Equality & Inclusion Business Fundamentals

Learning outcomes Understand the legislative requirements and duties. Understand the diverse needs of our population. Understand why we focus on health inequalities. Know how and when to undertake an EqIA. Understand the implications for Staff, Directorate & CCG.

Section 1 - Legal Duties

Clinical Commissioning Groups Key role in addressing equality and health inequalities As a commissioner As an employer As a local NHS system of leaders Creating high quality care for all

Equality and Health Inequality Duties for CCGs as public bodies set out in: Equality Act 2010 Health and Social Care Act 2014 Other relevant legislation includes: The Public Service (social value) Act 2012 The Autism Act 2009 The Children’s Act 2004

Equality Act 2010 The General Duty Eliminate discrimination, victimisation, and any other conduct prohibited by the Act Advance equality of opportunity between persons who share relevant protected characteristics and persons who do not. Foster good relations between persons .

Equality Act 2010 The Public Sector Equality Duty (PSED) Publish information at least annually to demonstrate compliance with the equality duty. Information about employees (150+ staff) Prepare and publish one or more specific and measurable equality objectives at least every four years.

Purpose of PSED Help public bodies be transparent and accountable. Ensure public bodies make decisions based on robust evidence, understanding the potential effect on members of the community in relation to: Health outcomes Experiences of patients, communities and workforce

Responsibility and Due Regard CCGs can not delegate responsibility for compliance. CCGs can not consider equality retrospectively to comply with the PSED. CCG’s must demonstrate due regard.

Due Regard Brown Principles ‘what is important is not the preparation of a particular document but that decision makers give proper informed consideration at the right time and that they keep a record of that consideration’ Equality analyses / Equality impact assessments (EqIA) are one of the many ways of demonstrating due regard. The findings of EqIA should be able to influence decision making.

Protected Characteristics / Groups Age (all age groups) Disability – (physical , mental , sensory, LTC , HIV , MS etc) Gender Reassignment. Marriage and Civil Partnership. Pregnancy and maternity. Race – language, culture, colour, nationality Religion or belief – including lack of belief. Sex (man or woman) Sexual Orientation.

Health and Social Care Act 2012 First legal duties about health inequalities Specific duties for CCGs to have due regard to reducing avoidable health inequalities between the people of England. NHS Five Year Forward view sets out need to address health and wellbeing gap and prevent further widening of inequalities.

Health and Social Care Act 2012 Reduce inequalities between patients in access to health services and the outcomes achieved. Ensure health services are provided in an integrated way where this would improve quality, reduce inequalities in access and outcomes. Set out how the CCG proposes to discharge its duty to reduce inequalities. Include an assessment of how effectively it has discharged its duty.

Health Inequalities WHO: ‘differences in health status or in the distribution of health determinants between different population groups’ NHS constitution: ‘NHS has a duty to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population’

Summary CCGs as an organisation must: Demonstrate compliance with legal duties Consider (and record) the impact on people with protected characteristics and on inequalities as part of all decision making processes. Set out how it will discharge its duties and publish the outcomes annually.

Summary Commissioners in discharging their roles will therefore need to demonstrate: An understanding of the needs of local population. Identify local inequalities in outcomes / access and experience and commission for the population. That they have considered best practice and can evidence of what works in reducing inequalities. Use equality impact assessments as a tool to record and evidence Due Regard.

Section 2- Our population

Our local population Population can be segmented in different ways: Aggregated picture is the one in slide however Sandwell population is different to Western Birmingham.

Our local population

Our local population Ethnicity Sandwell % West B’ham % diff White British 65.8 20.1 -45.7 Pakistani or British Pakistani 4.5 15.9 11.4 Black/British Caribbean 3.7 11.2 7.5 Bangladeshi, British Bangladeshi 2.1 8.4 6.3 Indian or British Indian 10.2 16.0 5.8 Black/British African 1.4 5.6 4.2 Black/British: Other 0.8 2.9 Other Asian 2.4 Mixed/multiple ethnic group 3.3 4.9 1.6 Chinese 0.3 1.3 Other ethnic group Other White 3.4 4.1 0.7 White Irish 1.2 0.5 Other ethnic group: Arab 0.4

Our local population One of the 20% most deprived areas in England 30% of children live in low income families. Life expectancy is 6.8 years lower for men and 6.6 years lower for women

Healthy Life Expectancy Our CCG features in the bottom top when ranking healthy life expectancy

Healthy Life Expectancy Our CCG features in the bottom top when ranking healthy life expectancy

Healthcare literacy In 2016/17 the CCG commissioned interpreting for over 28,000 patients in Primary Care, covering almost 100 different languages

Wider determinants Social determinants Employment Housing Poverty Education Isolation Lifestyle and behavioral determinants Smoking, alcohol, weight management Action on health inequalities requires action across all the social determinants of health, including education, occupation, income, home and community

Peers Our peers are demographically similar. NHSE develop data packs to identify opportunities to improve healthcare in populations

Patient drivers Protected characteristics and specific need Vulnerable groups face ‘double whammy’ effect . Accessing services and over coming barriers (e.g. information) Vulnerable groups are most at risk of facing poor outcomes due to circumstance. Patients may feel they are not as well served by the NHS as they should be Patients with protected characteristics have specific needs and circumstances Accessing services may become a barrier for patients especially there is a change to the way services are commissioned Information about services needs to made accessible Vulnerable groups are most at risk of facing poor outcomes due to circumstance.

