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| | | 5 December 2008 |
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"It has to be recognised that numbers alone are not the only determinants of priorities. Everyone is entitled to fair access to health care and the right to opportunities for better health - this is the founding principle of the NHS."
1. Introduction
This summary sets a context for the work undertaken by the Scottish Executive to establish a baseline, or 'stocktake' of ethnic minority health issues in Scotland.
It draws out key themes and suggests ways of taking this agenda forward in order to improve the health and access to services of ethnic minority groups and the wider community in Scotland.
2. The Ethnic Minority Population of Scotland
The 1991 Census shows that the ethnic minority population in Scotland is approximately 1.3% of the total population. The main ethnic minority groups are of Pakistani, Indian, Bangladeshi, African, Asian, African/Caribbean and Chinese origin. These are unevenly distributed in some parts of Scotland.
Evidence shows that over 60% of ethnic minority communities are resident in the four major cities: Aberdeen, Dundee, Edinburgh and Glasgow, where they make up nearly 3-5% of the population.
Within the central belt the main ethnic minority communities are from the Indian
sub-continent, particularly Pakistan.
In rural areas such as Grampian, Highlands, Borders, and Dumfries & Galloway, the Chinese community forms the largest ethnic minority group.
While the numbers of ethnic minority people in rural areas may be small, there is a growing body of evidence that the health of these groups are further complicated by the problems associated with living in a rural community.
Data to date suggest that 45% of ethnic minority communities were born in the UK.
There is evidence that the 1991 Census under-estimated the ethnic minority population. More accurate statistics are likely to become available from the census in 2001.
3. Setting Ethnic Minority Health Issues within a Strategic Framework
Given the relatively low proportions and numbers of ethnic minority communities, especially in some parts of Scotland, a key issue that emerged during the fieldwork with a number of NHS organisations is 'why is this issue a priority?'.
This may be an issue for the population as a whole, particularly given that there are other disadvantaged and socially excluded groups that may be seen as having distinctive needs.
It has to be recognised that numbers alone are not the only determinants of priorities. Everyone is entitled to fair access to health care and the right to opportunities for better health - this is the founding principle of the NHS and is reflected in the current Government's commitment to reduce inequalities in health. The Macpherson Inquiry into the death of Stephen Lawrence has also provided an added impetus to tackling inequalities and the effects of racism on ethnic minority health.
The challenge of addressing inequalities experienced by black and ethnic minority groups is succinctly described by the Social Exclusion Unit:
Ethnic minority disadvantage cuts across all aspects of deprivation. Taken as a whole, ethnic groups are more likely than the rest of the population to live in poor areas, be unemployed, have low incomes, live in poor housing, have poor health and be victims of crime, (Social Exclusion Unit, 1998).
Of course, not everyone within ethnic minority communities experience the same disadvantage. Ethnic minority groups are heterogeneous, and it is well known that particular groups have greater health needs than others.
The Scottish Executive's Equality Strategy: Working Together for Equality reaffirmed the Government's commitment to '... secure a just and inclusive Scotland. This means tackling discrimination and prejudice across Scotland. It also means tackling systems, behaviours and attitudes that cause them or sustain them.'
Our National Health: A Plan for Action, A Plan for Change was launched recently by the Minister for Health and Community Care. In it the Executive has given further 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.'
The plan will include the development of Diversity Frameworks to ensure the NHS meets the distinctive needs and an expectation that there will be investment in primary and secondary care services that are accessible enough to cater for homeless people, ethnic minority groups and other excluded groups. The NHS will be required to work with Local Authorities and other organisations to ensure their needs are met.
By April 2002 every NHS Board in Scotland will have set up at least one 'Partners in Change' programme that will put the experience of patients at the heart of service change. Particular attention will be paid to people from ethnic minority communities to ensure they receive high-quality advocacy support to nationally agreed standards.
This report attempts to take forward this commitment and highlight what might be done, much of it is generic good management and professional practice, to ensure the NHS in Scotland is able to deliver on these commitments.
4. The Framework
The framework for the 'stocktake' was developed to assist the NHS in Scotland in taking practical steps to improve health services for ethnic minority communities in a strategic way. The framework is generic and can be utilised in relation to other socially excluded and disadvantaged groups.
The key elements of the framework were:
The understanding of ethnic minority make-up of the local population, their concentration (or dispersal), socio-economic conditions and the ways the data have been utilised in priority setting, planning and developing services to meet specific identified health needs.
The degree to which NHS organisations were aware of the legislative framework, including the scope for positive action, and had up-to-date, integrated race equality and equal opportunity policies in place.
The extent to which policies were communicated, and staff made aware of their significance in day-to-day work.
The understanding of the widely documented access issues and concerns that might arise for ethnic minority communities and evidence of action taken to address them.
The degree to which any core standards were being identified to facilitate monitoring of progress on these issues.
The extent to which race and equal opportunities issues are integrated into Human Resources development strategies, including recruitment, training, learning, and retention of staff.
