‘Everyone counts’ when it comes to health and care. That’s the latest thinking by the NHS Equality and Diversity Council, which sees reforms to support integration and greater patient and public involvement as an opportunity to build on collective strengths and find new ways to create a truly personal, fair and diverse care culture.
The concept of equality is nothing new when it comes to health and care. After all, the NHS was created in 1948 out of the ideal that good healthcare should be available to all, and based on core principles that the service should meet the needs of everyone, be free at the point of delivery, and based on clinical need, not the ability to pay.
The NHS Constitution published in 2011, reiterates the same basic aim of providing “a comprehensive service available to all … irrespective of gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy and maternity or marital or civil partnership status”.
The constitution also states that the NHS “has a duty to each and every individual that it serves and must respect their human rights. At the same time, it has a wider social duty to promote equality through the services it provides and 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”.
The aims may be the same after more than 60 years, but is the reality any nearer?
Shifts in focus
It has already been a long and winding road, with shifts in emphasis along the way. Initial equality legislation largely focused on eradicating discrimination in employment, education and training, with Acts of Parliament such as the Equal Pay Act 1970, the Sex Discrimination Act 1975 and Race Relations Act aiming to level the playing field between genders and to protect people from specific groups from harassment and discrimination.
These laws did cover provision of services, but it was not until the UK began complying with EU directives, such as the Disability Discrimination Act 1995, that there began a shift towards combating wider discrimination, with more emphasis on providers changing the way they deliver goods, facilities or services and manage premises to make them accessible to everyone.
The Equality Act 2006 and the creation of the Equality and Human Rights Commission (EHRC) in 2007 were perhaps the first real steps towards embedding equal opportunities and respect for people’s rights throughout society, while at the same time recognising and celebrating the differences between individuals. A specific EHRC goal was “mutual respect between communities based on understanding and valuing of diversity”.
The Equality Act 2010 pulled everything together (over 116 individual pieces of legislation) in a single legal framework to tackle disadvantage and discrimination, protect individuals from unfair treatment and promote a fair and more equal society. The NHS Equality and Diversity Council was set up in 2009 to implement the Act and raise the profile of equality and diversity in the NHS.
Fairness in practice
Now we’re seeing another shift in focus, in line with fresh thinking about what equality and fairness look and feel like in practice, and the barriers individuals face that can result in health inequalities.
A core principle of the NHS Constitution is that “everyone counts … Nobody should be discriminated or disadvantaged and everyone should be treated with equal respect and importance”.
Words like respect, dignity and choice have become firmly linked to the concept of equality. The focus is more on personal experience and the effect on individuals.
Reforms of health and social care in recent years – and the realisation that the two need to be considered in tandem – have no doubt played a part in prompting this new thinking.
The EHRC’s 2009 research into care and support looked at, among other things:
· Who could access state-funded care and who was excluded from it
· Whether the way care and support was delivered promoted equality and human rights
· The implications of the care and support system for carers and whether all carers were treated equally.
Personalisation the right direction
The conclusion was that the nature of care and support is moving in the right direction, particularly the potential of individual budgets and direct payments to enhance the rights of individual service users.
“Consultation with stakeholders – and evidence from the literature review – strongly suggests that the policy direction in relation to personalisation is exactly what is required in order to better promote equality and human rights,” says the report.
When set up in 2009, the Care Quality Commission (CQC) registration system was intended to move from purely systems and processes to an emphasis on people’s views and experiences. Outcome 1 of the CQC’s essential standards is: ‘Respecting and involving people who use services’, including recognising their diversity, values and human rights.
The Marmot Review in 2010 was another big step forward, with its exploration of social factors contributing to health inequalities, such as low income and poor housing. The resulting report, Fair society, healthy lives,pinpointed empowerment, enhancing people’s potential and protecting vulnerable groups among themes “significant to the task of reducing health inequalities”.
The Social Care Institute for Excellence felt that the Marmot Review made little reference to social care as a fundamental means of improving health and reducing health disadvantage, and produced its own briefing, highlighting examples of effective approaches in the care sector.
Impact of care intervention
The SCIE report points out that social care staff are in an ideal position to make a difference to those individuals and communities most likely to require help with their health and wellbeing.
The briefing says: “Social care services are by and large delivered to people with social and health disadvantage, a large proportion of whom are already ill and/or disabled. Social work and social care have established experience of working with marginalised groups, and may play an important role in promoting individual and community health and wellbeing. The value base for social work includes a focus on social justice, and individual development and empowerment, which may directly impact on the social determinants of health.”
But the SCIE warned that although social care interventions can reduce individual health disadvantage, to have an impact on health inequality they “must be adequately and sustainably resourced”.
The Health and Social Care Act 2012 has prompted further fresh thinking and new ways of working to support the health and system to promote a fair and inclusive culture.
The NHS Equality and Diversity Council aims to create and lead strategic discussions that will:
· improve understanding of how people’s differences can affect their experiences, health outcomes and quality of care
· inspire health and care organisations to go far beyond the legal duties required by the Equality Act 2010
· create health and care services and workplaces that are truly personal, fair and diverse for everyone.
One of the council’s new initiatives is to hold regular NHS Value Summits, to bring together patients and members of the public and healthcare leaders and frontline staff, so that they can explore and understand how people’s differences affect their personal experiences, quality of care and health outcomes.
Another way of raising and addressing challenges in promoting equality and tackling health inequalities at local level is the ‘Personal, fair and diverse NHS’ campaign by NHS Employers.
This focuses on the small but important things that individual health and care workers can do to help create services designed to give people what they want and need, offering real choice and where fairness is ‘built in’, everyone counts and is treated with dignity and respect.
The campaign aims to develop a network of champions but also to encourage staff to think about the contribution they can make on a day-to-day basis, such as providing a voice on behalf of people who find it difficult to make their views heard, learning more about the Equality Act and letting their employer know when they “see things that don’t feel right”.
The Personal, fair and diverse NHS campaign provides resources and tips you may find you can adapt to use in promoting good practice in your own care setting, like the ambulance service worker who visited mosques, churches and a synagogue to learn about how best to enter such buildings in an emergency or the NHS trust that developed a protocol for providing services to transgender patients. Visit http://www.nhsemployers.org/employmentpolicyandpractice/equalityanddiversity/creatingpfdnhs/Pages/Signuptoday.aspx to find out more.