Improving the Health of the Scottish Minority Ethnic Communities

FAIR FOR ALL PROGRESS REPORT

INTRODUCTION

It is a founding principle of the NHS that everyone is entitled to fair access to health care and has the right to opportunities for better health. This is also reflected in the Government's commitment to reduce inequalities in health. Whilst numbers within ethnic minority communities in Scotland are small (and are particularly low in rural areas), it has been accepted that numbers alone cannot be the basis for setting health priorities. The McPherson Inquiry into the death of Stephen Lawrence gave an added impetus to tackling inequalities more generally, and the effects of racism on ethnic minority health specifically.

In February 2000 the Scottish Executive Health Department commissioned a comprehensive stocktake to examine the extent to which NHS Boards and Trusts were delivering culturally appropriate services to ethnic minority communities in Scotland. The Fair For All stocktake revealed that, while much good practice existed on an ad-hoc basis, there was still some way to go in planning and developing a culturally competent NHSScotland in partnership with communities.

This report provides a summary of the progress being made by NHS organisations in implementing Fair For All. As the report will show, there has been considerable progress in many areas, but much remains to be done.

Fair For All does not exist in a vacuum and it is important to recognise the main external influences which impact on work with Scotland's minority ethnic communities. For example, since the publication of Fair For All, the government has developed a range of new policy initiatives which are directly relevant to work in this area, including a recent Health White Paper Partnership for Care published in March 2003.

At a wider level, the Race Relations (Amendment) Act 2000 placed a series of duties on health organisations, and, by the end of November last year, each had produced a Race Equality Scheme and Action Plan. Much of the detail of this report draws upon organisations' Schemes and Action Plans. Scotland itself is also changing. Since 2001, the ethnic mix of Scotland's population has changed (and continues to change), most noticeably in Glasgow, with the presence of just under 10,500 asylum seekers and refugees (Primary Care Trust Asylum Seekers and Refugee Co-ordinating Group 2003).

This report is in four main sections:

The first section provides a summary of the main strands of the Fair For All agenda and the key challenges identified.
The second section provides a summary of some of the key external influences on the Agenda and work with minority ethnic communities.
The third section summarises the progress made by the NHS so far.
The fourth and final section sets out our assessment of both the progress made and the key work which remains to be undertaken.

There are two Annexes to this part of the report. The first (Appendix C) provides a more detailed thematic summary of the assessment of Fair For All Action Plans, and is, in effect, the raw material upon which much of this report is based. The second (Appendix D) provides a summary of the progress made by each of the NHS Boards.

SECTION 1: FAIR FOR ALL

The Fair for All stocktake assessed not only whether there were any specific well defined health policies for ethnicity and health within Health Boards and Trusts but also what quality of health services and employment opportunities were available to minority ethnic groups. Issues of access and appropriateness of services are also relevant to many other groups (for example people with mental health problems, disabled people). Addressing these issues will bring benefits to the whole population.

The key findings of the Fair For All stocktake

The Summary Report published by the Scottish Executive provides a useful summary of the key findings as follows:

Health Boards and Trusts were at very different stages in responding to the health and service needs of ethnic minority communities.
The priority accorded the issue has been low in some areas. This is as a direct result of the relatively low visibility of ethnic minority communities and the wider pressures on resources.
While some NHS organisations had undertaken some good project development work, many were in the early stages of acting on ethnic minority health issues and concerns.
In rural areas a 'colour-blind' approach to ethnicity and culture may result in services that fail to reach ethnic minority people or meet their needs.
There were examples of good practice and these should be drawn on more widely by NHSScotland in developing models of good practice that are systematic rather than piecemeal.
The service needs a strategy for progressing on a number of fronts, rather than addressing ethnic minority health problems through one-off projects.
NHS staff are keen to build ethnic minority issues into mainstream organisational processes. This will also help to address resource issues.
The stocktake has acted as a catalyst for a wide range of NHS organisations to begin thinking about how they address ethnic minority health needs. ¹

The key challenges identified in Fair For All

The key challenges identified include:

Equal opportunities

Chief Executives must ensure that policies, procedures and practice are not discriminatory.
Race equality and diversity issues must be integrated into recruitment and training strategies as well as equal opportunities policies.

Leadership

As legally responsible officers, Health Board and Trust Chief Executives must provide culturally competent services, charging a senior lead individual to undertake the necessary work.
Senior members of Executive teams of Health Boards and Trusts must take responsibility for delivering culturally competent services, charging a senior operational manager to ensure effective implementation.

Strategic planning

Chief Executives must ensure that there is a Strategy and Action Plan in place to address minority ethnic health concerns. This includes meeting the health needs of refugees and asylum seekers.

