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fair for all
"This highlights the importance of recognising where individual
organisations are, setting differential targets, and making tools relevant ...
if the NHS in Scotland is to achieve more."
Data from Interviews
Overall Commentary
1. The preparation for the interview process included:
- a letter sent from Scottish Health Executive to Chief Executives of Trusts
and General Managers of Health Boards informing them of the work and seeking
their co-operation for the proposed 'stocktake';
- a second letter from Dr Rafik Gardee elaborating on the key areas which
the interviews would cover;
- a short version of the questionnaire sent in advance of the visit to enhance
the organisation's ability to comfortably respond to our semi-structured interview.
2. Some of the organisations visited had problems identifying appropriate
person(s) to respond to issues relating to ethnic minority health. This meant
that some of the key areas were not covered during the interview. Organisations
occasionally failed to elicit relevant responses from their colleagues to ensure
gaps were filled.
3. Generally, ethnic demographic profile was poor or not available. There
is a need for a consensus on the importance of data collection, as it is difficult
to see how organisations can plan services to reflect ethnic minority health
needs without reliable data.
4. Almost all respondents in areas where there were small numbers of ethnic
minority groups were convinced that 'low numbers' was a justification not to
prioritise ethnic minority health issues. Some had attempted to incorporate
these issues under broader generic priorities, for example: Achieving Better
Services for Patients, Health Inequalities and Public Involvement.
5. Equal Opportunity Policies, where they existed, were generally out of
date. With very few exceptions there was little evidence of communication of
the policy, for example in induction processes, or training being delivered
to staff to support them in delivering on the policy.
6. There was a lack of diversity in the employment profile of many organisations.
Organisations appeared to have done little to actively encourage ethnic minority
applicants in areas where they are clearly under represented, or to look at
specifically developing their ethnic minority staff.
7. Data on ethnicity of applicants, appointments, or by staff category is
generally very poor. Organisations that have made an attempt to collect some,
or all, of this information have not effectively used the data to develop recruitment
strategies. Little attempt has been made to develop proactive approaches to
ethnic minority recruitment, for example by widening advertising media and talking
to ethnic minority organisations.
8. With a few exceptions, there was a widespread practice of using family
members, community volunteers and bi-lingual staff to provide language support
to ethnic minority service users. Where agreements existed with the local authority
or voluntary agencies to provide this service, it was often an informal arrangement.
This makes it difficult, if not impossible, for organisations to set quality
standards or to monitor the level of services received.
9. Many respondents assumed that designated lead responsibility for Community
Involvement, Achieving Better Services for Patients, Equal Opportunities and
Designed to Care meant they had integrated race and health within their organisation.
However, there were little or no specific examples of ethnicity and health as
key result areas.
10. Some organisations that had begun to tackle issues of ethnic minority
health and come across difficulties, appeared to have lost track of what they
were trying to achieve, were uncertain about what to do next, or disillusioned
with the work required to make a visible impact. This highlights the importance
of recognising where individual organisations are, setting differential targets,
and making tools relevant to stage of development of organisations if the NHS
in Scotland is to achieve more on these issues.
Commentary on Health Board Interviews
Argyll & Clyde:
- The organisation appeared unprepared for the visit. Two visits were required
for a comprehensive response to the questionnaire interview.
- There appeared to be limited corporate commitment to race equality issues,
though gender equality has received some endorsement.
- The organisation had no ethnic minority staff; of the 170 employees none
was from ethnic minority groups. The questionnaire had done little to raise
awareness of the need for greater diversity in the workforce.
- The 'visibility syndrome' was apparent throughout the discussion. The organisation
was convinced that low numbers of ethnic minority groups justified a lack
of knowledge of the issues facing these communities. The organisation appeared
to have had very little interaction with ethnic minority communities.
- The visit highlighted the lack of understanding of the needs of ethnic minority
communities by the Board. However, the Board did acknowledge that they are
weak in this area and would welcome some support from the Scottish Executive.
Ayrshire & Arran:
- The Human Resource Department of the Board had one member of staff at the
time of the interview, and it was difficult to see how one individual could
effectively develop the corporate equality agenda.
- It would appear that some work has been done with the Chinese community.
- Although responsibility for training of staff has been devolved to line
managers, there was little evidence of equality or race equality training
featuring high on the list of priorities for the staff competency-based training
programme.
- In general, it appears that the Board has begun to address certain issues
in relation to minority ethnic health but the work would need to be strengthened
and extended to cover other ethnic minority groups as well as the Chinese.