The degree to which NHS organisations are 'outward facing' and concerned with involving local ethnic minority communities and organisations in promoting their own health. The degree of understanding, dialogue and support for forums, networking, advocacy and service delivery organisations that make up the 'infrastructure' for ethnic minority communities.
5. Main Findings of the 'stocktake'
Overall, the key findings of the 'stocktake' were:
6. Key Recommendations emerging from the 'stocktake'
The 'stocktake' has proved an invaluable exercise in raising awareness of the issues in the field. We have noted its catalytic effect has resulted in many NHS organisations developing a wide range of activities, which are outlined in the postscripts. The sensitisation of the service can be built on and momentum sustained in a variety of ways.
In outlining these recommendations, we want to stress that they are systemic, in other words, we do not believe that any one of these steps, on its own, can make a difference. The recommendations are intended to be mutually reinforcing and need to be taken forward simultaneously if they are to have a significant and sustainable change.
In many Boards and Trusts where there was work taking place, the approach tended to involve undertaking short-term, time limited projects to improve understanding of needs, consultation, and access to interpreting and translation services.
A more strategic approach to ethnic minority health issues is a key area for development for the NHS in Scotland. There is a need to identify a core set of values that will underpin services and provide clear guidelines for action.
This will involve securing commitment at executive and non-executive levels, the integration of these issues into Board or Trust strategies and planning processes (including partnership arrangements), and development of implementation plans with mechanisms for managing performance on the issue.
Some Health Boards and Trusts had no designated lead for ethnic minority issues at top or near senior management level. This made it difficult to determine accountability, assess all current work programmes and secure relevant documentation.
It is imperative that a lead responsibility for race and health - along with other responsibilities for addressing the needs of disadvantaged groups and increasingly diverse communities - is taken at top or senior management level.
NHS Managers' as part of their performance/management review, will be held accountable for meeting the national standards as set in 'Our National Health' and forthcoming Executive Guidance HDL 2001.
Managers and professionals at board level need to be active in both setting priorities and targets for ethnic minority health improvement and monitoring performance against set objectives and standards.
Although a small number of Health Boards and Trusts had undertaken needs assessment, a large number had not done so, or had little collective knowledge of the ethnic minority populations for whom they were responsible.
More qualitative needs assessment is needed, including focus groups and dialogue with representatives of community-based organisations or places of worship particularly where these are the 'hub' of local communities.
Even where work has taken place, there is a need for effective processes to translate the knowledge gained into priorities and actions for delivering services that meet the needs of these communities.
A wealth of information and intelligence is available and the service should not be reinventing the wheel. At the same time, understanding the local population profile, identifying and assessing specific health needs in consultation with service users and carers might be necessary. There is a need for better and co-ordinated assessment of the needs of ethnic minority communities at national and regional levels.
In some cases, much is already known about the needs of specific communities at a local level. The gap between public health knowledge, planning and resourcing of services at local level needs to be bridged. This will require public health professionals to influence managerial processes more effectively, and managers to be more responsive to the evidenced-base knowledge available in public health.
The emerging Public Health Institute should facilitate better understanding of the issues and the dissemination of good practice models. It will encourage more efficient and effective ways of collating evidence-based public health medicine on race and health. It can also begin the task of building capacity within organisations to rise to the challenge.
This capacity-building support is likely to become even more vital with the dispersal of refugees and asylum seekers across the country and the response this requires from public agencies in Scotland working together.
There is clearly a scope for public health expertise and resources to be shared across the NHS in Scotland.
Few Health Boards and Trusts had built ethnic minority health issues into HIPs, TIPs or Joint Community Care Plans except in the most general of ways, and none had done so systematically.
Further work should be done to review the degree to which health issues, and ethnic minority health concerns have been incorporated into local authority-led Community Plans.
The police service, social services and education may be aware of new and emerging issues for ethnic minority groups (e.g. alcohol and drug use, involvement of young people in gang-related warfare, sexual health issues) well before the impact is felt on health service provision.
Given that the needs of ethnic minority groups often fall between the 'gaps' within agencies or across agencies in distinctive ways, these would need to be understood and planned for, if the benefits of multi-agency working are to be realised. Effective working on these issues requires a greater understanding of the social, cultural and religious influences and emerging dynamics within communities - especially amongst the second and third generations born, bred and living in Scotland.
There is a need for a preventative public health research agenda to identify and assess the emerging issues for these communities.
Many Health Boards and Trusts had no specific race and equal opportunities polices in place, and where they did, they were often out of date or had not been subject to recent review. Some are struggling with inherited and outdated policies. In common with many public agencies, policies and procedures had often been accumulated over time.
We suggest a different approach is taken that is based on the emerging vision and principles for the NHS in Scotland; where HR/Equality Polices and procedures are principle-based, and designed to achieve organisational and managerial objectives.
There was also little evidence that policies were communicated, and staff given essential awareness training on the significance or implications of the Race Relations Act. This will be increasingly important in the context of the amended Race Relations Act and The European Convention on Human Rights. There were specific issues relating to HR capacity within a number of Health Boards and Trusts to undertake this work.
