 
# **Contents**

Title Page

Dedication

The Authors

Reviews

Copyright

1. Historical Background

2. Why Equality Matters

3. Why Change Often Fails

4. Global and Theoretical Perspectives

5. An Evidence-Led Culture Change

6. The Need for Evidence

7. Turning Evidence into Strategy

8. Tools and Strategic Interventions

9. Measuring Performance

10. Building Leadership Competence

11. Making Change Sustainable

12. Measured Outcomes at NHS North West

Postscript - The New NHS

Appendix 1 — Case Studies

Appendix 2 — Publications

Appendix 3 — Online Resources
**Making Equality Work**

****

****

**Shahnaz Ali, Christine Burns and Loren Grant**

****

****

**Copyright © 2013-16**
**Dedication**

**In memory of Barbara Burford, who sadly died in 2010**

Barbara Burford was a lifelong champion of equality and diversity in the health service and directly inspired hundreds of health professionals and managers through her work. Throughout her career, Barbara worked closely with the NHS, government departments, minority groups and public sector organisations to raise the profile of equality and diversity in the NHS.

It was as director of equality and diversity at the Department of Health, from 1999 to 2002, that Barbara was able to raise the national profile of her field. She spearheaded a number of initiatives including the development of the first practical guide to managing equality and diversity in the NHS.

**The Authors**

**Shahnaz Ali, OBE, MA** was the Director for Equality, Inclusion and Human Rights at NHS North West from December 2007 until the dissolution of the English Strategic Health Authorities in March 2013. Prior to that she was the Director of Education Commissioning for South Yorkshire Workforce Development Confederation, Director for Local Authorities and Wider Partnerships for South Yorkshire Strategic Health Authority and she has held various senior roles both in the NHS and local government in both the North and South of England. Her speciality lies in influencing, negotiating and managing change in large complex systems. It is Shahnaz's strategic vision which underpins this book.

**Christine Burns MBE, MSc, BSc (Hons), CEng, MBCS, CITP** is Managing Director of Plain Sense Limited, a consultancy specialising in Equality, Diversity and Human Rights. Prior to setting up Plain Sense she was a senior level business and IT consultant, advising blue chip businesses in Britain and abroad. She also has experience of managing a medium size social care provider. As the Programme Manager for Equality and Diversity at NHS North West, as an advisor on LGBT health for the Department of Health, and as the former chair of the North West Equality and Diversity Group, she has been at the forefront of both formulating and implementing strategic development in this area for many years. Christine is the principal author of this book.

**Loren Grant, MA, MSc** was an Assistant Director for Communication and Engagement at NHS North West and worked within the equality, inclusion and human rights team from January 2010 until the dissolution of the English Strategic Health Authorities in March 2013. She has worked in journalism and in the public sector in the UK and specialises in the communications and engagement aspects of equalities and human rights. Loren is the book's editor and academic researcher.
**Reviews**

_'Would the work of William Wilberforce have been described as "political correctness gone mad" in the 18th century? How far have we come on our journey to ensure everyone, yes everyone, in the UK receives healthcare free at the point need? This is a huge 'little' book. A text book for Equality and Diversity professionals that reads more like an engaging novel. Full of facts, statistics and testimony. A brilliantly researched book with a strong narrative outlining the context for equality in the NHS and why, despite considerable progress, equality matters more today than ever before. But this isn't just a book providing an overview and research. What you get is a book written by people with a passion and an expertise, who have got their hands dirty, detailing a candid, system wide case study highlighting approaches and successes but realistic about progress and lessons learnt. No hubris here just a brilliant opportunity to dive into the complexity of change management in the NHS.'_

— Dean Royles, Chief Executive of NHS Employers and Acting Chief Executive of the NHS Confederation

_'This is the first comprehensive historical account of equality and diversity in the NHS that I have read, and it is a must read for all those who work not just in healthcare but in other sectors too. There are real examples of where there have been discriminatory issues, and what's more there are helpful solutions which I would encourage policy holders to adapt to their services. Shahnaz, Christine and Loren are to be congratulated for putting such a sterling effort into such a vital issue.'_

__

— Dr Kailash Chand OBE, Deputy Chair of the British Medical Association

_'It is refreshing to see a book which gives the important background and context of equality laws. We would not have our legal rights against discrimination were it not for the brave struggles of men and women over the last 50 years or so. It is frustrating that so few people know how the law protects them and how they can seek redress if their rights are infringed. This book is important in making the equality laws understandable, in plain English. 'Making Equality Work' goes a long way to giving everyone the tools to fight back if we need to. It is also vital that we all know how we can ensure that we do not infringe the rights of other people. Well Done Christine and colleagues for making your work both available and accessible.'_

— Linda Bellos OBE, Chair of the Institute of Equality and Diversity Practitioners

_'This e-book gives a solid local, regional and national context to equalities and human rights in the UK and how and why they should be embedded into the work of public authorities. It examines the case for past failures to truly embed and offers lessons learnt for the future. It is a refreshing reflection on real life experiences of equality work in the last 7 years of the NHS and any due diligence in building new health and social care systems should pay regard to the lessons of the past. This book offers many of them.'_

— Jackie Driver, Programme Head - Public Policy at the Equality and Human Rights Commission and Chair of Breakthrough UK

_'Making Equality Work is essential reading for equality practitioners as well as senior management in the health sector and indeed beyond. In a refreshingly jargon-free way, the book shows how it is possible to work strategically to achieve positive change, against formidable obstacles, in a very large organisation where promoting equality was not always a priority. The NHS has been very good at talking about equality but much less good at implementing it. Shahnaz, Christine and Loren were at the heart of the most sustained and successful effort I know of to change the NHS's approach and (most importantly) its outcomes. I was particularly pleased that, from the outset, they recognised that improving the unnecessarily poor health of men and boys was fully part of their remit. This book will hopefully ensure that their very valuable legacy is not lost in the reorganised NHS.'_

— Peter Baker, Men's Health Consultant

_'Making Equality Work is a key text for all those working within organisations that are hoping to increase their impact. It sets out the struggle for equality that minority groups have faced, particularly throughout the 20th century, and places it in its rightful place as a key requirement for getting better outcomes, particularly in the health sector. It also contextualises equality in modern Britain and provides a fresh perspective on why equality matters. More importantly, it provides a model that has been shown to work on a large scale and presents it in a way that makes understanding it manageable. This is an essential textbook for those want to bring about real change in their organisations, and provides a roadmap to enable this.'_

— Sîan Payne, Director of Organisational Development at the Lesbian and Gay Foundation

_'What's different about "Making Equality Work'" is that it not only examines why addressing diversity is important for organisations, but that it goes a way towards identifying why delivering equality is so elusive. Not only that, it offers tools and expertise to change this — tools and expertise that have been tried and tested. The work explains the importance, and the potential difficulties, of an evidence-based strategic approach, such as aligning equality aims with core organisational goals. After comprehensively outlining the work that they led on equality and diversity the authors conclude by considering how this work can be continued in the current rapidly changing landscape of the NHS. This is an important and welcome publication, not just for the NHS but in any organisation or venture: it is not only a "how to" book but also a "why to" book. The "why" is often the biggest barrier, and it is well tackled here.'_

— Lorraine Gradwell MBE, former Chief Executive of Breakthrough UK
**Copyright**

First published September 2013  
Smashwords edition February 2016.

Copyright © 2013-16

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, screen shots, recording or storage in any information retrieval system, without prior permission in writing from the author.

The right of Shahnaz Ali, Christine Burns and Loren Grant to be identified as the joint authors of this work has been asserted in accordance with Section 77 of the Copyright, Designs and Patents Act 1988.

Cover design © Christine Burns 2013-16

**Smashwords Edition, License Notes**

This book is licensed for your personal enjoyment only. This ebook may not be re-sold or given away to other people, If you would like to share this book with another person, please purchase an additional copy for each recipient. If you're reading this book and did not purchase it, or it was not purchased for your use only, then please return to your favourite ebook retailer and purchase your own copy. Thank you for respecting the hard work of this author.
**Chapter One**

****

**Historical Background**

**Immigration, partly spurred by the post-World War II expansion of public services and the creation of the NHS, helped to enlarge notions of diversity in a Britain which, until the 1950s, was assumed to be largely homogenous. As the decades progressed, more and more groups became visible in the pursuit of equality.**

The Secretary of State for Health Aneurin (Nye) Bevan steered the National Health Service Bill through Parliament in 1946 and it came into effect on July 5, 1948. The event was marked by the formal opening of Park Hospital (later renamed Trafford General) in Manchester, Britain's first NHS hospital. It was the first of 2,571 hospitals to be handed over to the NHS. There had been a hostile reception from Conservative Party MPs, who voted against the NHS Bill on both its Second and Third Reading, and from the doctors' main representative body, the British Medical Association.

The Conservatives feared that the NHS would soon be bankrupted by the 'feckless poor who would rush in to strip the chemist shops of every pill on the shelves, then head for the dentists' surgeries to have their mouths filled with gold and silver'. (Andy McSmith, The Independent, June 28, 2008).

The medical profession's opposition was based on more complex reasons. Many doctors believed that their professional freedom would be jeopardised, that they would treat fewer private patients and so lose out financially. They also believed that the NHS would not allow patients to pick their doctor – though this proved to be an unfounded worry.

By and large though, the NHS was generally welcomed as a pillar of the new welfare state. But the expansion in capacity required to run the new service created a demand for 42,000 staff members that could not be met from the domestic population in a country only just beginning to recover from the ravages of six years of war (Snow & Jones, 2010a).

All types of staff were needed: nurses, midwives, ancillary workers, cleaners, cooks, and porters. The greatest need was for nurses in hospitals for the chronically sick, mental hospitals, and geriatric wards, but none of these specialties was particularly attractive to existing staff.

**Drawing on the Commonwealth**

The arrival at Tilbury of the Empire Windrush on June 22, 1948, brought 500 Caribbean men and women to the United Kingdom, marking the start of post-war mass immigration. They were responding to the need for workers across many parts of the economy (Kramer, 2007), Not everyone was destined for the NHS, but many were being actively recruited for that purpose. Nurses from Ireland were also arriving to fill posts In in the NHS, continuing a trend that had begun in the years of World War II. The 1950s and 1960s were a heyday for overseas recruitment, especially as the NHS offered women more jobs and better promotion prospects than could be found in Ireland or Commonwealth countries.

The pace of recruitment increased rapidly. By the time the Labour Government returned to power in the 1950 general election, some 5,000 Black Commonwealth citizens had already arrived in Britain to work or join relatives. By the end of the decade, between 20,000 and 30,000 a year were joining the UK economy. Selection committees had been set up in the Caribbean to recruit nurses for NHS hospitals and, 'by the end of 1965, there were between three and five thousand Jamaican nurses working in British hospitals, many of them concentrated in London and the Midlands.' (Snow & Jones, 2010b). Approximately one in three NHS doctors and nurses today are from Black and minority ethnic (BME) groups (Snow & Jones, 2010b).

Numbers continued to increase in the 1960s. By 1961, about half a million Caribbean and South Asian people had come to Britain, or approximately one per cent of the population (UK Census Reports, 1961). In 1962, Minister of Health Enoch Powell announced a 10-year plan for community care under an expanding NHS (Hansard, 1962). To meet rising demand, the country once more turned to the Commonwealth, recruiting more than 18,000 doctors from the Indian subcontinent.

Source: <http://writefix.com/?page_id=924>

The influx of people from Commonwealth countries wasn't universally welcomed, as many of the newcomers recall. In 2008, NHS North West set out to compile a comprehensive history of the contributions of Black and Minority Ethnic (BME) workforce to the NHS, including filming interviews with many NHS staff, past and present. The contributors included Louise Garvey. She trained as a cadet nurse at Congleton Hospital (now part of East Cheshire NHS Trust) and remembers that the early years in the NHS were 'good because people sort of got on and supported one another', but that both patients and staff could be racist.

Despite this, she set her sights on becoming a sister:

'I did extra training, whatever was going in the hospital. Opportunities were always there for nursing but at the same time there was the racism and the feeling at the time that we were only there to do the bedside things. You put yourself forward to ensure that whatever internal training is being offered you got on board. I used to do what I called the watching game. I would watch and see what training was available, who was going for it and how often. I used to challenge the situation. I would say nurse A and B and whatever, she's had x amount of training, why haven't I? This training is available and I am interested, here is my application and that's how you got on in those days. You had to fight for your chances.'

Through the 1960s, numbers of immigrants continued to rise, as men, who may have come on their own to begin with, sent for their families to join them. The obvious changes in the population, especially in the areas where immigration was concentrated, led to increasing disquiet. Some employers and service providers operated a so-called 'Colour Bar', refusing to employ or house black people. This type of practice continued until the mid 1960s and the arrival of the first non-discrimination legislation outlawing it (BBC, 1966). Ironically, considering his role in stimulating immigration, the social concern and anxiety was epitomised by Enoch Powell's 'Rivers of Blood' speech in 1967.

Immigration might have been the factor that most clearly marked a change in Britain's population, as visual and language differences were too obvious to miss. This may also be the reason why people often still use the term 'diversity' as a synonym for race and ethnic differences. Immigration obviously changed the nature of towns and communities, but it wasn't the only factor signalling that British society wasn't as homogenous as people had assumed.

**Women's rights**

Some parts of the nation's diversity were not imported but had been present all along. However, it required the development of awareness, brought about by people making their issues more visible, to put these concerns on the same footing as the obvious difference in people's skin colours.

The 1960s and early 1970s saw the emergence, for instance, of a women's rights movement, often referred to as 'The Second Wave' of feminism. The term ' _second wave_ ' in this context acknowledges the struggles of the suffragists in the early part of the 20th century — the _first wave_. As with racial civil rights, this was something that was happening in parallel on both sides of the Atlantic.