Borders:
- There was no evidence the Board recognised the need to demonstrate equality
of opportunity in their working practices. Racial equality concerns are woven
into a two-page policy document, which has not been reviewed over the last
seven years.
- The organisation is proud to have community volunteers as stand-by helpers
when language support is needed. There was no evidence of any other interaction
or dialogue with ethnic minority communities.
- There was a general agreement by the respondents that the lack of visibility,
or large numbers, of ethnic minority groups, had resulted in complacency around
the kind of issues that the interview raised. '... ethnicity does not feature
high in this part of the world ...'.
Dumfries & Galloway:
- The Board has been dynamic in addressing the different challenges faced
by ethnic minorities, including the Irish and the travelling/new age community.
The Board was of the opinion that '... any group which define themselves as
an ethnic minority group, should be treated as such ...'.
- Despite the small size of the Board, resources are being committed and targeted
to areas of development with ethnic minority groups and the new age community.
- Overall, the Board was welcoming of any initiative from the Scottish Executive
that would allow them to take further steps to meet the needs of their local
ethnic minority groups.
Fife:
- The organisation appeared unaware of when the Equal Opportunity Policy was
last updated, and there was complacency about equality or race equality issues
in employment. However, there have been some initiatives with partner agencies
that show early development in this area:
- '... there are substantial and enough links with translation and interpreting
services to ensure that anybody requiring language support is made to feel
very welcome ...', '... there is no danger of ethnic minority groups being
ignored in this area ...'.
Forth Valley:
- The Board appeared to have given little attention to reappraising its equality
policy. Equality training was delivered to staff, some nine years ago.
- The Board felt they should only do more to recruit ethnic staff if 'it can
be proven that their employment was necessary for the specific performance
of the job ...'. The organisation did not appear to see a problem in having
an under representation of ethnic minority staff among its workforce.
- There appeared to be some positive work taking place by the Board, such
as the work with RAHMAS that has lead to the production of a very comprehensive
pack on racism and health.
Grampian:
- The Board appeared to have only recently recognised the need to address
the legitimate concerns and expectations of ethnic minority communities. However,
the efforts made by the organisation, even in the early stages, were encouraging.
The Board, together with their NHS partners, have pooled their resources and
are working collaboratively to ensure that ethnic minority issues are woven
into the fabric of 'everyday business'.
- The Board gave us three opportunities to visit them, and were keen to see
some direction from the Scottish Executive that would help them to take the
next step.
Greater Glasgow:
- The Board was direct in questioning the basis of the exercise at a time
when they had begun work on this issue. The Board felt it was doing much better
than many others on the issue.
- Overall, the organisation appears to be pressing ahead with its agenda for
race and health with some encouraging results. A priority will be to deliver
some of the key areas that have been identified for further development.
- 'We have not yet had a complaint, so we have not had a reason to question
the quality of services which we are provided with,' was mentioned as a positive
indicator. However, there was no evidence of significant recruitment, selection
or training strategies on the issue, and this may reflect a reactive rather
than proactive approach.
Highland:
- The Board welcomed the Scottish Executive stock take but emphasised the
need for the 'stocktake' to recognise the special challenges faced by rural
Health Boards.
- There are problems associated with geography and resources, which has led
to the use of family members and bilingual staff, to provide community language
support. The lack of CRE presence in the region has also made matters difficult.
- Overall, the Board was encouraged by the visit and the capacity to be gained
from an ongoing exploratory study of Minority Ethnic Communities in Scotland
(De Lima, PJF).
Lanarkshire:
- There was an indication of under representation of ethnic minority staff
within the workforce but little commitment by the Board to address its employment
profile.
- Over the last year, the Health Board has formed a Multi-Agency Short Life
Working Group on ethnic minority communities. The work of the Group is in
the early stages, but it has already produced an action plan that looks at
key issues for developmental work. The Health Board is committed to do more
to raise the profile of ethnic minority health.
Lothian:
- This was one of the few occasions where a Chief Executive was in attendance.
The Board has begun to integrate equalities into policy and practice. The
Board states '... only those policies and activities that would reduce the
health gap between the affluent and impoverished sections of Lothian, would
be endorsed by the Organisation ...'.
- The organisation now has vital statistics that show that, although the health
of both affluent and impoverished sections of Lothian has improved, the gap
between them has increased significantly. The Board is leading a Lothian Wide
Multi-Agency initiative to ensure that commitment to inequalities is at the
heart of the everyday business of the partners.
- The obvious energy demonstrated by the Board in tackling health and inequalities
could become a great asset in the Scottish Executive's drive to raise the
profile of race and health.
