Making EqIAs work: Assessing services and setting priorities

Equality Impact Assessments (EqIAs) don’t always make an impact. An innovative framework developed by Bradford Teaching Hospital NHS Foundation Trust’s head of Equality and Diversity shows how EqIAs can be used for service evaluation and real improvement.


Equality impact assessments (EqIAs) are an often used mechanism to encourage staff to consider what aspects of a proposed policy, or changes to services, might affect people from a disadvantaged group. For example, the process might raise the issue that a proposal to send text messages for appointment reminders would not be helpful for visually impaired people, so an extra phone-call for these people should be made. The aim is to ensure that policy and practice are fair for all potential users, and that any changes made do not negatively affect one group more than another.

Many organisations conduct EqIAs whenever there is a new policy, procedure or service, or if a service is being withdrawn. In recent years, they have been used when services are being decommissioned to make sure that the impact on a particular group or community can be mitigated. Often they are used as a rationale for keeping a service that targets a specific community.

While not a mandatory process, the guidance from the EHRC has changed recently to specify Equality Impact Analysis as opposed to Assessment, aiming to discourage organisations from just completing a ‘tick-box’ exercise, by filling out a standard form but instead to actually engage with evidence more explicitly, considering different factors appropriate to each different context. Standard templates have often been used in organisations for EqIAs, as in this example, but it is the process of examining the proposed change to policy or practice that is important, rather than the format of the EqIA itself.

When done properly, EqIAs can be an effective way to improve equality in a service delivery organisation, especially when they engage stakeholders in the process such as: managers, commissioners, front line staff, service users, or community representatives. EqIAs can also be a good way of demonstrating to senior decision makers why a proposed policy or change in practice would exacerbate inequality, and how it could be mitigated. While there is no set way to do an ideal EqIA, an example from Bradford Teaching Hospital Foundation Trust (BTHFT) shows how useful they can be, and provides an innovative approach to use these to assess existing services.

Assessing a whole organisation

Like most hospital trusts, BTHFT delivers hundreds of different services, from on-ward catering to complex surgery. Head of Equality and Diversity (E&D), Lorraine Cameron, wanted to find a way to assess all 179 recognised discrete services, as well as 201 policy documents, for potential equality issues. However, EqIAs are usually a very time-consuming process, taking days of work to complete, and much more time to ensure they are then used and change services. So Lorraine developed a spreadsheet which was essentially a mini-EqIA, that could be used to think through every service that was offered, and identify those likely to have issues that would warrant a full EqIA.

Lorraine worked with equality leads from each department, and discussed each service, including how it operated and whether there were likely to be equality issues for service users with each of the statutory protected characteristics. This discussion was a vital part of the process; making staff step back and think about how their procedures might have unintended effects on equality.

A scoring system was created in the spreadsheet, drawing on the knowledge and experience of the equality leads and service managers. This assessed: which protected groups could be adversely affected; what evidence and data existed on services might be relevant; and whether staff were already aware of equality issues from their experience or patient feedback. While this score was subjective, it allowed for comparisons with the other services that could quickly highlight the services that needed a full equality impact assessment.

In-depth analysis

One of the services identified by this process as being a priority for a full Equality Impact Assessment was the mobile breast screening service. Staff from this service team had previously contacted Lorraine for advice on responding more effectively to service users who had difficulty in communicating in English, and it was clear there were potential issues here to address. A working group was put together of service managers and staff, who were tasked with collecting as much evidence as they could. Data from complaints, patient feedback, locations of the unit, and service utilisation were examined for equality issues. All this evidence was collated in the EqIA document.

Immediately, two potential issues around minority ethnic groups came to light. First, the mobile unit could be placed in areas with a different ethnic mix to facilitate easier access from particular communities. Second, people attending with appointment letters were being turned away if they were unable to confirm in English their name and date of birth. If the service could make sure that an interpreter was booked for appointments with people who did not have English as their first language, patients would be saved a second trip, and costly wasted appointments could be avoided.

Using funding managed by the E&D lead, the group booked sessions with an experienced diversity trainer, to highlight equality issues with the staff, and to demonstrate the ease of using the telephone booking service for interpretation services.

Following up progress

Although definite, positive actions came from the EqIA process, there has so far not been capacity to do any follow-up work and see if services have been made more accessible. Part of the issue is in identifying outcomes that can be measured, and comparing them to the evidence collected at the time of the first EqIA. For example, an increase in use of the interpretation service could be a good indicator, or an increase in use of the service by people from particular ethnic groups. However it is clear that this work has not yet been fully mainstreamed within the organisation, as the work was not taken forward while the E&D lead was on sick leave.

Service managers and front line staff need to be persuaded of the value of ensuring equally accessible services, and given the means to measure improvement, so that successful changes can be celebrated. Until equality work is genuinely a core business of all health professionals, there will remain the need for experts and champions to lead and bring forward equitable services.

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