The early part of the 20th century had witnessed the first concerted calls for women's rights, in the form of campaigns for a voting franchise. However, the roots of the first calls for women's rights in Britain and the USA can be traced back beyond the Pankhurst sisters and their fight for women's political equality (the term 'suffragette' was coined by the _Daily Mail_ ). In fact, as early as 1840, women from Britain and the United States had begun a debate about their status relative to men.

At the World Anti-Slavery Convention in London that year Elizabeth Cady Stanton and Lucretia Mott were among several female delegates denied the right to participate in the proceedings. It would still be many decades before any tangible progress was made on either side of the Atlantic; however, it illustrates the long gestation for some movements which then appear to erupt as if from nowhere when they are eventually noticed.

Over the next 50 years, women in many countries campaigned for equalities, including the right to vote. In 1881, the Isle of Man allowed women property owners to vote in parliamentary elections within the British Isles. Elsewhere within the British Empire, New Zealand and the Cook Islands were the first to acknowledge women's right to vote in 1893. South Australia followed in 1895. In Europe, Finnish women won both the right to vote and the right to stand for election in 1906, Norway followed in 1913, Denmark in 1915, and the Netherlands in 1919.

The British women's suffrage movement needs to be seen in this context of a long build up, strong international precedent and the resistance to change. British women over the age of 30 obtained the right to vote in 1918, but it was only in 1928 that this right was extended to all women over the age of 21, on the same basis as for men.

The suffrage movement in Britain was helped by the social changes brought about during the First World War, where women were needed to undertake work that had previously been reserved for men. Apart from the new right to vote, however, the interwar years (1919-1939) were characterised by a retreat into traditional roles. Women were expected to relinquish their jobs in favour of men returning from the front. This persisted until mass male mobilisation in 1939/40 allowed women back into large-scale employment.

After the Second World War there was an expectation that women would once more relinquish the jobs they had performed for six years on the 'home front' and make room in the workforce for men. The ideas of psychiatrist John Bowlby, Deputy Director of the Tavistock Clinic , who pioneered the concepts of 'Attachment Theory' and 'Maternal Deprivation', were held to be reasons why women belonged in the home, raising children (Bowlby, 1951). However, on this occasion the retreat for women wasn't nearly so complete. In particular, the burgeoning public services, like the NHS, created by the post-war Labour government, provided more roles which demanded the talents of women.

The otherwise general pressure on women to adopt traditional roles left tensions, however, which couldn't so easily be put back in their box. By the 1960s therefore a new narrative about women's equality, especially in employment, began to emerge. In 1968, 187 women employed in the manufacture of car seat covers at the Ford factory in Dagenham took industrial action to campaign for recognition that their work was of equal worth to that of their male colleagues. Their action — unprecedented at the time — led to the enactment of the first Equal Pay Act in 1970.

Well-publicised events like this contributed to a growing realisation that the working population of Britain couldn't be reduced to a single stereotype anymore. Similar developments were occurring on other fronts.

**Gay and Lesbian people**

Male homosexuality became illegal in Britain in 1885, through Section 11 of the Criminal Law Amendment Act (the Labouchère Amendment). Ten years later, Oscar Wilde was accused of gross indecency using this law. His highly-publicised trial coloured the public view of homosexuality as an aristocratic vice and an affliction — a view which lasted until the 1950s. Homosexuality was still seen as an _act_ , rather than an identity.

In 1954, a Parliamentary Committee was formed under the chairmanship of John Wolfenden to discuss possible decriminalisation of homosexuality. Recently released BBC archives provide a fascinating insight into the cerebral approach to the question at the time (BBC Archive).

Progress was slow but positive. In 1959 Alan Horsfall, a Labour Councillor in Nelson, Lancashire, tabled a motion to his local Labour party to back the decriminalisation movement. The motion was rejected, but Horsfall and fellow activist Anthony Grey would later form the North West Homosexual Law Reform Committee. This, alongside activity closer to Westminster, began to gradually chip away at public opinion.

Thus it was that Parliament eventually passed the Sexual Offences Act of 1967, legalising sex in private between consenting males, over 21. The Sexual Offences Act began to enable wider activism by gay men, and eventually more visibility for sexual minorities.

The Campaign for Homosexual Equality (CHE) was formed and held the first ever UK gay rights conference in Morecambe, Lancashire, in 1973. That same year, homosexuality was removed (at least in part) from the Diagnostic and Statistical Manual of Mental Illness, published by the American Psychiatric Association. However, it was only in 1993 that the government finally removed homosexuality from its list of psychiatric disorders in England and Wales. (Scotland followed in 2000).

The intervening years were marked by slow advances in social acceptance of same sex relationships, including setbacks such as the Conservative government's introduction of 'Clause 28' in its Local Government Act of 1988.

This prevented local authorities from:

'intentionally promot[ing] homosexuality or publish[ing] material with the intention of promoting homosexuality' or 'promoting the teaching in any maintained school of the acceptability of homosexuality as a pretended family relationship.'

Such setbacks help to explain why people are still today less conversant with the equality issues of Lesbian, Gay and Bisexual people than other protected groups.

Other groups were at different points on the road to recognition and articulating calls for equal treatment. In the 1960s and 1970s when attention was focussed on immigration, women's liberation and gay rights, very little was known about transsexual people for instance.

**Gender reassignment**

Newspapers had reported occasional instances where someone was discovered to have had a 'sex change' (to use the tabloid parlance) from as far back as the mid-1930s. These cases were considered a curiosity and, in fact, transsexual people had posed little overall concern, as the law had not troubled itself with questions of their status. People seeking gender reassignment either found discreet support from UK clinicians or sought treatment on their own abroad. There were several unremarked cases in the 1950s and 1960s where people discreetly underwent gender reassignment treatment (usually in Casablanca), then quietly settled into their new lives, including having their birth certificates annotated and marrying.

That was all to change in 1969, when a high profile divorce case involving socialite April Ashley and millionaire Arthur Corbett (heir to a considerable fortune) defined the former as legally a man, for the purposes of marriage. Defining her status in this way enabled the marriage to be declared ' _void ab-initio_ ' — it could be treated as though it hadn't taken place. The consequences of this case were to progressively marginalise transsexual people in a way they had not experienced before — so effectively that their rights did not re-enter public debate until the mid 1990s.

**Disabled people**

Disabled people also had a long journey towards a formal and public recognition of their rights. If disabled people were considered at all in post-war Britain, the prevailing attitude would be one of pity, informed by a belief (enforced by medical attitudes) that they were defined and limited by whatever medical label was attached to their impairments.

Whether disabled through wounding in war, congenitally, or through diseases such as scarlet fever or polio, disabled people were assumed to have few prospects for participation in normal life. As children they were sent to special schools, where staff had only low expectations of their pupils' attainments. People with mental illnesses or learning difficulties were likely to face long-term institutional care. Adults with physical disabilities and no family support were also likely to be institutionalised. The barriers posed by the inaccessibility of many public facilities also meant that even disabled people living in the community were relatively invisible.

According to the All Party Parliamentary Disability Group (established in 1968), the disability rights movement had little real form or shape before 1965 and the question of rights had never arisen in parliamentary or public debate. This is not quite accurate, as the National League of the Blind had been in existence as a trade union since 1899 and was affiliated to the TUC in 1902. The league organised a strike in 1912 and national marches on London in support of what became the Blind Person's Act, 1920. That action is credited as an inspiration for the subsequent Jarrow March. However, from the 1966-67 parliamentary session onwards, the volume of references to disability and disabled people in Hansard certainly grew. It was clear that there was increasing pressure for the improvement of services and rights. This is attributed in large measure to the influence of Stoke-on-Trent MP, Jack Ashley.

Jack Ashley became deaf shortly after first becoming elected as an MP in 1966. He founded the All Party Parliamentary Disability Group two years later. In those days disability benefits were inadequate and the obstacles which disabled people would meet in performing normal everyday tasks, such as going to the shops, could often be daunting. As Jack later wrote: 'The failure to tackle disability was a failure of democracy. Millions of disabled people were being ignored and their views disregarded.'

The work of Jack Ashley and others (notably Alf Morris) led to the enactment of the Chronically Sick and Disabled Persons Act 1970 and therefore a measure of official (if not public) awareness. People who were born disabled were still likely to be trapped in long-stay hospitals with little or nothing to do; older people becoming disabled were faced with a struggle to preserve their dignity against all odds; people of all ages were living in dire poverty and isolation, warehoused in restrictive institutions or imprisoned in the back rooms of unsuitable housing (All Party Parliamentary Disability Group, 2008).

As often happens, the legislation encouraged more people to become active as campaigners. From the 1970s, groups of disabled people began to spring up around the country, as rights-based organisations. An early example was the Union of Physically Impaired Against Segregation (UPIAS). Groups like this began a successful challenge to the belief that disabled people should be pitied and the objects of charity. They promoted an alternative understanding that disabled people did not have (but were entitled to) independent and dignified lives as full members of their families and society.

The movement gained a stronger voice in the 1980s with the promotion of a radically different way of viewing disability, first defined by Professor Mike Oliver. The Social Model of Disability (Oliver, 1990) was radical in the way that it opposed the dominant view of disabled people being 'defective' and limited by their impairments. The social model of disability positions the responsibility for barriers faced by disabled people squarely on the shoulders of society. A wheelchair user is not prevented from entering a building because his legs don't work and he needs a chair, but because of the fault of the architects and builders, creating premises where the only access is via steps. Solve the problem with the steps, and the wheelchair user is no less able than anyone else to enter the building and work, or access facilities and services.

**Legislating for diversity**

Starting from different points, we can see therefore how Britain progressively changed in the second half of the 20th century: from a society in which everyone was presumed to be more or less alike, with no special needs, to a more diverse community made up of people whose differences could mean they got a less equitable deal, and who were all finding the voice to demand equality.

The inevitable response to the ensuing calls for equality in employment, pay and access to goods, facilities and services, was a progressive growth in legislation.

The Race Relations Act 1965 marked Britain's first step in legislating on discrimination against visibly different immigrants. It was passed as the new political narrative began to emerge, viewing immigration rates as a problem to be limited.

The 1960s also witnessed the re-emergence of a feminist politics in both Britain and the United States, giving rise to demands for legislation to address pay and wider sex discrimination. The Equal Pay Act was passed in 1970, followed by the Sex Discrimination Act in 1975. As sex and race discrimination law was enacted, and as the discourse about the importance of equality grew, there were calls for previous legislation to be revised and given wider scope.

The 1965 Race Relations Act outlawed overt discrimination in public places and had set up the first Race Relations Board to investigate cases of unlawful discrimination. It was followed swiftly by a 1968 Race Relations Act, making it also a _criminal_ offence to discriminate in the provision of housing or public services and creating a 'Community Relations Commission' to promote 'harmonious community relations'. The 1975 Sex Discrimination Act (SDA) and a new Race Relations Act 1976 introduced more sophisticated definitions of direct and indirect discrimination in employment, education, and the provision of goods and services. The SDA also created the Equal Opportunities Commission (EOC). However these two Acts, and everything that followed were framed as civil as opposed to criminal law (requiring individuals to seek redress for themselves).

For disabled people, as already noted, the Chronically Sick and Disabled Persons Act 1970 provided a small measure of protections; this did not, however, outlaw discrimination.

Although not an equality law, the 1967 Sexual Offences Act could be seen as an enabler for moves towards equality by homosexual men. Lesbianism had never been unlawful, but the change in the law, which enabled the emergence of activist groups seeking equal rights, also indirectly advanced the rights of lesbian women and bisexual men and women.

Yet transsexual peoples' rights were paradoxically moving in the opposite direction at that time, with a loss of civil status following the April Ashley case and subsequent adverse judgements. That would only be corrected by the Sex Discrimination (Gender Reassignment) Regulations 1999, which outlawed employment discrimination; and the Gender Recognition Act (2004) which created a framework for legal recognition of reassigned gender, measures to protect privacy, and the ability to marry.

Then the development of legislation appeared to virtually stall. Between 1976 and the passage of the first Disability Discrimination Act in 1996, there was little further legislation tackling inequality and discrimination. The hiatus coincided with an uninterrupted period of Conservative government between 1979 and 1997. This isn't to say _no_ progress at all was made.

A report by the Committee on Restrictions Against Disabled Persons (CORAD), chaired by Sir Peter Large, found in 1979 that discrimination was just as extensive in relation to disability as to race or sex. However, despite recommendations for new legislation, the government omitted to take action.

In 1983 Jack Ashley drew up the first private member's Civil Rights (Disabled Persons) Bill to outlaw discrimination on grounds of disability. It provided for a commission, with powers to conciliate and to take legal action when necessary, just like the Equal Opportunities Commission (established by the Sex Discrimination Act in 1975) and the Commission for Racial Equality (created by the Race Relations Act the following year). The bill was tabled, unsuccessfully, by another back-bencher Donald Stewart.

Three years later, Tom Clarke also obtained a place in the ballot for Private Member's Bills and tabled what developed into quite a radical bill, which included the right to appoint a representative to act on a disabled person's behalf; the right to a voice in the assessment of support needs; and improvements in coordination of public services. Clarke's Bill was passed in July 1986 as the Disabled Persons (Representation, Consultation and Services) Act, although the Conservative government showed little interest in enacting many of the most important provisions.

Once it became clear that the Government didn't intend to put Tom Clarke's bill into effect, there was a much stronger response from disabled people and their supporters. A mass lobby took place in Westminster Hall on 8th April 1987, attended by 200 MPs including (by then) the leaders of all the parties. The government eventually implemented more parts of the Disabled Persons (Representation, Consultation and Services) Act, although some features unimplemented to this day.