Accountability

Health Boards and Trusts will be held accountable for developing a partnership approach and links with local minority ethnic organisations, including utilising their services where appropriate.
Health Boards and Trusts will be held accountable for ensuring information and communications are tailored to multi-cultural needs.
Health Boards and NHS Trusts will be held accountable for achievement on race equality; monitoring and evaluation of policies and practice is essential.

Awareness and assessment of needs

Chief Executives must ensure that multi-cultural awareness, and sensitivity to minority ethnic health issues, are integrated with mainstream organisation planning processes.
Chief Executives must ensure that there is a fuller understanding of local minority ethnic health needs and improved responsiveness to those needs.

Developing practice

The Scottish Executive Health Department must work with all the professions to ensure that practice becomes more culturally sensitive.

Delivering the Fair for All agenda

Implementation of the Fair for All agenda was promoted in the NHS HDL (2002) 51 published in June 2002 setting out a three-year programme of targets. This HDL laid out guidance to all NHS organisations in Scotland. Figure (3) summarises the five strands emphasised in the HDL.

diagram

Figure 3: The deliverables reflect the five major strands of policy developed in the Fair For All framework and the HDL (51) .

¹ These bullet points are taken from Fair for All Summary and Recommendations, Scottish Executive, December 2001

SECTION 2: THE WIDER CONTEXT

Although Fair for All is the Executive's main health-related policy guiding work with Scotland's minority ethnic communities, there are other policies which impact upon this work. For example, the Scottish Executive, in Our National Health: A Plan for Action, A Plan for Change (published in December 2000), gave a commitment to:

'... ensure that NHS staff are professionally and culturally equipped to meet the distinctive needs of people and family groups from ethnic minority communities.'

More recently, the Health White Paper Partnership for Care (published in March 2003) stated emphatically that:

'We have been working to ensure that the needs of ethnic minorities and refugees in Scotland are being effectively met, by implementing Fair For All. We believe there is also a need for a more coherent approach within NHSScotland to meeting the needs of disabled people. In this European Year of Disabled People, we will extend the principles set out in Fair For All across the NHS to ensure that our health services recognise and respond sensitively to the individual needs, background and circumstances of people's lives.'

The European Convention on Human Rights (1998) places a positive obligation on public authorities to ensure that respect for human rights is at the core of their work. This includes ensuring that, for example there is no racial discrimination in

the drafting of rules and regulations;
internal staff and personnel issues;
administrative procedures;
decision-making;
policy implementation; and
interaction with members of the public.

The Race Relations (Amendment) Act 2000 places a statutory duty on public authorities to promote race equality in carrying out their functions.

There are many other drivers for equality in NHSScotland including:

The Sex Discrimination Act (1975)
The Disability Discrimination Act (1995)
The Human Rights Act (1998)
The Data Protection Act (1998)
The Scottish Executive's Equality Strategy 2000
Spiritual Care HDL 2002 (72)
The NHS Reform Bill (based on Scotland's Health White Paper Partnership in Care 2003)
The Patient Focus/Involving People Strategy 2001.

The changing composition of Scotland's minority ethnic population

The 1991 Census showed that the minority ethnic population of Scotland was approximately 1.3% of the total population. At April 2001, the overall proportion of Scotland's population recorded as being minority ethnic was 2.01%. Simple proportions do not, however, provide a complete picture. For example, just over 55% of the minority ethnic population is aged 30 or under, compared with just over 36% in the population as a whole. Within minority ethnic communities, just under 7% are aged 60 and over compared to 21% in the whole population. The 'youngest communities' are Bangladeshi followed by Pakistani and other South Asian communities.

Glasgow had, at April 2001, 31% of the total Scottish ethnic minority population. This represented 5.5% of Glasgow's total population, compared with 4% in Edinburgh, 3.9% in East Renfrewshire, 3.5% in Dundee and just under 3% in Aberdeen and East Dunbartonshire.

The picture of Glasgow in particular, but also in other parts of Scotland, has been changing significantly over the past few years, with the arrival of asylum seekers and refugees. Just under 10,500 people are registered with designated local GPs in Glasgow, and, about 45% are staying in the city as a settled community after achieving asylum seeker or refugee status.

In most urban areas the largest minority ethnic community is Pakistani, but in rural areas like Ayrshire and Arran, the Borders, Grampian and Dumfries and Galloway, the Chinese community is larger in number. (Census data 2001)

Gypsy/Travellers were not listed as a separate group under ethnic origin in the 2001 census. In the Scottish Executive's first report to the Equal Opportunities Committee in June 2001, the Scottish Gypsy Traveller Association (SGTA) was quoted as stating the numbers were between 10,000 and 15,000. In the Scottish Executive's Central Research Unit report 'Moving On' (2000), the Scottish Office official count in 1999 indicated a total population of around 1800 in winter and 2200 in summer but underestimates those Travellers using unauthorised roadside camps or settled in housing. It is thus very difficult to gain an accurate picture.