Orkney Health Board:
- The Board's Equal Opportunities Policy has a section on racial equality
and progress has been made to ensure that staff job descriptions specify their
obligations to deliver a responsive service to patients.
Shetlands Health Board:
- Overall, the Board is keen to work with the Executive, to address specific
issues in relation to minority ethnic health. The organisation also states
that staff training with respect to the Equal Opportunity Policy will be rolled
out before the next financial year.
Tayside:
- The designated person for interview appeared unaware that the organisation
had an Equal Opportunity Policy. The visit was somewhat unproductive with
many key discussion areas not covered due to the absence of some key people.
- The Board felt somewhat overwhelmed by the stream of priorities from the
Scottish Executive, and considered that ethnic minority health issues are
not an area of greatest need at this point in time.
- However, the Board does appear to accept that they have not done enough
and would welcome any help and support from the Scottish Executive.
Special Health Boards
Western Isles Health Board:
- The Board has minimal awareness of the ethnic minority make-up of their
local population, or of their needs. However, the organisation welcomed the
Executive's commitment to look at ethnic minority health.
Carstairs State Hospital Board:
- The Board has been pro-active in meeting the needs of all patients including
those from ethnic minority communities. There is a regular review of an individually
tailored 'care plan' to ensure that the service is 'patient centred'.
- The strategy is being developed to work with ethnic minority patients. The
last time the organisation employed black staff dates back some twenty years
ago. The Board is of the opinion that the recent appointment of a black staff
member indicates their willingness to redress this imbalance.
Common Service Agency:
- Overall, the work of the agency is received via the Scottish Executive Health
Department and also includes the provision of support to the Health Boards
at their request.
- There is no mention of work with ethnic minority groups in the Boards Contract
of Management.
- The only noticeable progress on the issue of translation and interpreting,
has been made by the Scottish Blood Transfusion Service (SBTS).
Health Education Board for Scotland:
- The Board has no member of staff from the ethnic minority groups. However,
a designated senior manager has lead responsibility to look at how services
are accessed and received by ethnic minority communities.
- The organisation has commitment to fund the voluntary sector but not specifically
the ethnic minority voluntary sector.
- No other initiative is taken by the Board to look specifically at the health
promotion needs of ethnic minority groups, although it is of the opinion that
local health promotion departments should be actively involved in doing so.
Scottish Ambulance Service:
- Overall, the organisation appears to be taking a positive attitude to equality.
In its policies and practices it is seeking to deliver an unrivalled service
and excellence to all people. It has devoted significant resources to ensuring
that more ethnic minority staff are recruited and promoted to senior levels
within the organisation.
- The Board has a proactive approach to equality and this is underlined by
a huge investment in training. Staff are also expected to attend the training
as part of their competency appraisal process. The organisation has a pilot
mentoring scheme and a Post Provision Course which forms part of the annual
certification process.
- The organisation appears to be receptive to any initiative designed to increase
staff competency in dealing with members of the public.
Scottish Executive Health Department:
- The department has commissioned the current 'stocktake' exercise which will
contribute towards future DEPLAN, the Scottish Executive Strategic Plan.
- The commitment to race and equality has been further demonstrated in a robust
and comprehensive equal opportunities policy, which will be a 'model' for
all NHS organisations in Scotland to follow.
- The department is also keen to adopt the principles of the recent equality
strategy in their work with ethnic minority communities.
Commentary on Trust Interviews
Lomond & Argyll PCT:
- The general impression is that the organisation regards ethnic minority
groups as being so small in number that their health 'is not recognised as
a major issue'. 'All our communities are self reliant ...' is representative
of the broad response received.
Renfrewshire & Inverclyde PCT:
- The Trust agreed that their work in this area is in the very early stages.
- There was willingness by the organisation to engage further with some of
the issues raised by the interview. The Trust stressed the need for the Executive
to maintain a database of all the black voluntary and community organisations
in Scotland.
- The Trust would be interested in assistance to help them grapple with the
issues of public involvement, including ethnic minority groups.
Argyll & Clyde Hospital:
- It would appear that staff are operating on the basis of equality policies
inherited from the former organisation. The lack of harmonisation of former
policies appears to have resulted in some staff confusion over what policy
to adopt within the new Trust. Communication structures appear weak within
the organisation, and this may have led to some complacency towards training
in anti-discriminatory practices.
- The organisation was of the opinion that the Executive needs to set in place
clear guidelines for the NHS organisations to follow. There was a strong view
that there should be identifiable individual within the various Health Boards
and Trusts with a remit for mainstreaming race and health.