The government of the day continued to be set against legislation for disability rights all the way into the early 1990s. The Civil Rights (Disabled Persons) Bill was once again tabled as a private member's bill by Roger Berry in 1994. This time it was defeated at Final Reading. The ensuing public uproar finally pushed John Major's administration to bring forward its own Disability Discrimination bill, enacted in 1995, ending more than a decade of resistance to legislating formally for disabled people's rights (Hicks & Allen, 1999).

The impetus for further legislation in the 1990s and 2000s came as a result of events outside of government control. A European Court of Justice finding in an employment case in favour of a transsexual manager required the new Labour government in 1997 to table regulations extending the Sex Discrimination Act to cover people who are planning to undergo, currently undergoing, or had undergone gender reassignment. A lesbian couple mounted and lost a challenge in the same court regarding survivor NHS pension rights.

These actions began to widen the concept of equality and spawned a growing understanding about diversity as a specific demographic concept. (Until then, the term 'Diversity' had been utilised mainly as a euphemism for 'Racial Equality' at a time when Margaret Thatcher's government disliked the latter). The new Labour government, which came to power with a landslide majority in May 1997, also had a different attitude towards social inclusion and fairness than the preceding Conservative governments. Instead of resisting change, they were proactive about it. This was most clearly epitomised by the manifesto commitment to incorporate the European Convention on Human Rights into British Law. In 1999, the new government also created the Disability Rights Commission, charged initially with reviewing the Major Government's 1995 Disability Discrimination Act, and enacted regulations to add explicit employment and education protections for transsexual people to the Sex Discrimination Act.

**Human rights**

We'll talk in more detail about the development of Human Rights principles in the next chapter. Suffice to say at this point that although Britain had been very much involved in the evolution of both the Universal Declaration of Human Rights (ratified by the United Nations in 1948) and the European Convention for the Protection of Human Rights and Fundamental Freedoms, commonly known as the European Convention on Human Rights, (ECHR — ratified between the parties of the Council of Europe in 1953) it had never incorporated the principles into United Kingdom law.

The unincorporated nature of the ECHR meant that British citizens could not rely on human rights principles being taken into account within the system of UK justice, except where they were implicitly provided for within existing statute. The right to life (article 2) was protected, for instance, in the sense that national law prohibited murder and punished manslaughter. The right to liberty (article 5), the right to a fair trial (article 6) and the right to no punishment without law (article 7) were all effectively protected to a degree by the construction of judicial and penal processes, and an unwritten trust that the government (which could in theory change any of these) was guided by principles of so-called 'natural rights' extending back to the British Bill of Rights (1689), the French declaration of the Rights of Man and the United States Bill of Rights (both 1789).

Indeed, the opponents of further integrating specific enumerated rights into UK law argued that it was precisely because legislators have had that long (almost axiomatic) tradition of understanding 'natural justice' that no more explicit connection was required. The reality was different, however. There were many cases where courts were limited in being only able to judge cases in the terms of the statutes before them. Put simply, if the law makers hadn't provided for (say) the situation of an elderly person left lying in wet and soiled sheets in a hospital bed (which it hadn't), the justices had no basis on which to rule that any existing law had been broken. In order to apply Article 3 of the ECHR ('the right not to be tortured or treated in an inhuman or degrading way') a plaintiff would need to work their way up to the very top of the courts system through the appeals process, exhausting all possible domestic remedies, before they could then apply to the European Court in Strasbourg to consider their case. If the European Court upheld their plea, in terms of the 14 Articles of the convention, the decision could be a pyrrhic victory, as the United Kingdom was not absolutely bound to honour the finding. In practice Britain almost always _did_ honour such decisions; however, it was a precarious position for anyone prepared to spend the many years which such a process could take.

The Human Rights Act of 1998 ended such uncertainty, brought a new level of interpretation to existing statute, and introduced everyone to thinking in every day terms about the principles of equity, which ought to apply regardless of whether the rights at issue concerned gender (or gender reassignment), race or ethnicity, disability, sexual orientation, religion or belief, age, or circumstances such as caring responsibilities, marriage, or parenthood. The Human Rights Act meant that, for the first time, judges sitting in the ordinary courts of the land could decide how to interpret the gaps or ambiguities in the existing law in terms of the the underlying principles (such as the right to respect for private and family life, home and correspondence - article 8). They could declare that an existing law was incompatible with those human rights principles, and lawmakers drafting new statutes in Parliament had to test the provisions against those same principles, to ensure they were compatible.

**Public sector duties**

A racial discrimination case led to the next major development. Stephen Lawrence, a Black British teenager from Eltham, London, was stabbed to death while waiting for a bus on the evening of April 22, 1993. Five suspects were arrested but not convicted at the time. Two of them were eventually convicted in January 2012.

An inquiry headed by Sir William Macpherson examined flaws in the original Metropolitan Police investigation and concluded in 1999 that the force was institutionally racist. The recommendations of the Macpherson report led to the Race Relations (Amendment) Act 2000, which included a new Public Sector Race Equality Duty that came into effect in April 2002.

The Race Equality Duty marked a radical change in the approach to tackling discrimination and exclusion. Until then, the responsibility fell on the victims of discrimination to initiate legal action. Even if litigants won their case, there was no obligation on organisations to take account of the lessons learned and embark on institutional change.

The Race Equality Duty reversed this. Section 71(1) of the Race Relations (Amendment) Act required public sector organisations to have 'due regard to the need' to eliminate unlawful racial discrimination and to promote equality of opportunity and good relations between persons of different racial groups. The duty was obligatory and had to be applied to all functions that are 'relevant' to race equality. The role of the Commission for Racial Equality was also extended to ensure the duty was being fulfilled.

The Race Equality Duty generated a demand for professional managers who could help the public sector meet it. The new law, coupled with the arrival of an expanded European Equal Treatment Directive (2000/78/EC), also created a need to update the language and breadth of other equality legislation. The Disability Discrimination Act 2005 contained a Disability Equality Duty that came into force in December 2006. This again added to the scope of powers for the corresponding Disability Rights Commission (DRC), enabling it to work more proactively on dismantling barriers to equal participation in society.

The Equality Act 2006 created a new single equality regulator (the Equality and Human Rights Commission) plus a Gender Equality Duty, which came into effect in April 2007. Regulations protecting people on the grounds of sexual orientation and religion or belief were first enacted in 2003 and augmented in the 2006 Equality Act. The legal recognition of gender change by transsexual people was codified in the 2004 Gender Recognition Act; the Civil Partnership Act introduced civil partnership for same-sex couples later that year; the Marriage (Same Sex Couples) Act 2013 took legal relationships for same sex couples even further (though not completely) along the road towards genuine equality.

**A Single Equality Act**

With the move to set up the new Equality and Human Rights Commission came a parallel desire on the part of the Labour government to rationalise equalities legislation, remove anomalies in the provisions for different protected groups, and introduce the same levels of protection and public-sector duties for all. An extensive public consultation ensued, and a new Equality Act was finally passed in the last week of the Labour administration in April 2010. The legislation, replacing more than 100 existing acts of Parliament and regulations with a single Act and public sector duty, began coming into force in October 2010.

The coalition government has not, however, brought all of the Equality Act's provisions into force. Home Secretary and Minister for Women Theresa May dropped the provisions for creating a 'socio-economic duty,' dismissing them as 'ridiculous.' The socio-economic duty would have obliged public bodies to consider and address inequalities caused by class and income factors and would have included addressing health and educational outcomes. The coalition also dropped provisions requiring organisations to perform detailed pay audits. Pay disparities for women and men doing the same job have remained largely resistant to change in the 43 years since the Equal Pay Act was passed in 1970 (Fawcett Society, 2013).

The substantive parts of the Equality Act are now in force and cover direct and indirect discrimination; harassment, bullying, and victimisation; discrimination by association with a protected group; or the perception of being part of one.

The law applies to employment, education, and the provision of goods, services, and housing.

The law applies to men and women; gender reassignment (no longer dependent on medical treatment); race and ethnicity; disabled people; sexual orientation; religion or belief, age, caring responsibilities, and (in some contexts) marriage or civil partnership.

However, although Britain now has an almost 50 year history of enacting protective legislation and more than a decade of experience with public-sector duties and human rights law, there are few signs that discrimination is being eliminated or that the need to change public awareness and behaviours is reducing. Between 2002 and 2010, the number of claims accepted by the Tribunals Service more than doubled (from 115,042 to 236,100), with claims relating to sex discrimination, disability, equal pay, race, and sexual orientation all seeing a significant increase (Ministry of Justice, 2010).

Chapter 3 will show how laws and duties don't themselves bring about changes in behaviour by either institutions or individuals. Something else has to happen and, as we'll argue, it's vital to understand how to bring about successful culture change if we are not to confuse hopeless effort with solid outcomes moving us towards more equality.

That is our purpose in writing this book: to shine a light on the part of the equation which needs to work in order for the intentions of a massive tradition and framework of equalities law to actually have a permanent and lasting effect in society and its public institutions. Before that, however, we need to discuss a concept which is in danger of being taken for granted: why equality matters.

**References in Chapter One**

All Party Parliamentary Disability Group (2008). 'A celebration of the work of the All Party Parliamentary Disability Group and its Chair Rt Hon Lord Ashley of Stoke'.

Retrieved from :

<http://www.lordjackashley.co.uk/pdf/appdg.pdf>

BBC Archive: 'The Gay Rights Movement'.

Retrieved from :

<http://www.bbc.co.uk/archive/gay_rights/>

BBC Archive: '1966: Euston Staff Colour Bar Ended'

Retrieved from :

<http://news.bbc.co.uk/onthisday/hi/dates/stories/july/15/newsid_3043000/3043439.stm>

Bowlby, J. (1951). Maternal Care and Mental Health.New York: Schocken. P.89.

Fawcett Society. (2013). 'Equal Pay'.

Retrieved from :

<http://www.fawcettsociety.org.uk/equal-pay/>

Hicks, J., & Allen, G. (1999). A century of change: Trends in UK statistics since 1900 (Research Paper 99/111). Retrieved from :

<http://www.parliament.uk/documents/commons/lib/research/rp99/rp99-111.pdf>

Kramer, A (2007). 'Many rivers to cross: The history of the Caribbean contributions to the NHS'. Retrieved from:

<http://www.manyriverstocross.co.uk>

Ministry of Justice. (2010). 'Annual statistics for the Tribunals Service, 2009-10'. Retrieved from:

<https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/218501/tribs-et-eat-annual-stats-april09-march10.pdf>

Oliver, M (1990). 'The Politics of Disablement: A Sociological Approach'. Palgrave Macmillan.

Snow, S., & Jones, E. (2010a). 'Against the odds: Black, minority and ethnic clinicians and Manchester, 1948-2009'. New York, NY: Carnegie Press.

Snow, S., & Jones, E. (2010b). 'Immigration and the National Health Service: Putting history to the forefront'. Retrieved from:

<http://www.historyandpolicy.org/papers/policy-paper-118.html>

'The Birth of the NHS'. Andy McSmith, writing in The Independent:

<http://www.independent.co.uk/life-style/health-and-families/features/the-birth-of-the-nhs-856091.html>
**Chapter Two**

****

**Why equality matters**

In the previous chapter we described how, in turn, groups within our society moved from a position of being hidden, marginalised or discriminated against, to finding their voice and creating a public understanding of the need for change. Each became an embodiment of the position of the women's movement that 'the personal is political' (Hanisch, 1969).

As we've seen, the response by a society faced with the demand for greater equality is to legislate. The usual first step is to provide redress via the courts, and then (as that fails to address embedded and systemic frameworks), to create legally enforceable duties for representatives of the state to take the initiative in tackling inequality.

But do these responses work? Not so far. If it were that simple then most forms of inequality would surely be history by now. Employers, policymakers, managers, staff and the public would say, 'The law says it's wrong to discriminate directly or indirectly against this group of people, so we'll stop it.'

Clearly that isn't the case. In fact, if yearly comparisons of tribunal cases are anything to go by, incidents of discrimination are on the increase, and not just because there are more types of discrimination that are now legally banned. There are more cases of sex discrimination, even though the Sex Discrimination Act has been in force continually from 1975 until it was replaced by the Equality Act in 2010. (This law brings together the principles of more than 100 pieces of legislation and replaces them with a single Act) . In addition, pay disparities for women and men doing the same job have remained largely resistant to change in the 43 years since the Equal Pay Act was passed in 1970 (Fawcett Society, 2013).

Simply having a public sector duty in place doesn't, on its own, produce change either. Certainly, public sector organisations can say that they have 'complied' with the duties placed on them by publishing documents to show that consideration has been given to eliminating discrimination, promoting equal outcomes and fostering better relations (in the case of the race duty).

However, the Race Equality Duty was in force for nine years from April 2002, until it was replaced by the Equality Act's integrated Public Sector Equality Duty, and still people were saying that sections of organisations such as the Metropolitan Police were institutionally racist. In _The Stephen Lawrence Inquiry 10 Years On_ ' (2009), the independent think tank The Runnymede Trust reported that, in some cases, relationships between the police and Black communities had actually worsened in the previous decade.

'Annual government data on race and the criminal justice system shows that Black people continue to be up to seven times more likely to be stopped and searched than their white counterparts. This figure is worse than in 1999, and with the continued low arrest and conviction outcomes stop and search procedures remain questionable as an effective method of crime detection'

(Runnymede Trust, 2009)

The picture for Black and minority ethnic employees of the police is not encouraging either.

