleague Loren Grant via

Sunday, January 30, 2011

Where do equality stakeholders fit in the new NHS Landscape

According to Minister, Andrew Lansley, the changes he proposes to bring about in the NHS will put patients at the centre of everything the NHS does.

That's a bold claim, which should be seen in the context that NHS organisations like the 152 Primary Care Trusts (PCTs) and the ten (regional) Strategic Health Authorities (SHAs) have specific statutory obligations to consult with the public, plus obligations (as public sector bodies) under the past and future Public Sector Equality Duties.

It's a bit hard to see how claims about the new system hold up when you look at the structure:


In this picture, the existing public sector entities which will still be around in the new landscape are in yellow, whereas the completely new bodies are in blue.

This isn't a complete picture, in part because some of the details are still only gradually coming to light.

Notice where Equality Stakeholders sit, however .. right out at the edges. And remember that the new GP Commissioning Consortia, although treated as public sector bodies, are consortia of private partnerships (the GP practices) who most certainly aren't.

Already, questions are being raised about whether the meetings of the pathfinder consortia are in the public domain. Some pathfinders are treating their meetings as closed affairs.

Consortia are expected to be quite lean organisations, which will most likely outsource a lot of what they need to do to people who are lining up for the business.

Companies like KPMG and Tribal are already well in the frame for undertaking the hard graft behind commissioning. Some existing NHS staff in the 'clusters' will also probably create subregional 'commissioning offers' -- turning themselves into social enterprises to do this. A body called 'NHS Shared Services' is marketing services to manage collective purchasing and handle functions such as HR.

None of these players, undertaking crucial functions in the new landscape, will be directly accountable in any way to local stakeholders.

The great white hope offered for the public to have a voice is the Health and Wellbeing boards and local 'Health Watch' organisations which will sit within local authorities.

Plans for Health and Wellbeing boards are sketchy at present -- mainly because the Government is leaving the details for local players to thrash out for themselves. Mainly these are likely to be dominated by the institutional stakeholders though.

Questions also need to be asked about the capability and capacity of local 'Health Watch' bodies, as these will be based on the existing Local Involvement Networks (LINks). The problem here is that the position with LINks is patchy. In particular, it's hard to establish just how inclusive the existing organisations are. And do they really have the wherewithal to challenge the big hitters in the system?

I don't doubt that some of these questions will resolve in the fullness of time. However, given the number of times that the Secretary of State churns out the mantra that 'patients will be at the centre of everything the NHS does' you'd think it would be a bit easier to see how.


Welcoming LGBT History Month

February is LGBT History Month in the UK and I am one of the event's patrons. To mark the launch of the 2011 programme I recorded this video message.\

Ensuring that prioritisation doesn't mean discrimination

As with the previous post, this one is adapted from our public domain NHS Equality and Diversity Blog.

Ensuring that prioritisation doesn't mean discrimination

In the present operational climate many PCTs across the country are instituting short or medium term policies to defer or reduce referrals for a variety of conditions.

In some cases these involve forms of temporary embargo on referrals from GPs lasting only until the end of the financial year in March. In other cases more permanent policy changes are being proposed.

Policies like these must be impact assessed

Any policy changes of this nature must be scrutinised for any disproportionate impacts they may have on particular equality groups, and for the possibility that the measures may not be proportionate in those circumstances.

For example, a policy deferring or restricting hip replacement surgeries would be likely to affect older patients (and older women in particular) whilst having very little impact on the rest of the population.

Whilst the legitimate aim of the organisation may be to address a short term financial crisis, a policy that did not take account of this disproportionate impact could be subject to legal challenge through judicial review.

Outright bans and exceptional cases

The general position is that it is unlawful to operate any policy that amounts to a blanket ban on particular treatments unless, of course, the evidence genuinely indicates that there is little or no benefit.

Prioritisation through exceptional case review processes is acceptable. However the decision process in such instances must be rational, evidence based and must take account of the way in such policies may directly or indirectly affect specific groups more than others.

Where an exceptional case review is required then the policy must have a transparently fair rationale indicating what would constitute an exception.

Hard decisions in hard times, fairness and proportionality

Like everything else, commissioners need to consider whether the way the conditions are set may affect some groups more than others.

If the conditions are set in a way that no patient in a particular equality group (or overall) would be likely to qualify then these could be challenged as being equivalent to a ban in all but name.

The indications from the way that some of these policies are emerging around the country (as at December 2010) is that the necessary EIA scrutiny is maybe not happening in some circumstances.

Anecdotal evidence suggests that in some cases little or no consideration is being given to the impacts on affected minorities.

Ad-hoc or ill-informed assumptions may be made about the clinical need for some interventions, rather than taking account of evidence and best practice. Also the amounts actually saved could be small in proportion to the impacts on the communities most affected.

A policy where low volume, socially unpopular, cases were targeted could be challenged as discriminatory and irrational if higher volume "mainstream" needs were proportionately unaffected.

Working smarter, not harder

As all PCTs will be likely to be looking at the same range of treatments then it would make considerable sense for organisations to work collaboratively on impact assessment so as to avoid reinventing the wheel.

Individual PCTs may have their own commissioning and referral policies; however the impact of limiting access for particular groups is likely to be similar across large areas, and evidence gathering and consultation can certainly be done once and be shared, rather than repeating this.

Equality Impact Assessment and the BIG system changes

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

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

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

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

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

Scrutiny isn't unusual

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

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

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

Basic tests

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

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

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

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

Not academic

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

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

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

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

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

Scrutinising the transfer of community services

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

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

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

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

Don't assume zero impact without checking

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

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

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

Why we do it

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

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

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

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

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

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

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

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

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

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

The continued importance of Equality Impact Assessments

Welcome back to the Just Plain Sense Blog and I'm sorry that I've not posted anything for a year or so. The main reason for the gap is that the last year has been exceptionally busy, engaged in some groundbreaking work for my NHS Clients.

During 2010 I prioritised any time I had into producing new shows for the Just Plain Sense Podcast. However, I thought it was time to try and get back into the business of blogging too.

So here goes...

Whither Equality Impact Assessments?

I was asked recently whether the new Equality Act meant that public sector organisations needed to update their Equality Impact Assessment templates, or whether indeed there was still a need for the process under the new law.

My advice is primarily that  EIAs remain a useful (and arguably essential) methodology for doing what the forthcoming equality duty will require. I.e. You can’t do any of the things relating to identifying discrimination / adverse outcomes or promoting equality if you don’t have a tool for carrying out a gap analysis to begin with.

The difference is that whereas the previous statutory requirement was a bit of a blunt instrument, and led to people having to do EIAs on everything in sight and publishing them, we can all in future take a far more intelligent approach.

Lose the blunderbuss, keep the bullets.

The coming changes mean that that instead of everyone producing equality schemes (as the legacy equality duties required), we’ll be looking at a requirement for organisations to formulate prioritised outcome focussed action plans, targeting specific inequality areas each year. In the NHS, where most of my work is focussed, this will be linked with the proposed Equality Delivery System.

However, as I say, without the basic tools of investigation ... EIAs, desk research, consultation with Equality Target Groups, and targeted local research ... it wouldn’t be possible to say what those priorities need to be and whether the interventions you plan are fit for purpose.

This means that you might modify the design of your EIA templates to support the new process better, especially in terms of covering all the protected characteristics. You might also review how and when you carry out the assessment process. However, I don’t expect people to be ditching the methodology altogether ... it's too useful and informative for that.