- The Trust championed the NHS in Scotland Good Practice Guide in Recruitment
and Selection. The organisation wanted to do more but felt restrained by lack
of knowledge and of a clear direction.
Ayrshire & Arran PCT:
- The Trust has committed resources to working with the Chinese community.
This work needs to be extended to include other ethnic minority groups.
- The organisation appeared to particularly value staff, and has recently
been IiP accredited for the second time running. Although training in racial
equality is considered important for staff who interact frequently with ethnic
minority people, it needs to be made available for all employees.
- Generally, the respondents were open as to the shortcomings, but wanted
more support to address some of the issues, which the questionnaire had raised.
Ayrshire & Arran Acute:
- The organisation appeared to lack knowledge of how race and health could
be integrated into their usual way of doing things. The Trust admitted ignorance
of some of the health problems of ethnic minority groups and requested support
to help them in translating patient information leaflets into various community
languages.
- Otherwise, the general impression gained was that the Hospital plays a crucial
role in the life of the area and that staff interact well with the local community.
The significance of the organisation locally could be harnessed to meet the
needs of ethnic minority communities.
Borders PCT:
- The only apparent dialogue with ethnic minority groups was in service planning
review for mental health services. Generally, there was a lack of specific
attention to the needs and requirement of ethnic minority communities.
- The organisation appeared to be anxious about what the Executive expects
of them and how they would be judged in the light of issues raised by the
questionnaire.
Borders Acute:
- Problems associated with geography means that the Trust appeared to be some
years behind what is happening in urban areas in relation to ethnic minority
health. Two visits to the Trust failed to reveal the extent to which community
language support was provided.
- The indications were that the Trust was unaware of ethnic minority groups
in their area. '... they are so small that it would be surprising if they
are organised into any groups or organisation in the area ...'.
Dumfries & Galloway PCT:
- The Trust relies on line managers to take responsibility for training staff,
but there appeared to be no mechanism to ensure that managers are training
staff in relation race equality issues.
- Some of the minor initiatives with ethnic minority groups appear to have
been sparked as a result of a local incident some years back.
- The organisation appeared to have real difficulty in identifying the ethnic
minority groups in their area.
Dumfries & Galloway Acute:
- The organisation appears to believe that there is no need for stand-alone
training in racial equality, but that the principles have been 'locked' into
the way things are done. There appears to be little recognition that ethnic
minority groups might have specific needs in addition to mainstream provision.
Fife PCT:
- The Trust appears to be at the early stage of addressing the health needs
and concerns of ethnic minority groups.
- The organisation welcomes the Scottish Executive's work in this area, and
emphasised the importance of translating talk into action. Their expectations
are that the Scottish Executive will set realistic and achievable targets.
Fife Acute:
- The Trust felt there was a great deal of ignorance in relation to race and
health. The organisation accepts their shortcomings, and would welcome any
initiatives to look seriously at ethnic minority health.
Forth Valley PCT:
- The Trust's work with the Multi-Agency Racial Attack and Harassment Monitoring
Group (RAHMAS) appears exemplary. It received commendations from the Home
Secretary, Mr Jack Straw, and the Scottish Executive Justice Minister, Mr
Jim Wallace. The Trust also felt that there is a lack of expertise on these
issues in Scotland, in particular advice and support to organisations struggling
to meet the health care needs of ethnic minority communities.
- The organisation welcomed the 'stocktake' and said that it will be looking
forward to standards from the Executive to help strengthen and progress some
of their existing work with ethnic minority groups.
Forth Valley Acute:
- The Trust feels the numbers of ethnic minority groups locally is 'not great'
and appeared to feel that this justified a lack of progress in this area.
The organisation appeared to work on the implicit assumption that staff would
provide equitable services regardless of the user's background.
Grampian PCT:
- The Trust appears to be on a learning curve in relation to these issues.
It has engaged with other local NHS organisations in a Multi-Agency Collaboration
to look realistically and systematically at the general concerns of ethnic
minority groups in relation to health.
- However, the Trust also stressed that they will be expecting an 'enduring
strategy' from the Executive to help them standardise their response to ethnic
minority health issues.
Grampian Acute:
- The Trust felt that the small ethnic minority numbers has made it difficult
to target provision. However, the current involvement with other NHS organisations
in Grampian should lead to a number of actions for the Trust.