'Retention and progression of Black and minority ethnic officers is also a problem for the police service. Disproportionate numbers of Black and minority ethnic officers leave the service within their first 5 years of service' (ibid)

****

In all these cases, the law simply draws a line in the sand. It defines a society's official view on the acceptable boundaries of behaviour. However, it doesn't (of itself) guarantee change in that behaviour. Something is missing. If we want to succeed in bringing about sustainable changes in behaviours and outcomes, we must be clear about what that missing element is, and be capable of persuading others of the case. In short, 'Why does equality matter?'

If you were to ask a lawyer this question (and it is lawyers who draft these Acts of Parliament) then you would most likely be referred to a long egalitarian tradition and social theory. Although the 20th century saw the origins of most specific non-discrimination legislation, in the UK as well as the rest of the world the underlying principles are much older.

**First generation of human rights**

The 17th and 18th centuries saw historic declarations of what were characterised as 'natural rights' in Britain, France and the United States. These were the first generation of modern rights: the right to life, the right to freedom of expression and the right to liberty. They reflected in many ways the political turmoil which preceded them, since they had been won by confrontation, revolution or declarations of independence. Equally important, these declarations were attempts to codify principles in order to prevent ruling elites easily withdrawing these hard-won advances. The codification has been taught to successive generations through schooling, as something precious. The result is that they are far more likely to be seen as axiomatic, and foundational principles of the culture.

A moment's reflection will also allow us to see that accepting these principles is also a matter of enlightened self interest. All of us, regardless of our station in life, can see that these are rights that would hurt us if removed. This is important, as people who feel that they are not in a minority or vulnerable group may find it harder to empathise with experiences of discrimination; they may therefore feel legislative rights are unnecessary or over-protective.

**Political correctness**

The seemingly more superficial manifestations of equality, such as respecting people's self-definitions, and avoiding negative stereotypes in language and images, have provoked accusations of 'political correctness gone mad' from some quarters, particularly the more conservative and reactionary sections of the mass media. This has contributed to the creation of a public narrative that characterises the struggle for equality and the protection of human rights as an expensive and ridiculous indulgence, and in some cases, foisted on an unwilling British nation by foreign bodies such as the European Court of Human Rights.

So part of the challenge of explaining the relevance of Human Rights to people in a safe, comfortable, nominally democratic world, is to relate them in terms they can understand for themselves and their family if their comfortable circumstances were to change.

**Workers' rights**

Returning to the question of how lawyers understand the tradition of rights, the second generation of thinking mostly belongs to the first half of the 20th century. Principles of worker rights were ratified in 1919 by the International Labour Organisation (ILO), established as an agency of the League of Nations at the end of the First World War.

This development was based on a belief in the universality of worker rights. The aim was to assist in establishing social stability in the postwar order. The principles concerned issues such as child labour, forced labour and the idea of minimum wages. These kinds of socio-economic rights were discussed and developed (often on the international stage) in terms of whole populations, but it makes equal sense to frame these developments in terms of personal benefits and and self interest.

For example, we know how damaging it is for children to be forced into the labour market instead of going to school. There is plenty of evidence from historical experiences in the UK of child labour in factories, mills and mines; and today from parts of the developing world. We wouldn't want it for ourselves, or our children either.

Similarly, those in comfortable, well-paid jobs can appreciate how the protection of their rights has contributed to their career progression; or how they or their families might be exploited if circumstances suddenly changed. Common socio-economic rights like these don't require much effort to sell to us (unless born into a position of such privilege that we just can't imagine being poor or jobless.)

For lawyers contemplating how to turn such principles into law, the strength of a statute relies on its integrity and universal application. Once you start making exceptions to the idea of rights, wedges can be driven in, undermining the whole principle.

**Rights are indivisible**

Therefore, it makes sense - both practically and ethically - that if workers have rights then they should apply in all circumstances, including if you are a woman, or of a different ethnic heritage, are disabled, or LGBT. Where the universal principle appears to fall down, because of prejudice or because the people affected form too small or politically weak a group to complain, then lawyers will look to see whether existing law can provide a remedy and, if not (and assuming they don't share the prejudice themselves), the logic commands that the law should be explicitly strengthened.

In 1948 the United Nations ratified the Universal Declaration of Human Rights. Two years later the European Convention on Human Rights was also drafted, and finally ratified by the Council of Europe in 1953. The principal difference between these two is that, whilst both contain unqualified core provisions on questions such as the right to life, the right not to be tortured and the right to not be subjected to cruel and degrading treatment, the European Declaration _avoided_ committing states to some of the more social provisions in the UN form, such as the right to work.

Equalities legislation has tended to address that gap between the two charters, as it has been minorities for whom the deficit in protections has been most obviously felt. Our society may have balked at signing up to the right to work for everyone, but it has been prepared to legislate explicitly to protect the rights of minorities to be no worse off than the norm in terms of that social settlement. Lawyers perhaps see no particular need to justify equalities beyond the fact that any particular requirement fits within a long philosophical tradition about what is morally right to do.

**The politician's view**

Similarly, if you were to ask a politician: 'Why does equality matter?', you would most likely get an answer which also appeals to historical moral philosophy and religion, coupled with assertions on pragmatic concerns such as social justice and community cohesion.

It's clear from the history of rights struggles that politicians only initiate moves to promote specific equality when prodded with the pointy sticks wielded by activists on behalf of the affected groups. A case needs to be made out by those activists, along the above lines, and then the politicians belatedly act, not out of altruism or from a genuine sense of strategic vision, but rather when they judge they have no other options and it is expedient to do so.

The fight for women's suffrage in the UK in the early 20th century is just one of many examples where grassroots activism, part of and a contributor to irresistible social change, forced the government's hand.

The history of government action on equalities is marked by attempts to water down rather than taking the initiative to expand on the provisions which people seek. The UK Conservative Government in the 1980s fiercely resisted calls for protecting the rights of disabled people, and actually legislated _against_ the interests of gay and lesbian people.

The Labour government in the 1990s legislated for protections for transsexual people only after decades of resisting challenges in the European Courts; they changed their approach only when that resistance was exhausted and they had lost.

The Conservative government in the second decade of the 21st century has watered down the Equality Act for women by deciding not to implement the provisions for pay audits and the concept of combined discrimination (which would have benefitted Black and ethnic minority women in particular).

**Resistance to equality for its own sake**

Clearly, then, except in the rarified circles inhabited by rights lawyers, social scientists and the victims of discrimination themselves, there is a resistance to equality for its own sake. It is not so much a question of whether there is a moral or egalitarian case for equality but a question that in some cases people find it easier to think of self serving reasons to preserve the status quo.

So where does the wider population fit into this?

It is obvious that for some people the concept of 'equality' may be anathema. There are people who are actively and passionately racist, sexist, homophobic, or unfriendly towards disabled people for visceral reasons that they may not be able to explain. Such people appear to be in a minority, otherwise Parliament would simply not be able to pass the legislation that they have. And it is for the behaviours of such dyed-in-the-wool opponents of equality that most legislation seems to be designed. The implicit message in laws against discrimination is that, 'as a society we are not going to debate this with you further; these actions will be punished'.

It is probably fair to say that most people do not fall into such an extreme category though. They may indeed be swayed by tabloid newspapers telling them that promoting equality for the latest unpopular minority is 'political correctness gone mad'. However, history shows the moral relativism of such positions.

For example, an 18th century version of the _Daily Mail_ would have bellowed 'political correctness' at attempts by William Wilberforce to outlaw slavery in the British Empire. Similarly, people are less inclined to see equality for Black and ethnic populations or women as politically correct today, although that view had more traction in the 1960s and 70s when legislation was being enacted.

Early usages of the phrase can been found in various contexts from as early as the 18th century. By 1970, New Left proponents had adopted the term 'political correctness'. In the essay 'The Black Woman', Toni Cade Bambara says: '... a man cannot be politically correct and a [male] chauvinist too.' Widespread use of the term politically correct and its derivatives began when it was adopted as a pejorative term by the political right in the 1990s. [WikiPedia]

Yesterday's 'political correctness' is, very often therefore, today's accepted social norm. However, for all that, discrimination persists. People may no longer roll their eyes when equality is advocated for disabled people; however this doesn't change the fact that less than equal outcomes tend to be the default, except when we tap people on the shoulder and point out what they may be carelessly doing.

**Careless discrimination**

And it is this notion of 'careless discrimination'... things done without malice, thought or comprehension, which probably defines the position of the majority in society. Most people aren't against equality. If you asked the 'average person' on the street if they were in favour of equality, they would be most likely to agree, as this would fit the self-image we like to have as fair and reasonable people. However, people don't always understand when they might be _unintentionally_ discriminating. It is this group we want to reach - whether that is an NHS manager who writes a policy in ignorance of how it could play out for different people, or a front-line worker who is simply oblivious to the way that their words may cause offence.

In theory it should be easy to reach out to these people — the majority — with information which can help them make 'equality-conscious' thinking the norm in everything they do. Where words are sensitive, it is very often because they have become symbols of an experience of oppression; however, if you haven't personally experienced discrimination in a systematic way, or if it hasn't been explained to you, you won't necessarily understand that reaction.

Nevertheless, there is resistance to overcome first. There are those whose fear of change makes them resort to the accusation of 'political correctness'. And there are those who simply question the time and effort that it takes in a large organisation to impart that knowledge and win hearts.

Underpinning all this is the need to go back to basics: 'why does equality matter?'

**Why do people _think_ equality matters?**

A legal framework that is not founded on equality before the law, or which cannot produce the same outcomes regardless of the people appealing to it, would be felt to contain the seeds of its own downfall.

So lawyers can state why equality matters.

The government of the day might be accused of seeing equality only in terms of votes or short-term expediency. It may develop a narrative that borrows religious or sociological moral rhetoric as a _post hoc_ justification for bringing forward legislation. However, if that were their real motivation then you would ask why it took them so long and why (in almost every case) the impetus has to come from activist stakeholders.

In their book _The Spirit Level_ , Richard Wilkinson and Kate Pickett present a meticulously researched case that inequality is the root cause of many of society's ills. The authors contend that levels of violent crime, mental illness, drug addiction, illiteracy, obesity and other social problems are almost always higher in more unequal societies and that even the affluent are adversely affected by inequality. In our own field of health they say, 'National standards of health [..] are substantially determined by the amount of inequality in a society.' (Wilson & Pickett, 2009)

Of course, Wilkinson and Picket's observations should be open to challenge from competing evidence and analysis; however we do need to ask why the _achievement_ of genuine equality is not higher on the agenda, given that legislators are apparently so concerned with reducing crime and the costs of so many public health issues that might be attributed to unaddressed inequalities. Maybe it's because they've not made the connection?

So politicians may give mixed messages about equality which, in turn, communicate to the wider public. Ask anyone on the street: 'Why is equality important?' and you are liable to get a mish mash of responses about 'being fair' (or, less charitably, 'being politically correct').

As that same public will include the people who recruit employees and who design, commission and run the services which almost all of us use, this should be of concern. These attitudes could explain why service providers may be reluctant to spend scarce time or resources on understanding how adverse outcomes occur, and how to avoid them in what they do.

What's required is a better narrative about 'why equality matters'... not a lawyer's or a politician's reasons, but a case that makes sense to the rest of us.

**So why does equality REALLY matter?**

First, as set out in Chapter 1, the starting point is that we are not all the same.

Statistics are only just emerging from the last public census (March 27, 2011), which has been criticised for not covering certain characteristics (most notably sexual orientation) and for potential flaws in the way that a question relating to religious belief was posed. Even though national statistics based on the 2001 census are now 10 years out of date, there are enough broad indicators of the diversity of the population.

In mid-2001, there were 33 local authorities (LAs) in England (out of a total of 354) in which more than one in five of the population was non-White, and for a further 25 LAs, the proportion exceeded 1 in 10 (PEEG, 2011).

The Census results also show that almost 9.5 million (18.2%) of the population report a long-term limiting illness, health problem, or disability (PEEG, 2011).

Estimates that 6% of the population are lesbian and gay and 3% are bisexual are only indicative figures from the Government's Actuaries Department, because sexual orientation monitoring is either not performed or poorly carried out. In 2009 the North West Development Agency (NWDA) commissioned Ecotec to undertake more detailed research __ which concluded that the region (pop. 6.9m) had an LGBT population of roughly 430,000. As the authors put it, 'that equates roughly to a population the same size as the region's second city Liverpool'. (Ecotec, 2009)

Over the past 25 years, the percentage of the population aged 65 and older increased from 15% in 1985 to 17% in 2010, an increase of 1.7 million people (PEEG, 2011).

There are potential overlaps between these characteristics (one person can have some or all of them), and it is clear that a substantial part of the population has one or more. In 2006, research by the North West Regional Assembly (since disbanded) suggested that, by 2010, only 20% of the population in the region would be white, male, non-disabled, heterosexual, and aged 18 to 45. Yet this latter group, which has been declining in number since the Second World War, still persists in the popular imagination as being in the majority.

For public sector organisations such as the NHS, funded to serve the whole population, observations such as these are important. A raft of statistics indicates why this may affect public health planning and the commissioning of health care. Research compiled by us for NHS North West's five-year equality and diversity strategy, _Narrowing the Gaps_ (2008b) indicated a host of reasons why understanding the diversity of the population is of fundamental importance when planning health services.

For a start, in the North West as a whole, life expectancy is significantly lower than the national average for both men and women and even lower for BME groups. But how do you tackle that without breaking it down... 'disaggregating' the numbers, as we say?

When you _do_ peel back the layers you find that three times more men than women die from suicide. Men are much less likely to visit their family doctor than women, yet are twice as likely as women to develop and die from the 10 most common cancers affecting both sexes. Gender is the most universal of all factors — we all have one — yet it is surprising how many policymakers have little hunger to drill into statistics like those and find out the reasons, rather than treating the differences as axiomatic.