Equality and inequalities As a commissioner you need to consider: Diversity within and between groups. Variation in health outcomes – do all groups receive the same intended outcomes? Variation in access – Are all groups able to access the services in the same way? Variation in experience – Do all groups experience the services in the same way? How will you measure any of the above? How do we compare to our peers?

What is required? Commission the right services first time. Evidence informed decision making. Understand which groups are accessing or not accessing services & how this impacts health outcomes. Listen to our local population - Engage and involve stakeholders. Models of care that are universal but pathways that meet diverse needs. Consideration of health inequalities into commissioning decision helps to decisions more robust Develop local insight and evidence to inform service improvement Put in place models of care which serve the needs of a diverse population. Reduce the gap in inequality

Questions Commissioning decisions Access Evidence Service design to meet diverse needs Develop local insight and evidence to inform service improvement Put in place models of care which serve the needs of a diverse population. how do we design services for these groups? Accessing services may become a barrier for patients especially there is a change to the way services are commissioned protected characteristics are doubly disadvantaged Action on health inequalities requires action across all the social determinants of health, including education, occupation, income, home and community

Thoughts on what you heard How does this relate to your role? Questions Thoughts on what you heard How does this relate to your role? Feedback; Consideration of health inequalities into commissioning decision helps to decisions more robust Develop local insight and evidence to inform service improvement Put in place models of care which serve the needs of a diverse population. how do we design services for these groups? Accessing services may become a barrier for patients especially there is a change to the way services are commissioned protected characteristics are doubly disadvantaged Action on health inequalities requires action across all the social determinants of health, including education, occupation, income, home and community

Section 3 - Lets go Shopping

Lets go Shopping: Break into smaller groups Discuss scenario and answer questions on flipchart Group Feedback 30 mins total

Scenario learning One size does not fit all. Understanding more about your population provides better insight into commissioning the right services. Reliable sources of evidence help to inform your decision making. Engagement should be targeted and timely. Measures of success / outcomes should be the same.

Section 4 Equality Impact Assessment Process

Equality Impact Assessment (EQIA) Process How to follow the EQIA process Sources of evidence Best practice

Principles Proportionate Evidence-based Integrated Timeliness Responsibility Governance Proportionate ; to contract value /to political impact / to patient impact . The more political the more robust your governance. The higher the contract value the more robust the evidence base Evidence based: Integrated : into commissioning process Each stage may require an EQIa to inform the decision making process and should build up the picuture of DUE REGARD e if you are Timeliness – must be planned to inform decision making Responibility – see table below Governancy – part of good governance. Any risks (negative impact ) that can not be mitigated must be recorded on the risk log.

Process

Impact

Questions to ask yourself What is the purpose of the service/policy? What is the intended outcome? Who is affected by the service/policy? Which groups may experience a negative/positive impact and why? What are your sources of evidence/data/consultations? Are there any gaps? What action needs to be taken to reduce negative impacts?

Responsibility for EqIA   Purpose of Equality Impact Assessment (EQIA) Commissioning Approach EQIA to inform the development of new service EQIA to inform review or evaluation of existing service EQIA to inform decisions to disinvest or substantially change an existing service. CCG commissioned Service CCG officers CCG has delegated authority to commission a service CCG is a partner in a jointly commissioned / funded service but NOT the lead commissioner Lead Commissioner of joint Service. CCG should be engaged in process Lead commissioner of joint service. (impact of disinvestment / change to service where proposed by the CCG) CCG is a partner in a jointly commissioned / funded service and LEAD commissioner Partners should be engaged in process

Sources of evidence CCG Business Intelligence Team Contractual Data collected/Service Outcomes – Historical Information NHSE Rightcare -  comparison with peers https://www.england.nhs.uk/publication/similar-10-ccg-explorer-tool/

Sources of evidence Health Profiles on FingerTips https://fingertips.phe.org.uk/ Kings Fund research on health inequalities https://www.kingsfund.org.uk/publications?f%5B0%5D=topic%3A8137 Aristotle

Best practice Prioritise Plan Get the basics right Make it core business Ensure good governance of decision making Engage and Involve everyone Monitor & Review Keep a record.

Section 5 - Scenario

Scenario 1: Aim: To commission a mental health and well being service across the CCG footprint . The contract value is in the region of £1.5 million. a) What sources of information will you use and why? b) Who will you engage with and why? c) How will you know if needs have been met?

Local evidence suggests… Suicide rate in SWB is higher than the national average A recent local report revealed significant barriers exist within the Sikh community (when talking about mental health experiences) PCCF data for 2016/17 reveals disparities in GP recording of alcohol related harm. https://twitter.com/bbcmtd/status/996760125296857088 http://www.britishsikhreport.org/british-sikh-report-2018/

Best practice reminder Prioritise Plan Get the basics right Make it core business Ensure good governance of decision making Engage and Involve everyone Monitor & Review Keep a record.