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Embedding ethnic equality in commissioning practice

Name, date, contact

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Introduction

This is a tool from the Evidence and Ethnicity in Commissioning project (www.eeic.org.uk). It is a flexible template, designed to be modified to present the case for considering minority ethnic health issues to colleagues and board members.

Findings from the EEiC project, plus other research and practice experience, tell us that many key actors within the commissioning arena do not view tackling ethnic inequalities as a top priority. These people may question the importance of the agenda, or see it as a luxury that can not be afforded. There is a tendency for some commissioners to view this area as the responsibility of provider organisations, or to question whether it is right to give 'special' attention to particular groups. Many commissioners also lack confidence, skills and knowledge to adequately describe, understand and address the causes of poor service access, experiences and outcomes. At the same time, individuals who are committed to addressing ethnic inequality, whether within or outside of commissioning organisations, can be isolated and struggle to influence the commissioning agenda.

Making progress towards better services for minority ethnic people requires a wide range of stakeholders to make a more consistent and convincing case for why this work is important, and how it can support other core commissioning priorities, including quality and efficiency, rather than complicate or undermine other work.

Individuals who are committed to this agenda need to identify opportunities to argue for why understanding and addressing ethnic inequalities should be part-and-parcel of commissioning work. These opportunities may arise in a variety of settings, both formal and informal.

This powerpoint template is designed to be adapted for your local context. It should help you make a strong case: for considering ethnicity when commissioning health services; bolstering attention in service redesign; securing funding for additional services; or even setting policy and guidance.

It will be helpful to identify contexts where such a presentation may be helpful and impactful. For instance, you might be able to book a slot on the agenda of senior team meetings or partnership boards, or request time to speak to a group of GPs at their practice, or a consortia of third sector organisations. It will be useful to discuss with like-minded colleagues what the objectives of the presentation should be.

Depending on the audience and your objective, you will then need to consider which parts of the presentation are important and where changes/improvements might be needed. You may want to alter some of the language and ensure that the presentation has a local focus.

Many resources can help you access local evidence and examples to customise the presentation: including Public Health analysis; data from your local Trusts; your JSNA; information from user satisfaction surveys; local research studies; insight work, and information collected by third sector organisations that work with minority ethnic communities. Examples from the EEiC project (www.eeic.org.uk) and other on-line resources such as http://needlibrary.info/ can provide more general examples.

You may also find it useful to read through the list of 'nightmare questions' and possible answers available on the EEiC website, so that you are ready for issues that may be raised, and to change the title to make sure it links to local objectives and is 'jargon-free'.

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What is ethnicity?

Common physical and cultural characteristics, shared values and history�
Affects health and healthcare via several routes:��- structural (exclusion; poor access to resources)�- cultural (risks; responses; healthcare experiences)�- biological/genetic factors

Fluid and dynamic, complex identities, variation within and between ethnic 'groups' (age, gender, generation, class, religion), BUT important axis of difference and disadvantage

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What is the issue?

We live in a multi-ethnic society; ethnic diversity is increasing; 8.7% in 2011, 14.0% in 2011

Ethnic identity impacts on health through varied routes

Health services should mitigate wider disadvantage, but can make things worse

Inequalities in access, experience and outcomes

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Local ethnic profile

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Why does this matter?

Commissioning has a key role in addressing unmet need and driving up standards of care. BUT, to-date, impact on inequality very limited.�
Legal duty to proactively identify and reduce inequalities (2010 Equality Act)
Morally right thing to do
Equity is core to the NHS constitution
Closely linked to other key commissioning drivers:�► Quality�► Efficiency�► Health Inequalities
YET, remains a side-lined concern with limited resource and expertise

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"Equality must be at the heart of the NHS. Each of us has a responsibility to ensure that care is high quality, personal and fair"

Sir David Nicholson, Chief Executive of the NHS

"A better NHS that: is genuinely centred on patients and carers; achieves quality and outcomes that are among the best in the world; refuses to tolerate unsafe and substandard care; eliminates discrimination and reduces inequalities in care"

Equity and Excellence, White Paper (Our vision for the NHS)

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Local examples : service access

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Insert here some local examples of differential access to healthcare services: there are lots of examples of ethnic inequalities in access to preventative, primary, and secondary care and treatments.

Uptake of screening, access to life-style interventions such as smoking cessation, access to rehabilitation services for cardiovascular diseases, access to self-management interventions for diabetes and other long-term conditions, and access to social care support services are some common examples where minority ethnic groups are often under-served.

The data presented here were produced by a public health analyst using national prevalence data and local population statistics. Similar patterns have been reported in other places.

It shows inequalities in access that are normally invisible: Rates of cardiac conditions are much higher in this ethnic group, but fewer people are accessing life-saving treatment. This demonstrates unmet need, and there is a need to understand in more detail the factors that lie behind this inequality.

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Local examples : service experience

“The GP will give more time to White patients but not to people from Somalia and Bangladesh. He treats them like shit”.

"Never contact the doctors at the hospital by phone, always in writing..You can't trust them. It is the way the professionals talk to you or deal with you because they don't understand our culture and our norms."

Local service user

Local carer

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Local examples : health outcomes

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Local examples: inefficiencies

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Local examples: a marginalised concern

"There’s a mind-set that says if we do anything for BME communities that’s on top of what we already do, rather than what we already do should incorporate the needs of BME communities"

(Local commissioning manager)

Annual Quality Report, 2010/11, references to equality, ethnicity, or ethnic inequality = 0

CQUINS with ethnicity focus/breakdown = 1/47

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What should healthcare �commissioners do?

Ensure that existing services and interventions provide equitable access, experiences and outcomes for all service users and carers regardless of ethnicity.�
Ensure that any transformational work pays detailed attention to the potential negative impact on particular ethnic groups.�
Examine the fit between existing services and minority ethnic health needs and respond to significant gaps.

Shift spend towards prevention and early intervention.

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What are we already doing?

... TBC ....

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What more could we be doing?

Mainstream attention across all our work.
Use Quality resources and infra-structure to tackle ethnic inequality.
Investing in a BME user forum that gives meaningful and consistent input to the commissioning process e.g. Westminster

...... TBC ...............

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What would be the benefits?

Legal compliance
More efficient use of resource
Progress towards key targets
Reduced risk of serious incidents
Reduced risk of challenge from local communities
More flexible and responsive �services
Better health for all!

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Stress both the rewards and the risks. Keep a balance between challenging and empowering.

You may have some specific examples to include here.

Perhaps example of local organisations taking issues to Scrutiny Committees.

At a national level, maternal deaths are higher among Black women, particularly new migrants, and have been linked to poor communication and late access to services.

Remember: the Equality act of 2010 requires public services to be able to demonstrate how they are providing equitable and accessible services to all the 'protected groups'. Technically, the Care Quality Commission (CQC) and the Equality and Human Rights Commission (EHRC) are able to challenge public bodies not meeting these duties.

Again, it's helpful to stress that reducing ethnic inequalities in health can help organisations meet all their quality and efficiency priorities

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Some key questions to consider

What factors obstruct such mainstreaming?

Who is responsible for leading on this agenda?

What role should other people be playing?

What resources/strengths can we build on?

What are we going to do next?

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