Is it really 'just a fact of life' that men, on average, live shorter lives than women? Actually it isn't. And behaving as if it is, and therefore not acting to deal with such a gross avoidable inequality, ought to be as scandalous in the 21st century as death camps and apartheid were considered to be in the 20th. Equality matters and, what's more, should be achievable.

Apart from the obvious affront to human rights and natural justice, why should avoidable early deaths matter if you're running the NHS or a local authority? Because when people die prematurely, it's usually because of avoidable illnesses that will have needed treatment, including hospitalisation and all the expensive tools at the clinician's disposal. On top of that, however, men dying sooner than they should are likely to leave behind partners or spouses, who in turn may require additional social care, if not immediately, then as they age. It is in the interests of society that people survive healthily to a peaceful end, minimising the support required from health and social care services.

Going only slightly deeper into the numbers, we discover that the differences in suicide and overall mortality for men and women are magnified for Black and Asian men and women. Ethnic minority groups have higher rates of diabetes, mental illness and other health problems. Some of this can be attributed to inherited differences; however, even where this is the case, an informed and targeted approach to health education and screening can narrow the gaps: hence the title of our five-year strategy for the region _Narrowing the Gaps_.

As an example, we know that South Asian women (in Britain and in India) are likely to develop breast tumours at a younger age than Caucasian women, so screening all women at the same age is likely to result in late detection for some groups. At this point, tumours are more advanced, interventions have to be more invasive, and the health outcomes are poorer (Jain, 2010 and Lofters, 2013) . As well as the painful inequalities of outcomes for the women concerned, the financial implications for health service budgets are obvious.

Further investigation reveals barriers for Asian women to accessing screening when it is offered. There might be simple language barriers in the patient literature, or cultural reservations about who might see you naked, or what the process involves. When both patients and healthcare staff are better informed about these issues, then our experience tells us that the barriers can be more easily overcome.

**Tailored approaches**

One solution may involve tailoring your message to different parts of the community, so as to maximise the effect. Some North West NHS primary care trusts (PCTs) made good progress by co-operating with local religious leaders, or making use of local radio aimed at the Asian community, such as the Mosque Radio in Bury. A clinician-led initiative, which we strategically funded, created leaflets about the importance of breast screening in a range of local languages, targeted at overcoming known barriers among women in BME communities. We supported the Men's Health Forum to spread an educational message about tackling male health inequalities by producing a 70 minute DVD resource for GPs and policymakers.

And this all highlights a paradox about achieving equal outcomes: you may have to put in very different kinds of inputs to obtain them. It can sound like a paradox: real equality is _not_ about doing the same thing in the same way for everyone. People start from different positions and face different barriers so may need different amounts of attention or different kinds of approach to end up with the same effect for all. Teaching managers that this is actually OK is all part of the process.

In a similar vein, research published by Stonewall in 2008 (Hunt & Fish, 2008) highlighted that lesbian women are less likely to take up the opportunity for cervical screening than their straight female counterparts. The causes for this are mixed. Either the women themselves mistakenly believe that you can only acquire the HPV virus through heterosexual sexual contact, or their GPs mistakenly advise that they don't need screening, in the belief that women who have sex with women have never ever had sexual encounters with men. Either way, as with the case for South Asian women and breast cancer and with men not taking charge of their health, the consequences can be late detection of tumours, with the need for much more invasive treatment and the possibility of higher mortality rates. Again, the financial implications are clear for commissioners and public health managers, and the benefits of targeted social marketing should be obvious.

Other research indicates that lesbian, gay, and bisexual people have higher rates of smoking as well as alcohol and drug addiction and are more likely to suffer mental health problems than predominantly heterosexual men and women. Why this is so becomes obvious once the social pressures on LGBT people, and the contexts in which people find community, are understood. However, this understanding may evade service planners if they are not aware of how people live different lives, under different pressures to themselves.

In a recent detailed meta-study of medical literature (Meads, Pennant, McManus & Bayliss, 2009) researchers noted that:

'There were higher rates of breast cancer, mental health problems (depression, anxiety, suicide attempts, eating disorders, self harm) and poor health behaviours (smoking, poor diet, illegal drug use). There were low rates of access to cervical screening but no data breakdown on cervical cancer rates in lesbians and bisexual women. There were higher rates of risk factors for cardiovascular disease but almost no data on the incidence of cardiovascular disease. There was a lower rate of successful hepatitis B vaccination in gay men compared with controls but no follow-up research to offer an explanation.'

Overall, the researchers were concerned by the paucity of mainstream research:

'Remarkably few peer-reviewed and published studies were found on LGBT health excluding HIV, sexually transmitted diseases and transitioning. Given that there are millions of medical journal articles listed in the databases such as MEDLINE and EMBASE, and many of these refer to UK research, 27 articles seemed rather a low number.'

**Inadequate research is an equality issue**

The difficulty of finding available research is an issue covered in Chapters 3 and 5 to 8. There is a clear disconnect (for whatever reason) between the volumes of studies that are funded and published in mainstream medical journals on so-called 'minority' groups, compared with those about the general population. Stakeholder groups respond to this by obtaining funding from other sources and publishing in less formal ways... so-called 'grey research'. However, as this can be missed by corporate librarians, commissioners and public health specialists, its invisibility reinforces the notion that perhaps disability or sexual orientation or ethnicity aren't an issue when designing services or working out how to screen and prevent serious illness more effectively. Reversing that impression is part of the challenge of demonstrating why equality matters.

For example, infant deaths are significantly higher in the North West, as well as obesity in children, poor health in under-15s, child poverty, and teenage pregnancy. Within the region, there are inequalities between certain geographic areas or communities. Many communities suffer disproportionately higher rates of these conditions too, and there are clear implications for health services and associated funding.

Instead of a scattergun approach to campaigns which address the whole community, but perhaps miss the people who most need them, if we understand our diverse communities, we will be able to target social marketing through networks that already exist. An effective campaign doesn't have to involve big bucks.

In 2007 Lord Ara Darzi asked Strategic Health Authorities to draw up plans within the context of eight areas of healthcare ahead of his 'Next Stage Review' of the NHS. These include topics such as staying healthy; maternity and newborn care; children and young people; and mental health. Yet there is little evidence that, in the reams of analysis and plans which followed from this directive, anyone gave much thought to thinking of the population as a diverse collection of individuals, where needs and susceptibilities might be different and therefore benefit from targeted action.

We do not make the last comment lightly. One of the strategic consultation exercises which we organised using our Health Equality Stakeholder Engagement approach involved bringing our SHA's stream leads for the above review together with the leading equality stakeholder groups in the region. It was notable that without our intervention this would not have occurred. Those tasked with working on the eight areas thought about them only in whole population terms. Put in front of stakeholders they admitted that the experience was immensely informative and thought provoking. The whole interaction was very lively. However, by the time they were receiving this input their work was all but over and there seemed little appetite to rush back and revise detailed plans that had already been drafted.

The nearest that public health and local authority planners can come to this is to think in terms of geographic pockets of deprivation... the idea that specific problems may be concentrated in particular areas of a large city or rural county, for instance. This is helpful to a certain extent. Ethnic groups can sometimes tend to concentrate geographically, for a multiplicity of reasons. For example, during the immediate post-World War II economic expansion, the mill towns of Lancashire recruited Pakistani and Bangladeshi workers into their textile industries. The 2001 Census shows the proportion of the population in Blackburn of South Asian heritage was by then 22%.

So, in some cases, an examination of the needs in one area of a town or city may indirectly address the health profile of a particular ethnic group. Many diverse groups don't cluster geographically though. Obviously men and women live everywhere, so do disabled people, and in most cases gay, lesbian and bisexual people too. They are not picked up by conventional social modelling, and it is an area where Joint Strategic Needs Assessments (JSNAs) are historically weak.

**Summing up**

We have only scratched the surface of all the available data which could be (but is not) used by commissioners and public health specialists to inform a more targeted, tailored, approach to the problems which they could and should address. Many more examples exist. Often the best way to access them is by engagement with the stakeholders who are expert in the needs of each community. We'll also discuss, in the second half of the book, some of the tools we developed to address this information need reliably.

In summary, we believe that the key to ensuring that equality and diversity are central (rather than peripheral) to the business of the NHS and other public sector institutions is to construct a convincing narrative about why it matters, in terms linked to the core objectives of the organisation.

If the objective is to ensure people use a service, then the case is based on evidence about the barriers which might prevent that. If the objective is to increase well being and either prevent illness or detect it sooner, then the case is based on what we can contribute to an understanding of different lifestyles and how to target vulnerable groups. If the objective is to reduce the loss of trained staff and recruit the very best people from the widest talent pool, then the case can be based on the evidence of why workplace discrimination militates against that objective and how the unique experiences of people from diverse communities bring fresh talent and insights into the organisation.

Above all, equality and diversity professionals need to ensure they are advocating change not just because equality is a fine egalitarian ideal, or because there are punitive consequences for not complying with the law. That is not to diminish the importance of these concerns; but to focus on them at the expense of the 'business case' for equalities is to risk being sidelined by busy colleagues. 'Yes, these things are important, come back when we are less busy and we'll talk about them', they'll say. We know it's too important to come back another day. The job is to persuade our colleagues to stop and listen now.

**References in Chapter Two**

Ecotec (for NWDA). (2009). 'Improving the Region's Knowledge Base on the LGB&T population in the North West'. Retrieved from:

<http://liverpool.gov.uk/media/100570/Improving-the-Regions-Knowledge-Base-on-the-LGBandT-NW-Population.pdf>

Fawcett Society. (2013). 'Equal Pay'. Retrieved from:

<http://www.fawcettsociety.org.uk/equal-pay/>

Hanisch, C. (1969). 'The Personal is Political'. Retrieved from:

<http://www.carolhanisch.org/CHwritings/PIP.html>

Hunt, R., & Fish, J. (2008). 'Prescription for Change'. Stonewall, UK. Retrieved from:

<http://www.stonewall.org.uk/documents/prescription_for_change.pdf>

Jain, A. Professor (2010) 'South Asian Women at the Crossroads'. _Ethnicity and Health_ , NHS Annual Evidence Update

Lofters, A. (2013). 'Using geographic methods to inform cancer screening interventions for South Asians in Ontario, Canada'. BMC Public Health 2013, 13:395. Retrieved from:

<http://www.biomedcentral.com/1471-2458/13/395>

Meads, C., Pennant, M., McManus, J., & Bayliss, S. (2009). 'A systematic review of lesbian, gay, bisexual and transgender health in the West Midlands region of the UK compared to published UK research'. Department of Public Health and Epidemiology West Midlands Health Technology Assessment Group. Birmingham. Retrieved from:

<http://blgbt.org/downloads/LGBT_health_26.03.09_final_version.pdf>

NHS North West. (2008b). 'Narrowing the Gaps 2008-2013: A five year equality and diversity strategy'. Manchester.

Papers in Evolutionary Economic Geography (PEEG). (2009). Utrecht University, Section of Economic Geography. Retrieved from:

<http://ideas.repec.org/s/egu/wpaper.html>

Runnymede Trust. (2009). 'The Stephen Lawrence Inquiry 10 Years On'. Retrieved from:

<http://www.runnymedetrust.org/uploads/publications/pdfs/StephenLawrenceInquiryReport-2009.pdf>

Wilkinson, R., & Pickett, K. (2009). 'The Spirit Level'. Penguin. London.
**Chapter Three**

****

**Why change often fails**

We decided to write this book to share our strategic vision for developing organisational cultures in which genuine equality outcomes are not only achievable but become a virtuous self-sustaining circle.

Before we set out that approach, let's consider why change fails. And make no mistake, much as it may offend many hardworking practitioners in the equality field, the most prevalent outcome is (at the most charitable) virtual stasis and (at worst) failure to get beyond first base.

Nobody ever discusses a date for the end point in the process... a point where equal outcomes are the norm and organisational culture determines that equality will be sustained. That should be the clue. The end point is seldom talked about because, in their heart of hearts, people feel that it is somehow, mysteriously, unattainable... that the best that can be hoped for is to mitigate the worst effects and hope that the high-profile compensation cases might somehow jolt people into a different approach.

Fact: Generally, punitive cases have no such effect.

The reason: Because it usually isn't any individual's money at stake. Staff permit discrimination, and the general public (through our taxes) pick up the tab for the fines.

This is not to say there aren't dozens of excellent islands of successful best practice. There are, although very few such pilot projects ever make the leap to universal adoption. When the funding runs out (as it always does), the projects often fold and the status quo ante resumes.

The failure is manifest. More than ten years after the race equality duty came into force, tribunals for race discrimination are still on the increase and equality practitioners are still doing very basic 'awareness training'. Seven years after the disability equality duty came into force most organisations still lack any accurate statistics on disability within their workforce and don't seem to understand how it might advantage them to attract and retain the expertise of people who just happen to have (often irrelevant) impairments. A gender equality duty has been in place since 2007 and yet, more than 43 years after the first Equal Pay Act, women still earn significantly less than male counterparts doing the same or comparable work.

In the previous chapter we set out the need for a clear, benefits-driven strategic narrative on why a concern for equality should be core business for organisations. As we said, it's not about the ethical, legal and religious underpinnings. People can pay lip service to the notion of equality and fairness, yet can still in the next moment carelessly do something which undermines it.

We also said it's not a consistent message, and can be muddied by the way governments act (as opposed to what they say). Our point is that if you want commissioners of public services to see the purpose in understanding diversity and the equality imperative then you need to link it to what they do, and show clearly how it can help them hit their objectives. The same goes for talking to quality managers, or OD managers, or human resources managers. In a way it is basic salesmanship. You understand what the person's objectives are; then you pitch the message that you've got something to help them reach those aims.