- The organisation has begun to explore ways of addressing the under representation
of ethnic minority staff but is having difficulty taking work forward because
of what it describes as prohibitive costs. The joint collaboration may allow
pooling of resources and encourage a long-term commitment from partner agencies.
Greater Glasgow PCT:
- The Race Equality Policy complements the Equal Opportunity Policy and clearly
demonstrates the corporate commitment to have an organisation that is culturally
competent and which reflects the needs of the diverse population which it
serves.
- The policy has been translated into action through the Multicultural Health
Development Programme. Other pieces of work carried out in partnership or
in collaboration with local and national agencies have further strengthened
the Trust's commitment to meeting the needs and expectations of minority ethnic
communities in relation to health.
- The Trust has also taken a range of steps to encourage more ethnic minority
staff into employment. They felt the work with ethnic minority communities
would need to be strengthened and further developed.
North Glasgow Acute:
- The Trust appeared to be non-committal and reactive to issues of ethnic
minority health, where these are identified by the community or through the
complaints procedure. Recently, some steps have been taken to acknowledge
the cultural and spiritual issues involved in service delivery to these groups.
South Glasgow Acute:
- It would appear that there has been some progress towards ethnic minority
health, for example, through the recent publication of a religious manual
and need for dietary spiritual sensitivity.
- The Trust is part of a collaboration between NHS Organisations in Glasgow
to look at a local response to ethnic minority health. There seems to be a
fresh approach towards this area of work.
Yorkhill Hospitals:
- The organisation appears to have a colour-blind approach to the issues.
The Trust does not distinguish between different groups as exemplified by
their response that '... children's developmental needs are the same, regardless
of their background ...'. This is of concern because child-rearing needs of
mothers and children are influenced by their cultural and religious background.
- No specific discussion took place on women and maternity services.
Highlands PCT:
- The organisation feels that the 'invisibility' of ethnic minority groups
has made it difficult for them to be identified as a priority. There seems
little indication that the Trust sees ethnic minority health as an area of
concern.
Highland Acute:
- The Trust believes that issues relating to rurality and remoteness in communities
were much more important than ethnic minority health.
- The Equal Opportunity Policy was last updated in 1993, as there are other
'pressing priorities'.
- Generally, the Trust felt '... there are not enough resources to address
this issue in the Highlands ...'.
Lanarkshire PCT:
- The Trust has taken steps to introduce a number of initiatives to promote
access and improved experience of ethnic minority communities in relation
to health. For example, Link Line helps to interface with the public from
9.00 a.m. - 5.00 p.m., with interpreters on hand to help answer queries from
ethnic minority groups.
- The LHCCs are strongly encouraged by the PCT to be progressive in developing
their plans in consultation with local ethnic minority communities.
- Overall, the organisation is becoming sensitised to issues of ethnic minority
health and there is a consensus that further encouragement from the Executive
will support and strengthen commitment.
Lanarkshire Acute:
- The Organisation is presently looking at 'joined up' policy on ethnic minority
groups and access to health care, but is in the early stages. There was some
confusion over the merits of having specific provision for ethnic minority
communities.
Lothian PCT:
- The organisation has already done considerable work to tackle some of the
issues identified by our questionnaire interview. For example, the Minority
Ethnic Heath Inclusion Project (MEHIP) ensures that ethnic minority communities
can access and receive appropriate primary care services. The review of recruitment
strategies will consider the advertisement of jobs in the local ethnic minority
library.
- The organisation appeared to be committed to tackling inequalities. The
Chief Executive was personally present at the interview and abreast of developments
in this area.
- The organisation felt that they will need to strengthen certain elements
of their work with the ethnic minority communities, and appear to expect 10
to 12 core standards from Scottish Executive in order to move towards a common
and national standard in race work within health.
Lothian Acute:
- The Trust has taken some steps to look critically at the health of ethnic
minority groups. However, lack of resources appears to have put a halt to
some of these initiatives.
- The major problem facing the Trust appears to be how to identify and interact
with the local ethnic minority groups. Overall, it would seem that the organisation
is struggling to meet the particular needs of ethnic minority communities.
West Lothian Health Care:
- The organisation recognises that it has done little to address the issues
of ethnicity and health.
- The Trust is generally optimistic that the new direction being spearheaded
by the Executive will provide an incentive to move ahead with this work.
Tayside Acute:
- The Trust believes that race equality does not need to be 'spelled out to
staff', and that they will deliver an appropriate and sensitive service to
all individuals irrespective of their backgrounds. The organisation also felt
that the local ethnic minority population have 'grown up' with their indigenous
residents and have become thoroughly 'integrated'.
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