Religion, housing, economic activity, educational attainment and employment as well as long-term illness and car ownership are available from the Census 2001 data.

SECTION 3: NHSSCOTLAND'S RESPONSE TOWARDS RACE EQUALITY AND CULTURAL COMPETENCE

Appendix D provides clear evidence of leadership on this issue, within the wider context for progressing equality issues throughout NHSScotland. Good practice models are being identified, and a few Boards have recruited dedicated staff to drive the agenda forward. This organisational commitment will in turn enable more effective policy to be developed and implemented. This evidence is summarised below.

Race Equality Schemes and Action Plans

Boards and Trusts were required under the Race Relations (Amendment) Act 2000 to produce a Race Equality Scheme by 30 November 2002, and by the HDL and Fair For All to produce an Action Plan to follow by 31 March 2003. The Schemes lay out the arrangements for meeting the General and Specific Duties laid out in the RRAA 2000. The Action Plans contain detailed, dated and costed arrangements for continuing progress towards cultural competence.

NRCEMH staff, particularly the Project Policy Manager and the Director, have provided support and guidance to NHS Boards and Trusts in development of Race Equality Schemes and Action Plans.

The Joint National Assessment Framework developed in partnership with the CRE is being used to show how the Schemes and Action Plans can be improved, and to identify gaps, particularly in terms of legal requirements.

National Review: summary and objectives

Independent consultants, commissioned jointly by NRCEMH and the Commission for Racial Equality (CRE), have conducted an analysis of all these Schemes and Action Plans to ensure that they fulfil their purpose.

The final report of this project, due to be published in September 2003, will offer guidance regarding the development and implementation of the actions proposed in the Schemes. The intention is to assist Boards and Trusts in refining and implementing their Action Plans and their Schemes.

In addition, the National Review highlights where national guidance on policy could be produced to avoid duplication of effort and to maximize sharing of resources and experiences. Through the Policy Network, NRCEMH will now begin to prioritise the need for guidance in the following areas:

i. Consultation: there is considerable work to be done on consultation with both minority ethnic users and carers but also with staff, in particular minority ethnic staff. Particular focus should be given to access and representation issues and power imbalances.
ii. Community development: guidance on capacity building and skills to enable more effective participation in decision making from planning to delivery and evaluation; and in the establishment of a consultative forum.
iii. Service provision: identifying barriers, raising awareness and meeting specific needs in areas of diet, spiritual care, interpreting and translation and advocacy. Guidance on these areas is urgently required.
iv. Human resources: this is considered to be one of the weakest areas, and there is, therefore, a need for guidance on positive action measures and inclusion of under-represented staff.
v. Procurement: many organisations are now beginning to contract out, and hence there is a need to meet the requirements of the RRAA and Fair For All.
vi. Impact assessment: Boards and Trusts require considerable support for carrying out race impact assessments. This is linked to the need to consider outcomes and benefits for stakeholders work of promoting good relations between people from different racial groups.
vii. Audit tools and performance indicators: national assistance is required in helping health organisations set practical targets where progress can be measured on both a short-term and long-term basis

SECTION 4: CONCLUSION PROGRESS TO DATE

We have compared the stocktake undertaken as part of Fair For All in 2000 with the Fair for All Action Plans prepared in 2003 (APPENDIX D) as summarised below:

The overall NHS response

There was confusion about the separate requirements of policy (HDL) and legal (RRAA) drivers.
There was also some resistance due to insufficient preparation in the early stages to enable greater understanding and 'buy-in'; Boards were juggling a number of priorities and had difficulties focusing limited resources on 'ethnicity', especially where race equality was not perceived to be a problem (due to small numbers, etc.).
There were fears around non-compliance and possible repercussions from CRE.
There was a lack of understanding of institutional racism and discriminatory practice.
There was a lack of awareness of, and trust in, NRCEMH as a mechanism for support and assistance.
There was a belief that it was more a 'paper-pushing' exercise, and was, therefore seen as an administrative burden rather than anything more positive.

Progress against expectations

Production of Race Equality Schemes and Fair For All Action Plans completed largely on time.
Analysis of Fair For All one year on indicates clear progress from most Boards.
There is evidence of strong commitment from the top in most Boards, although progress is clearest in those Boards which either recruited dedicated staff, or where the Chief Executive was particularly enthusiastic.
Additional support has been agreed by Scottish Executive to develop specific pieces of work which will help develop the evidence base and feed into national guidance.