**Understanding the relevance of equality, diversity and human rights expertise**

We often draw a comparison between Equality and Diversity, as a corporate function, and the IT profession as it was in the 1980s. Back then, a department of computer specialists would not have even been called 'Information Technology'. They would be known as the 'Computer Department' or, more likely 'Data Processing' (DP). The DP manager was often a sorrowful figure. The budget he (usually they were men) commanded, and his pay grade, meant that he was technically in an executive level position. However, even if the DP Manager had a place on the board, his position would often be seen as an anomaly. His peers would feel that DP was in some way detached from the core mission of the organisation. The DP team ran the computer (singular) and (in that respect) they were a bit like the people who kept the air conditioning operating. If the plant failed, there was a crisis until the system was repaired and working again. The rest of the time, the DP manager didn't speak the senior management team's language, and they didn't speak the DP manager's. DP was what accountants would call an 'indirect overhead'. Something you try to minimise as a cost.

In 1981 computers came out of the DP department and started appearing on the desks of finance, marketing, sales and production managers... and all the rest. Ironically this didn't happen because the DP department had been persuasive, but because the managers themselves had heard of tools that they could use, which would genuinely improve their productivity and outcomes. They went out and bought personal computers and software like Lotus 123, using their own budgets, and tried to set them up themselves.

Suddenly, the skills in the computer department became relevant because managers realised there were specialists in the organisation who could support what they wanted to get out of the new machines and software. Nowadays, everyone in most organisations is expected to be basically conversant with using computers and data communications as tools to achieve their goals, and Information Technology (the name reflects the new understanding) is seen as central to the needs of the organisation.

Let's draw a parallel. Equality and Diversity teams are often seen as a necessary cost rather than an asset because, where they've been formed, it has often only been in response to the risk of legal non-compliance. The leaders of the organisation expect the E&D team to mitigate the risk of landing in court as a result of a discrimination claim, or for non-compliance with statutory duties.

Organisations that introduce E&D expertise with that mindset are likely to see them as peripheral to core business and low in the pecking order for attention. Indeed, one of the challenges which we'll discuss later in this chapter concerns the personal qualities and skills which an equality professional needs in order to overcome that mindset, if they find themselves in such a culture.

This, however, is where the analogy with corporate IT ends. We can't see any 'killer app' on the horizon that will suddenly drive managers to become amateur equality practitioners on their own, and discover overnight the value of the support which the professionals can bring them. Unlike the lucky DP manager, E&D professionals will have to manufacture their own culture change.

If you work in the 'equality as risk' kind of organisational setup then everything starts out as a concession. You want staff to attend training in diversity and equality? You'll need to battle to obtain it because you're asking to take those staff away from the core business for something that isn't core. You want to draw attention to an adverse effect of a corporate policy? You'll have an uphill task as an outsider perceived to have no expertise in commissioning, or quality, or human resources or whatever. This is not helped by the fact that some E&D practitioners and leads came into the field from an activist background. Unlike their peers, such people parachuted into an organisation for their apparent technical knowledge will not have had the benefit of developing a career in the organisation, and discovering how influencing works. We'll deal with this issue shortly but for the moment keep it there in mind: Equality and Diversity professionals may have to battle the fact that they are cultural outsiders, as well as lacking formal development in leadership, change management and influencing skills.

If you're in this position then, on your own, the benefit narrative we described in the previous chapter is very hard to put across. 'You're an outsider. What do you know about these things? Just concentrate on the training and make sure we stay legally compliant.'

**Being part of the plan**

The first step towards success, therefore, is to be clear that you can't achieve your goals so long as the organisation sees _your_ purpose and contribution as peripheral to _its_ core purpose and objectives. We'll cover later the competencies required to be a credible and successful influencer and turn such a state around. For the present, we'll stick with the goal.

Successful organisations of any size, whether private, public or third sector, tend to start out by being clear about what it is they do (their mission), their targets (often called a business or operational plan), and how to get there in a set timescale (their strategic plan). To support that they also formulate policies to guide day-to-day decision making or set boundaries. Things which contribute towards the strategy or hitting the operating targets get core management time and resources. Those which _don't_ languish in relative obscurity, knowing that any resources they require are seen as a cost.

As we'll discuss from Chapter 5 onwards, one of the first things which we did in our own organisation was to examine how to align the benefit narrative about equality with the core aims of the Strategic Health Authority, and to try and ensure that the organisations which the SHA performance-managed were doing the same. Within the first year we had established the principle that all operational, strategic and commissioning plans submitted to the SHA for approval were also vetted to ensure that equality and diversity was factored in.

Commissioners whose plans failed to present the case for prioritised spending without disaggregated evidence of needs for different parts of the population were asked to resubmit. Within the organisation, we made the case for the commissioning development team to bring our expertise on board to help them lift the competence of commissioners. Our organisation's business objective in this case was to improve the quality and effectiveness of commissioning in 24 NHS organisations making those decisions. Our 'sell' was that, across the 10 competencies in the World Class Commissioning Framework (DH, 2010) it was not possible to be really effective in at least half of them without a thorough grasp of the specific needs of the diverse parts of the community and how to address them.

**Being clear about what needs to be done**

The next step is to be clear about the priorities. Obviously 'being part of the plan' has to be right up there at the top of the list if you want to ensure your vision is seen to make a credible contribution to what the rest of the senior management team is doing. But what about the next step?

In our experience it is evident that many people make the mistake at this point of forgetting to remain strategic. It's a huge temptation to become bogged down in operational matters, such as creating plans to train all the staff or impact assess all the organisation's policies. Those matters are almost certainly part of the standard tasks that need to be accomplished. However, how do you know they are the most important? And how do you avoid the risk of focussing so much on operational issues, that you have no time to maintain your strategic perspective?

Our approach, as we'll explain from Chapter 5 onward, was first of all to undertake a programme of research which would both highlight the strengths and weaknesses of our health economy in this area, and also create the justification and priorities for addressing them.

The NHS believes in 'evidence-based medicine'. We applied that principle to our own case. In so doing, we were able to present a coherent strategy for our own work, which not only aligned with the regional objectives of the NHS, but was also grounded in an analysis of what interventions needed to come together to support the intended outcomes.

Much of what we discuss in the second half of this book came out of that single seminal research and analysis exercise and the resultant five-year strategy — namely, the need for a performance measurement framework; to define and develop leadership competencies; to collate evidence that people could use; to have a sustainable approach to stakeholder engagement; and specific tools to plug specific strategic gaps. This meant that we could make a convincing, evidence-backed business case for the resources to develop what was needed, and the Board could see how everything we were constructing and rolling out at every stage was relevant to the core objectives of the enterprise.

**Mistaking activity for outcomes**

Over four years the programme outputs were impressive, as we'll discuss in due course. However, at this point anyone undertaking such a programme needs to take a reality check. It's all very well working hard and producing lots of systems and tools. Yet that's not the goal of the exercise, it's simply the means of getting there.

In our experience, a major reason people can miss the objective, and why equality endeavours fail, is because they can often mistake the effort they put _in_ , or the _processes created_ , as the target. They're wrong. Ask your service users. A disabled person doesn't want to know how many staff have received training but how that training has measurably changed the experience they'll receive when using the organisation's services or applying for a job.

In setting up our outcome-focussed performance measurement framework, which we'll discuss shortly, we encountered this misconception over and over again.

We would ask for evidence of how an organisation was increasing the diversity of its workforce to match the local population and, instead of charts comparing statistics over time, we'd be presented with policy documents that talked about the problems.

We would ask for examples of how organisations used evidence to guide their decision-making and they'd tell us where they obtained evidence from and how much of it they had.

We would ask for evidence of how services had been commissioned differently on the basis of that disaggregated evidence about needs. People would present reports that had been submitted, but not show us that anything had changed to align how services are designed and delivered to overcome identifiable barriers to equal outcomes.

In 2009, we set out to establish a baseline... an objective way of measuring where organisations were, so that we could judge where genuine improvements in outcomes took place. However, this proved surprisingly difficult.We found there was the tendency to conflate an input with an output - and an inability to distinguish between the amount of effort you put in and the tangible change you can show for it.

Our own outcome would not be measured by how much we wrote, or how much we tutored people to understand what a genuine measure would look like. Our outcome would be measured in the degree to which we could show, through concrete results, that we had overcome that mind set.

If this is the common misconception (and we had no reason to think the 64 NHS organisations in North West England were exceptional) it is not hard to see why, in spite of all their hard work, people might fail to bring about real changes. If you can't define what a change looks like, you are unlikely to have a clear vision of how to obtain it, or measure your progress. Heroic efforts alone are not enough.

**Not having the tools**

It's all very well to expect results but our initial research also demonstrated that it was unreasonable to demand success if people didn't have some of the fundamental tools to do the job.

One of the levers we've already discussed: being part of the plan. However, our research revealed some other big gaps too. We found, for instance, that people had universal difficulties finding the kinds of quantitative or qualitative information they need to help plan and justify their decisions, or to help their colleagues undertake impact analysis..

Unless you know where to look, and have a compendious memory of all the results presented by all the equality advocates at all the launches they organise, it's unlikely you'll know where to find the information to (for instance) support an analysis of the equality impacts of a policy decision. E&D professionals may well have that information; however unless the E&D team wants to be involved with every impact assessment ever undertaken in the organisation, a better way is needed to help other managers find that information more easily.

As this was a system-wide problem, this called for further research to see what tools we could find. When we came to the evidence-based conclusion that there _were_ no suitable tools, the logical conclusion was to create the solution ourselves. The Health Equality Library Portal (HELP) is described in Chapter 8. The key point is that it would not have been appropriate to build such a resource without the two stages of research first... identifying the need and drawing a blank on a pre-existing solution. The development of other tools, such as our sustainable approach to engagement with expert equality stakeholders, or our educational resources, started from a similar, clear, evidential basis.

One thing often struck us in developing these tools. As we looked to see what we could find, we were discovering that nobody had developed anything suitable before. There was no comprehensive evidence library like HELP bringing together research of this kind. Nobody had tackled how to carry out monitoring for Sexual Orientation. There was no definition of the qualifications, competencies and job description for an Equality and Diversity leader. But the evidence pointed to them being necessary to achieve successful outcomes. Without good quality resources it is perhaps no surprise that people were failing to achieve the sustainable outcomes they aspired to.

**What isn't measured doesn't get done**

When we drew up our five-year strategy _Narrowing the Gaps_ in 2008, we based it again on the evidence from our research (so that the objectives weren't just plucked from the air) and from desk analysis of other people's research. The five goals were designed to be co-dependent and to operate in such a way that, if all five were being achieved to a degree, then there would not only be measurable outcomes across the board, but those changes would also be on their way to becoming a self-sustaining part of organisational culture. The Board of NHS North West approved the strategy because they could see how it was based in evidence and clearly linked to the objectives of the whole organisation.

Drawing up a strategy is not much good on its own though. It's like the problem we've already discussed with legislation. We have a fantastic system of equality law yet discrimination still continues apace. That, after all, is why we are discussing the reasons change fails to happen. It's a managerial truism that 'what isn't measured doesn't get done'. Our detailed research pointed to the fact that there was no performance management framework in place for equality anywhere in the region. The closest we could get was the Equality Framework for Local Government, developed by the Improvement and Development Agency - I&DeA (later renamed the Local Government Improvement and Development Group).

The I&DeA framework had some attractive points. It provided a structured way for a Local Authority to rate itself in a number of areas (Goals). These were broken down into subordinate activities which could be rated and which contributed towards the over-arching theme of that goal. There was a familiar kind of Red-Amber-Green (RAG) style assessment scale. The I&DeA framework's goals weren't identical to those of our strategy but even cursory comparison revealed similar aims. However, we felt the I&DeA framework was weak in terms of the objectivity and consequent consistency of the process. It was a self-assessment regime without strong evidential challenge. Given our concerns that teams struggled to distinguish between inputs and outputs, and the natural tendency for organisations to rate themselves overoptimistically, we felt this wasn't enough.

We'll discuss in detail how we developed our own Equality Performance Improvement Toolkit (EPIT), improving on the I&DeA's model, in Chapter 9. Suffice to say that the key was to structure it to reflect all the goals of our strategy, and to build in an external governance process for rigorously verifying the claims made by organisations, on the basis of objective evidence of actual outcomes.

It is clear to us in hindsight that the attempt to measure performance with a self-assessment process alone would have failed. The system we devised was a tough regime. Organisations got their Chief Executives to appeal over our heads to our own Chief Executive because they initially hated it so much. One of us was subjected to loud and angry heckling at a regional meeting of Equality leads. Nobody likes a system that demands hard questions be answered. To his credit, our Chief Executive stood up to the calls... another lesson in why having your own Board totally on side with what you are doing is so important. The sometimes tense one-to-one discussions with organisations about their assessments were, however, valuable. They became part of the educational process. And the proof of the pudding was seen 18 months later when we repeated the process and saw a significant increase in the number of good examples of evidence from our commissioning organisations.

The lesson, therefore, is that people can kid themselves that they are doing better than they are unless you and they have the tools to encourage honest and objective reflection. Worse still, you can have all the fine words you like in a strategy, but it will sit on the shelf and gather dust unless the results — the genuine outcomes — are to be measured by an external critique.

Performance managing our system was the hardest and most painful task in our three and a half years of implementing the strategy. It was also the most rewarding when we were able to compare the baseline with the objectively measured progress that organisations could show they had made just 18 months later. We could see those organisations were proud too. And, in many cases, lightbulb moments had occurred. It was clear, as E&D leads brought their senior managers along to present the evidence in person on the second occasion, that the process had helped people understand what was expected... why equality mattered.