Rather than reinventing the wheel, NHS organisations could share expertise and good practice available across the country. This is the approach taken by the Scottish Partnership Forum, Partnership Information Network (PIN Board) which is preparing good employment guidance to promote fairness, consistency and equality in employment practice for staff whenever they work in the NHS. NHS employers are required to adopt the values and principles contained in the guidance and progress towards meeting these are likely to form a component part of the new Staff Governance Standard. Good practice has already been issued for Equal Opportunities and Dignity at Work.
While a number of Health Boards and Trusts were aware of some of the potential barriers to access for ethnic minority groups, in many cases this was limited to recognising that there might be a need for interpretation and translating services.
The development of interpreting and translation services and their closer integration across agencies would be helpful. The broader access to health issues, for example, through primary care, or the impact of sensitivity and cultural competence of staff have yet to be considered. Poor quality or lack of appropriate information and negative experiences of the health care service might be contributory factors that need to be understood.
There needs to be a better collective understanding in the service of how barriers to accessing health care services may in turn effect health outcomes for ethnic minority groups.
Many Health Boards' and Trusts' commitment in this area was ensuring that there was staff awareness of the legal framework in relation to existing anti-discrimination legislation. No Health Board or Trust had recruitment and selection strategies and processes designed to develop a diverse workforce with increasing representation of ethnic minority people either at frontline or at senior management levels.
This is a relatively new but vital area of development if the NHS in Scotland is to improve its employment profile. NHS organisations need to find new and more effective ways of presenting what they do and be more welcoming to ethnic minority people. This goes well beyond straplines in advertisements around equal opportunities towards proactive marketing of organisations and reaching out to communities.
Recruitment and selection processes may need to be reviewed to ensure ethnic minority applicants are not unintentionally discriminated against. More positively, managing race equality and equal opportunities issues should be an element of person specifications and be tested as part of recruitment processes.
The need for this type of action is highlighted in the PIN Board Guidance on Equal Opportunities and will be further addressed through the Guideline Development Group on Recruitment and Selection.
While many Health Boards and Trusts were undertaking a range of training and learning programmes for staff, there was little evidence of equality issues being integrated into staff development, or specific equality learning and training programmes.
Given the importance of retaining staff, and encouraging leavers to return, the NHS service needs to consider what it can learn from the exodus of ethnic minority staff in England, particularly nurses, over the last few decades and ensure that discrimination and harassment is eliminated. The recently published PIN Board 'Guidance on Dignity at Work: Eliminating Bullying and Harassment' will form an important set of guidance to accomplish this aim.
Where ethnic minority staff are already in the organisation, specific efforts should be made to look at obstacles to their development, and ensure that learning and training programmes are available so that they too have an opportunity of competing for senior positions on a level and fairer playing field. Work in progress in connection with the Education and Learning Strategy should inform this process.
Although some Health Boards and Trusts were engaged in consultation with ethnic minority communities, there was often a lack of clarity about the purposes of engagement. There was an over reliance on existing mechanisms, at the cost of direct consultation and engagement with users, carers and potential users of services from these communities.
Community Development involves building alliances with individuals, groups and organisations within the community. It includes commitment at three levels - the communities, at professional level and among policy makers to achieve sustained action.
More needs to be done to extend consultation beyond those groups and individuals that have traditionally been consulted, in particular to involve young people and women from ethnic minority groups.
There is a vital need for a shift in ways of thinking about the potential role of Health Boards and Trusts, both as employers, commissioners, and service providers in developing the capacity of these communities to improve their own health.
Improving the health of ethnic minority groups requires joint working in areas of mutual concern. This is more difficult if ethnic minority voluntary organisations are small, fragmented, and surviving on a shoestring. A vibrant voluntary sector is central to effective dialogue and engagement.
Participation involves more than just consultation. It includes active involvement and implies the opportunity to influence and contribute towards decision-making. This approach goes with the grain of a more general drive to develop advocacy as central to engaging the public and developing more effective services.
Public agencies need to look at ways of developing the infrastructure for ethnic minority organisations to thrive. Where ethnic minority organisations are able to offer more sensitive, flexible services to their communities, the NHS in Scotland needs to look at their potential to provide services directly.
Ethnic minority communities in rural parts of Scotland face additional problems in accessing health services. NHS organisations in these areas experience challenges in trying to work with very small numbers and finite resources.
There is capacity within the work of the Remote and Rural Areas Resource Initiative (RARARI) to support professionals providing services to these communities.
The current dispersal programme has designated Scotland as one of the 'cluster regions' for the refugees and asylum seekers. They face special health challenges compounded by difficulties of settlement in a new country.
There is a need to build capacity within NHS Organisations to deal with the specific problems of refugees and asylum seekers.
There is generally poor published information about the health status of this ethnic minority group in Scotland.
At the time of writing the Scottish Parliament Equal Opportunities Committee is conducting an inquiry into Gypsy Travellers which will address issues of health and access to healthcare. Their report is due at the end of June 2001.
The provision of personnel to co-ordinate and support developments, nationally, to improve the health status of Gypsy Travellers. This would ensure monitoring and evaluation of local initiatives which can be shared and extended.
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