Interaction with NRCEMH

In the early stages of its life, it was crucial that NRCEMH's Director was known and respected by those executives leading on the development of Race Equality Schemes and Fair For All Action Plans; NRCEMH's three project managers were completely new and had to take time to build the contacts.
Over the past 10 months, awareness of NRCEMH and its staff has grown considerably; there is also evidence of a greater willingness to approach NRCEMH for advice.
There is still some level of frustration that NRCEMH is not seen to be delivering as quickly as would be wished (although there is a conflict between short-term wins and long-term strategy).
Initial concerns that the NRCEMH's staff have an 'inspection' role have largely been dissipated and they are now viewed more as facilitators and encouragers.

Networks

There was an initial lack of commitment to the Lead Network demonstrated through a lack of attendance, inconsistency of representatives, etc.
There was also some misunderstanding of the leads' individual roles in developing the work and in feeding back to their organisations although this has improved considerably in last few months. This is largely due to the individual visits to Boards which have proved essential in building stronger working relationships.
NRCEMH's work plans highlight the three main networks on Policy, Training and Information. (These are included at annexure C). In addition, the themed networks have begun their work, facilitated by secondees from Boards and Trusts and overseen by the Project Managers.
There is a need to clarify the membership of these groups and ensure that representatives from Boards and Trusts who attend them have or develop the necessary expertise.

Challenges

Political agendas are rapidly changing, particularly in terms of the EU Directive and work towards a single Equality Commission.
There is a risk that the agenda becomes too big and that NRCEMH spreads itself too thinly.
Race equality needs to sit firmly within the diversity and social inclusion agenda, whilst ensuring that the issue does not become diluted or marginalised.
Similarly, there is a need to broaden the focus from service delivery issues (e.g. diet, spiritual care, interpreting) to addressing institutional discrimination at all levels, but in particular in the area of human resources.
Communication both within Health Boards and in relation to their Trusts needs to be strengthened as the providers sometimes have little or no knowledge of the developments that are taking place.
It will be essential to ensure change on the ground and to identify and implement ways to measure this.

Actions arising

In our plans to implement the Race Relations (Amendment) 2000 Act and the Fair For All deliverables, and in consideration of our broad priorities of Policy, Training, Information and Community Development; it would appear that:

There is a need to develop an increased awareness of NRCEMH minority ethnic communities, particularly through the Consultative Forums established by Boards, and also by involving representatives on networks.
There is a need to increase opportunities for sharing and stimulating good practice, particularly at regional level or through twinning opportunities for Boards.
There is a need to produce more national guidance, perhaps in form of 'do's and don'ts' or checklists.
There is a need to ensure closer working with national agendas around diversity and patient focus, and public involvement.
There is a need to develop performance indicators and targets which can measure change in practice.
The need for a website has been identified.
There is a need to strengthen regional networking of Health Boards this process has begun in the West of Scotland.
In response to National Health Boards which have Scottish wide responsibilities, collaborative working on a similar basis to Health Boards will be encouraged.

Conclusion

One of the major goals for the NHS in Scotland is to deliver a sensitive and an integrated service for all its communities. Our environment is dynamic and constantly changing. Scotland is becoming an increasing diverse and multicultural society. This in itself brings great opportunities but also presents challenges to all of our service providers, including NHSScotland. We have seen considerable good-will to address both institutional and personal discrimination but need to develop the necessary skills, and access the necessary resources, to tackle these and associated challenges more effectively.

The NRCEMH is just over one year old, and the Fair for All Guidance Letter was issued less than 18 months ago. All the excellent progress made in this period owes a great deal to the myriad of people already working in a highly committed and dedicated way in the field. The new infrastructures have been able to add momentum to the work, place it within a wider policy context, and bring it to attention. We sum up the overall progress as follows:

A national infrastructure is now in place through which NHSScotland will operate, e.g. networks.
Principles and values have been clarified, e.g. a commitment to involving the communities.
Partnership working has been developed (with the main stakeholders identified and brought into the process).
NRCEMH is developing a clear identity within NHS Health Scotland which we hope will encourage greater use, give confidence and facilitate awareness of its work.

In the last 18 months, utilising political will, managerial drive, challenging but specific guidance and legislation, and widespread goodwill within the NHS, Scotland has made considerable progress in tackling the formidable policy and strategic challenges posed by the goal of creating a health service responsive to the needs of a multi-ethnic, multicultural society. If this momentum is to be maintained, the strategy must be seen as long-term and needs to be focused on the highest priorities. There is no room for complacency because in relation to the hardest task, the implementation of plans, we have just started.

The pivotal role of the NRCEMH is evident already. One of the many key challenges for the next year is strengthening the infrastructure within unified NHS Health Boards, including, of course, the associated successors to the Trusts. Developing the links with Community Health Partnerships and other challenges will involve the continuing support of the Scottish Executive.

This report highlights the very new, exciting opportunities to support the development of a culturally competent NHSScotland. The initial stocktake proved a spur to action and at the same time provided a baseline to assess what needed to be done. The stage is now set to deliver.

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