EPIT was so successful that the NHS Equality and Diversity Council initiated a project to develop a similar framework nationally. The Equality Delivery System (EDS) was formally launched in November 2011 by the NHS Chief Executive, David Nicholson. In our view it's not as tight a framework as the one we created. It embodies a weaker governance process, for instance, so time will tell if it has what it takes to succeed. We remain clear, ourselves, however about how rigorous you need to be in order to ensure that a change driver like this doesn't fail.

**The need for leadership**

It is another truism that most (if not all) big culture changes depend on leadership. The NHS believes strongly in leadership. It has a Leadership Academy and a National Leadership Council. It mentors prospective leaders and involves them in developmental programmes such as Common Purpose. There are many definitions of what leadership means. One of the simplest is to say that 'leadership is the art of motivating a group of people to act towards achieving a common goal'.

For us this definition hits the nail on the head. Leadership is more than simply being appointed top dog in a hierarchy. It's not specifically predicated on knowledge or power. It is distinct from 'management', which involves marshalling people and resources. The leader is the inspiration and director of the action. He or she is the person in the group that possesses the combination of personality and influencing skills that makes others want to follow them. To be effective, a leader certainly has to manage the resources at his or her disposal. But leadership also involves communicating, inspiring and supervising.

It will be abundantly clear, when we are talking about why change can fail, that leadership (and especially the ability to influence others to pursue a goal) is central to the enterprise.

Leaders are not the same as experts or practitioners. In our work we've met many fine E&D managers who know more about the detail of equality law or particular diverse communities than we do. They can be brilliant trainers. Their presentations tick all the best practice boxes for communication. Yet that doesn't necessarily mean their objectives are understood and shared by the board, the senior management and the heads of functions in their organisation. As a result, their brilliant plans aren't picked up with gusto by the whole organisation. They may be respected, but they are not followed.

Our initial research, carried out in 2008, discovered much about leadership in our part of the NHS. From the data returned by almost 60 NHS organisations, it was clear that the whole environment in which E&D personnel were trying to lead was very often working against them. There was no consistency in job descriptions, qualifications or skills; no consistency in the grades at which people were appointed; some reported to a Human Resources Director (which implies a narrow idea of what equality is about), some to OD or quality managers, and some (in provider organisations) to the head nurse. Some staff were full time; some carried out the role part time within a larger and more defined brief. Some had dotted line relationships to the Chief Executive and Board; others had no way of being mentored or championed to work across the organisation, outside of their own managerial silo.

Any of these factors might predict why some people might be likely to fail. Many reflect our DP manager analogy: someone whose position is peripheral to the core business. Even among the most senior, it seemed remarkable that there was no real standard for competency, or to guide personal development. It would be unthinkable to staff the finance function in this way.

The NHS has an immensely detailed framework for defining the roles of most of the 1.4 million people who work in it. When recruiting to most jobs within the health service, managers can look up what the job description should contain, what competencies and qualifications they are looking for, and the seniority for the post. None of this exists for E&D leaders and managers. The NHS's Agenda for Change framework certainly mentions equality; it is one of the six core competencies which all staff need to have in varying degrees. But that defines the knowledge that someone needs within the function they fulfil. It does nothing to address the problems above.

The evidence we had was enough to justify a project to rectify this shortcoming on a national level... just as so many of our other conclusions pointed to national requirements. The eventual National E&D Leadership Competency Framework is described in detail in Chapter 10.

The key to the design of the Competency Framework, which was begun by the redoubtable visionary Barbara Burford (to whom this book is dedicated), was to identify what common factors successful E&D leaders possess. Unsurprisingly these turned out to be the kind of competencies that anyone would be coached to acquire in the course of being talent-spotted to lead other parts of the organisation. The leaders in our system who were most successful were those who had had that career history and the cross-training in other areas of their organisation.

Also important, of course, was subject expertise. Some existing leaders were stronger in this respect because they had come into an E&D role as their first appointment in the NHS, from an activist or NGO background. They were the leaders who you might expect to have to fight hardest against perceptions by other managers that 'they're not one of us'.

Our researchers finally distilled all their findings into five distinct competency areas and then tested this by devising a way to measure how over 30 volunteer E&D leaders from across the country (and from different kinds of NHS organisation) measured up. The results showed dramatically how E&D leads differed in their competencies, and how different their training needs would be if we were to try and level them up. We found that leads across the board were either strongest on the general leadership competencies that other NHS managers would have, or they were strongest on the technical aspects of E&D as a subject. Very few were strong on both, and a few weren't strong on either.

We present this in more detail in Chapter 10, where we describe the Competency Framework, how we integrated it into the system and the action we took on the weaknesses exposed. However, it will be apparent that this work uncovered another of the main reasons why change may not be successful.

**Summing up**

In this chapter we hope we've demonstrated some of the many reasons why change often fails, and the evidence-based approach we developed to address the fundamental areas. We also hope that the way in which we've addressed this topic provides a roadmap for others to investigate and address weaknesses in their systems in the same way. In hindsight, our evidence-led approach may seem obvious. The problem seems to be that others don't seem to have given it the thought that we have... hence our desire to share.

We've dubbed our method our 'Eco-system' approach, on the basis that whilst each of the parts could be undertaken in its own right, the change only takes root and flourishes if all the conditions are present in the right order and the right quantity.

First, we began with detailed evidence gathering and analysis. We published the conclusions from that analysis in "A Landscape of the Region" in October 2008, and we describe all of that in more detail in Chapter 6. That evidence base, coupled with further research down the line, is the underpinning for all our decisions to invest in tools and programmes of work. It was also key to ensuring that our Board understood the justification for what we were doing at each stage.

Next, our conclusions were refined with further research about adverse outcomes for particular groups, and the areas where existing core policy and strategy were deficient, to produce our five year strategy, "Narrowing the Gaps", published in the spring of 2009 (but covering the period 2008-2013 as we had already begun some of the actions). Again we describe this in detail in Chapter 7. The strategy identified five key areas which, together, would begin producing measurable levelling up of outcomes for equality target groups. It was aligned to the core business of the SHA and again endorsed by the board.

We soon realised we would need to build specific tools and resources to help address gaps which the evidence pointed to. These tools are described in Chapter 8. We couldn't find anything already available, so produced our own solutions — but they all have national application, and we've openly encouraged organisations everywhere to use them.

Some of the tools are mechanical, such as providing a national library of equality-related evidence which is easy to search. Some tools provided systematic ways of working, such as how to carry out monitoring for sexual orientation or set up effective and sustainable engagement with equality stakeholder experts. Some provided education and development, such as our historical timeline exhibitions, booklets and films, or our newsletters and development workshops. Some were structural, such as the National E&D Competency Framework. They address many of the common reasons that organisations advance for not being able to make better progress.

Once we had set out the strategy for what we wanted the NHS in the region to achieve, and when we had developed the tools to support them in this, it was then a logical next step for us to introduce performance measurement. We've already touched upon the Equality Performance Improvement Toolkit (EPIT) and provide much more detail in Chapter 9. We've also explained the fundamental principle — which is to measure outcomes through objective evidence, against the strategic goals, and to do that repeatedly over time so that progress can be compared.

Four years into our programme, featuring all these stages, it was fair to say that we could demonstrate how good outcomes were increasingly evident and how, through our development events and materials, we could see that our E&D teams were becoming more and more like true strategic leaders, bringing their colleagues with them in a way that was becoming contagious.

There is a danger that managers can be frightened off by the subject of equality, as it is so often presented in terms of how they are failing. Gradually, through spelling out the kind of evidence of outcomes which we were looking for, people began to understand what was being asked of them, and how providing it could actually enhance their own functions as commissioners, quality managers, clinical leads and human resources professionals.

We readily admit that the size of the challenge meant that, although progress was being made, we were still some way from being able to rest on our laurels. Were it not for the enormous reorganisation of the NHS in March 2013, we would have liked to go on pursuing this strategy and show even more dramatic results. Instead, our efforts were brought to a halt by circumstances way beyond us. We were disbanded even as we were at last really succeeding.

Nevertheless, we know from the results that we had found at least some of the keys to what works, and how to provide the leadership that ensures that change _doesn't_ fail. We think that's a trick worth sharing.

**References in Chapter Three**

Department of Health (DH). (2010). 'World Class Commissioning Competencies'. Retrieved from:

<http://icn.csip.org.uk/_library/WCC_competences.pdf>
**Chapter Four**

****

**Global and Theoretical Perspectives**

The previous chapter suggests an empirical view on why efforts to achieve genuine equality of outcomes within organisations such as the NHS (employing and providing services to the public) seem to have failed, in spite of all the legislation, duties and initiatives of the last 50 years.

In a nutshell, while lawyers and politicians have reasons to accept that 'equality matters', those charged with putting it into practice have not managed to make a compelling case which aligns the importance of equality outcomes with the core objectives of their organisation. The issue has languished at the periphery of everyday activity, regardless of any fine statements of intention to the contrary.

It is not just this lack of a 'managerial narrative', however. We strongly advise that

  * strategies need to be grounded in evidence
  * the right information and tools need to be available for people to use
  * progress needs to be monitored on the basis of solid outcome measures; and
  * managers need to be empowered to lead.

These four factors are in our view inseparable.

Firing from the hip — initiating projects without solid evidence to suggest whether they are the right actions or priorities — is just foolhardy. It satisfies the urge to 'just do something, anything': 'this is something... therefore we'll do it'. But scratch the surface of such activity (it's remarkably common) and you'll often find little by way of an underlying strategy or narrative.

In a similar way, we've probably all met people in this field who, though immensely knowledgeable about inequalities and their causes, somehow never succeed in changing the systems that give rise to them. In our researches we found this was more likely to be the experience of those who come into E&D leadership from outside an environment like the NHS, perhaps from the world of charity work or activism. Developing people to be effective corporate influencers is as important as ensuring they have an aptitude for the subject and are good analytical thinkers, communicators and teachers.

To return to the point about a coherent evidence-based strategy...

A review of the literature since 2002 (which marked the introduction of the Public Sector Race Equality Duty) identified a gap on equality and diversity strategies that are both evidence-based and outcome-focused and that address several different areas together.

At the theoretical level, there is a divide between commentators as to whether to think of population diversity as a problem to be solved or an asset to be celebrated. In workforce terms this has been described as a choice between a 'hard' approach (regarding the workforce as a 'resource' to be used most effectively to benefit the organisation); and 'soft', where people are seen as valuable assets whose experiences and knowledge are something to be nourished and cultivated (Storey, 2001).

Much of the literature does concentrate on workforce perspectives, perhaps reflecting the fact that the pressures to address equality are met first by human resources specialists, and the first legislative responses to discrimination concerned employment rights. However, the same thinking can be extended to the users of services. Do people address unequal experiences (which stem from people's differences) as a problem to be risk-managed, or an opportunity to be embraced as positive and enriching?

**The United States**

In the United States, for example, the emphasis has been on the benefit side of the equation, for both public and private sector organisations. A good example of this is the way in which business in America has responded over the last few years to the Corporate Equality Index (CEI) promoted by the Human Rights Campaign (HRC).

Despite its name, HRC is not an across-the-board Human Rights organisation. It is a lobby for LGBT interests, and the CEI is constructed to measure how organisations perform as good employers of LGBT staff. The index has been published annually since 2002. A very similar 'Workplace Equality Index' was introduced by the British LGB charity Stonewall (but without the trans dimension).

When the CEI was launched, there was scepticism about how it would fare in a culture where views on sexual orientation and gender identity are strongly polarised, and where there is a powerful right-wing Christian influence on the activities of companies which deal with the public. Almost from the word go, however, Fortune 500 corporations appeared to embrace the index competitively, seeking to ensure they obtained the highest possible ratings to give them an advantage when recruiting staff. The logic appeared to be that, where all other factors are equal, the best college candidates would opt to work for corporations which could show they had a modern and open outlook towards LGBT people. This wasn't just a pitch to LGBT candidates; the view was that prospective recruits would perceive a high CEI score as a proxy indicator for the organisation's overall culture.

Despite this notable example, however, there is some criticism of the repositioning of the rationale for equality from what might be termed 'the justice perspective' to a narrative of 'business benefit' (Vinz and Doren, 2007). The challenge is to find good quantitative research that demonstrates how E&D contributes to profits.

**The role of gender**

It is argued, for instance, that commercial organisations which have a more equal balance of men and women on their boards perform better (Kotiranta, Kovalainen & Rouvinen, 2007). This view was given added prominence in 2012 when UK Prime Minister David Cameron, on a visit to business leaders in Sweden (where the sex balance on boards is closer to parity, and seems to be a key factor in corporations' competitive success and profitability), warned UK businesses that they would face the imposition of quotas unless the gender balance on their boards improved. (Daily Telegraph, Feb 2012)

The problem with such an assertion, however, is that while this ought to make sense, the analysis needs controls. How do you compare like with like? There are always so many other possible variables which could account for increased performance. Companies aren't laboratory rats. They operate in a complex world of random interactions, which means you can't control for all the factors which might affect the operation. Therefore, arguments based on this kind of business case are always going to be open to criticism and give opponents of change the opportunity to divert the agenda from action to debate.

A study of this kind of academic debate therefore indicates that not all 'business narratives' for equality are equal, and that there are reasons to be careful about how you construct one. In our own case, within the NHS, it is easier to make a case for achieving clinical, public health and workforce objectives that have already been articulated, as the evidence of barriers and adverse outcomes support the underlying rationale. The case enhances an existing idea, rather than trying to introduce an entirely new one, with only one line of evidential justification.

**The need to disaggregate statistics**

Gender is an issue of particular interest in the NHS, where the numbers can be profoundly misleading if you don't approach them with care. In North West England, for instance, approximately 75% of the overall NHS workforce is female, which suggests that female emancipation in the system is more than complete. However, break that number down and a very different picture emerges. Most female staff are to be found in the lower grades of NHS organisations, whether in junior nursing, clerical or administrative positions. Look at the proportions in more senior clinical or managerial grades, or on boards, and a very different picture emerges.

The Men's Health Forum (MHF), a charity specialising in promoting improved health and well being for men and boys, undertook a desk study for the Department of Health (DH) in 2007, as the Gender Equality Duty came into force. (MHF, 2007). They examined the Gender Equality Schemes published online by the majority of England's 151 primary care trusts. The stark conclusion was that few disaggregated their workforce numbers to any significant degree, whether by pay grade or by occupation.

The MHF Report made the following recommendations, which the Department of Health included in its guide to implementing a gender equality scheme (2007):

Collection, analysis and use of data:

  * Data should always be collected, presented and considered in gender disaggregated form
  * All data presented to the general public (e.g. media releases, DPH reports) should be broken down by gender
  * Strategic Health Authorities should designate a 'Gender Lead'
  * An NHS training programme should be developed, incorporating local training events and an online resource

Learning from good practice:

  * A central database of good practice should be developed – preferably in advance of the implementation of the gender duty
  * Primary Care Trusts (PCTs) should establish standing local advisory groups to reflect and advise on men's health issues
  * The Department of Health should establish an expert advisory group to comment on gender issues and scrutinise the implementation of the gender duty
  * PCTs should review all existing local targets and consider re-writing them in gender disaggregated form
  * All future local targets should be expressed in gender disaggregated form

**Occupational segregation**

Occupational segregation is another factor that also often gets ignored. The term describes the tendency for certain roles to be considered more suitable for people with a particular characteristic. For instance, secretarial duties are regarded in our culture as women's jobs. This happens in clinical contexts too. For instance, the majority of Speech and Language Therapists in the NHS are women, although there is arguably nothing (other than cultural assumptions) to prevent men from pursuing the speciality. Once a role acquires cultural coding in this way a circular reinforcement process is set in motion. Men who might want to be office secretaries or speech therapists have to face not only their own internalised assumptions but also queries from their peers.

A 2002 study comparing occupational segregation by gender in the European Union with the USA found that although gender segregation has been declining across age cohorts in the case of female _graduates_ , there has not been much change for those with lower educational levels. The picture is better for women graduates in the USA than in Europe where there still tends to be more gender segregation. In addition, it seems to be positively correlated with the share of part time jobs, and also some evidence (although weak) that the gender wage gap and occupational segregation are positively correlated, particularly if Scandinavian countries are excluded from the analysis. (Dolado, Felgueroso and Jimeno-Serrano, 2002)

A more recent paper (2012), published by the USA National Bureau for Economic Research, shows that segregation by sex declined over the period 1970 to 2009, but at a slower rate through the decades, falling from 6.1% in the 1970s to only 1.1% in the 2000s.

The greater improvements in the 1970s were partly due to more women entering the workforce and encountering less labour market discrimination, the authors suggest. As with the Dolado, Felgueroso and Jimeno-Serrano study cited above, reductions in segregation were correlated with education, with the largest decrease among college graduates and very little change in segregation among high school dropouts.(Blau, Brummon and Liu, 2012)

Research consistently shows that there is a link between occupational segregation and the gender pay gap, which means women still are paid on average only 80% of what men are paid. Another US study published in 2009 by the Institute for Women's Policy Research indicated that occupational gender segregation continued to be a strong feature of the US labour market. (Drago & Williams, 2009).

Although they did not compare the USA with Europe, as some other studies have done, some of the findings are relevant to the NHS. For example, among the 502 occupations identified by the Census Bureau, and covering the entire US civilian labour force, about 40% of women worked in female-dominated occupations (those where at least 75 percent of incumbents are female); these occupations employ fewer than one in 20 men (4.5 percent).

The paper suggests that such stark occupational segregation should be of concern to policy makers.

'Even though some of these patterns may be due to gendered preferences — a substantial body of social science research suggests that socialisation in relation to gender norms continues to influence men's and women's average preferences and behaviour — much of these patterns reflects barriers to entry to occupations, ranging from lack of information about alternative job options to active discouragement and harassment.'

Such barriers artificially restrict the movement of the most qualified and motivated people into occupations that would suit them best, exacerbate skill shortages, and reduce economic growth (Hill, Corbett, and Rose, 2010).

A second reason for concern is the link between occupational segregation and gender inequality in earnings. (Hegewisch, Liepmann, Hayes & Hartmann, 2010).

This study is particularly relevant for the NHS where the analysis confirms that average earnings tend to be lower as the percentage of female workers in an occupation increases, and that this relationship is strongest for the most highly-skilled occupations, such as medicine or law. The authors add:

'Yet this is also a strong feature of jobs requiring little formal education and experience, increasing the likelihood of very low earnings for women working in female-dominated, low-skilled occupations such as childcare.' (op cit)

As we've shown already, there has been a large body of legal and other endeavours such as affirmative action to tackle inequalities over the past 50 years. In this context, the term affirmative or positive action is 'an umbrella term covering all kinds of activities, initiatives, strategies, and interventions that seek to achieve one or more of the goals identified for affirmative action in both employment and service provision' (Archibong & Sharps, 2011). However, these efforts have produced patchy results ( _ibid_ ). A 2006 study noted that progress in improving workforce diversity has been slow since the introduction of the Equal Pay Act in 1970, despite a subsequent raft of laws to protect minorities (Evans, 2006).

**Organisational approaches to diversity work**

In the USA, although diversity work, particularly in the workplace, began around the same time as the UK, 'the initial promise ...remains unfulfilled and progress remains elusive.' (Thomas, 2010). Despite gains in some areas, Thomas notes, organisations and diversity managers continue to struggle with the same issues, and often repeat the same efforts, that were prevalent four decades ago:

'One CDO described with enthusiasm how he and his corporation were 'going to do it right this time.' As he detailed his plans to me, I did not have the heart to tell him that what he was proposing indeed had been tried before and had been discarded by his company.'

It seems that while there may be several motives which drive the implementation of diversity management initiatives in organisations, a developed evidence base (alone) is not usually one them.

Pitts et al (2010) discuss the bases for the implementation of an official diversity management program in the USA. As the US workforce continues to become more diverse, they note, 'public managers are pressured to make cultures that allow workers from various fields to succeed.' In response, organisations develop a diversity programme, based on organisational theory, as a way of dealing with challenges and opportunities in the external and internal environments. It explains how these environmental phenomena work. Three key factors are involved... institutional isomorphism, environmental favourability, and environmental uncertainty. In other words, it would seem that the success of the program will depend on 'the way the wind blows'. In a period of economic uncertainty, or perhaps when a government hostile to the notion of equalities is in power, diversity programs are likely to be ditched.

**Evidence-based approaches**

In the early days, diversity work concentrated on redressing the wrongs of the past and improving the diversity of the workforce, but these address only part of the picture (Archibong & Sharps, 2011). There is little evidence, for example, of robust, evidence-based policies (Thomas, 2010). Pitts, Hicklin, Hawes, and Melton (2010) emphasise the importance of using empirical research to 'achieve cultural competency and diversity for the eradication of social gaps' in public administration.

The Archibong & Sharps study concluded there was overwhelming consensus that positive action is an effective and legitimate strategy to tackle inequalities in employment and service provision. Beneficial outcomes have been seen for disabled people, women and BME groups. However, there is a crucial gap... data monitoring and collection both to drive policy and help measure outcomes. The authors note:

'Much of the claims of the success of affirmative action are based on anecdotal feedback and the evaluation of progress of programmes, rather than systematic outcome data collection and evaluation. Many employers in the United Kingdom, even those identified as leaders in equal opportunity policies, do not have effective workforce monitoring at even a basic level.'

In addition, the study recommends the adoption of a more coherent and collaborative approach 'between organisations'.

A more recent discussion paper (Pitts, 2011) in the Journal of Public Administration Research and Theory, suggests that public administration research should focus on how particular tools can be leveraged to improve social equity outcomes. 'It should continue to examine how representation can be used as a mechanism for improving social equity, but it should move beyond race and gender to relatively under-explored dimensions of diversity like immigrant status, language, and sexual identity.' The paper highlights the importance of empirical research in the distribution of programs and policies to people to achieve cultural competency and diversity for the eradication of social gaps.

The author recognises that public officials 'are often muddling through with only anecdotal evidence as a guide.' That's why the more information that policymakers and managers have at their disposal, the better they will be at proactively addressing obstacles that could prevent effective implementation.

Pitt concludes by suggesting that some programmes and policies simply preserve the status quo, whereas others will make social inequities even worse. 'We must invest in empirical research', he argues, 'as we will be able to move beyond arguments about why social equity is important to more informed suggestions about how it can feasibly be accomplished'.

**Strategic approaches**

The lack of strategic focus is another weakness that seems to sabotage success. Lusk (2008) identifies six obstacles to the achievement of strategic goals in the public sector, arguing that strategy should be demand-led, and that developing and embedding a culture of 'strategic commissioning' at the level of political and permanent leadership is the fastest way to more strategic government.

Managing organisational culture is increasingly viewed as an essential part of health service reform, but it involves 'a complex, multi level and uncertain approach requiring a series of interlocking strategies and supporting tactics unfolding over a series of years' (Scott, Mannion, Davies, & Marshalls, 2003).

**Outcome-focussed**

Lusk notes that 'public value comprises three main components: services, trust and outcomes.' However, in the public sector employees tend to be measured and rewarded for success in refining _processes_ (for instance, better consultation, less regulation, the monetisation of benefits), or for helping to produce outputs (more nurses, more GCSEs passed) or for managing inputs (a bigger budget for recycling, a five per cent saving in administrative costs) but are very rarely recognised for the contribution they make to achieving outcomes (Lusk, 2008).

**A holistic approach**

Archibong and Sharps (2011) recommend the adoption of a more coherent and collaborative approach between organisations. Research on implementing diversity approaches in US health care organisations notes that 'most organisations continue to take a piecemeal approach to diversity issues and practices' (Archibong & Sharps, 2011). In this context, management is often reactive rather than proactive, taking decisions in response to problems that appear to become a crisis. This approach may partially explain the marginal success of health care's diversity initiatives, as it is becoming clear that every component of the health care organisation needs to be 'upfitted' to accommodate practices that promote inclusion (Hobby, 2006).

**Leadership of the agenda**

A review of three main approaches to promoting diversity in the U.S. workplace (training, including diversity awareness training; mentoring of individuals from disadvantaged groups; and programs designed to establish organisational responsibility) found that the third prong was the most effective in increasing managerial diversity, emphasising the role of leadership on this agenda. The study notes that 'although inequality in attainment at work may be rooted in managerial bias and the social isolation of women and minorities, the best hope for remedying it may lie in practices that assign organisational responsibility for change' (Kalev, Dobbin, & Kelly, 2006). A further study reported empirical evidence that managerial values are important in increasing the likelihood of diversity programme's adoption and shaping employee perceptions (Herdman & McMillan-Capeheart, 2010).

**Summing up**

Our background research has taken us across both Europe and the United States for both theoretical and practical perspectives on how to make equality work in a public sector or corporate setting. In the process we found ideas that concurred with our own, but not a lot of practical evidence of putting the theory successfully into practice, especially in a public sector context.

Starting with the next chapter it is our ambition to put right that deficiency, as we describe in detail our approach and the benefits it created.

**References in Chapter Four**

Archibong, U., & Sharps, P. (2011). 'A comparative analysis of affirmative action in the United Kingdom and United States.' Journal of Psychological Issues in Organisational Culture, 2(2), 17-38.

Blau, F., Brummund, P., Yung-Hsu Liu, A. (2012). 'Trends in Occupational Segregation by Gender 1970-2009: Adjusting for the Impact of Changes in the Occupational Coding System.' NBER Working Paper No. 17993. Issued in April 2012

Daily Telegraph. (Feb 2012). 'David Cameron warns companies to promote women or face quotas in the boardroom' Retrieved from:

<http://www.telegraph.co.uk/news/9072742/David-Cameron-warns-companies-to-promote-women-or-face-quotas-in-the-boardroom.html>

Dolado, Juan Jose, Felgueroso, Florentino José & Jimeno-Serrano, Juan Francisco. (2002). 'Recent Trends in Occupational Segregation by Gender: A Look Across the Atlantic.' CEPR Discussion Paper No. 3421. Available at SSRN:

<http://papers.ssrn.com/sol3/papers.cfm?abstract_id=321092>

Drago, R., & Williams, C. (2009) 'The Gender Wage Gap'. Institute for Women's Policy Research. Retrieved from:

<http://www.iwpr.org/publications/pubs/the-gender-wage-gap-2009>

Evans, R. (2006). 'Variety Performance'. People Management, 12(23), 26-31.

Hegewisch, A., Liepmann, H., Hayes, J., & Hartmann, H. (2010). 'Separate and Not Equal? Gender Segregation in the Labor Market and the Gender Wage Gap.' Briefing Paper. Institute for Women's Policy Research. Retrieved from:

<http://www.iwpr.org/publications/pubs/separate-and-not-equal-gender-segregation-in-the-labor-market-and-the-gender-wage-gap>

Hill, C, Corbett, C., & St. Rose, A. (2010). 'Why So Few? Women In Science, Technology, Engineering, And Mathematics.' Washington, D.C.: AAUW. Retrieved from:

<http://www.adapp-advance.msu.edu/resource/hill-catherine-christianne-corbett-andresse-st-rose-2010-why-so-few-women-science-technolog>

Herdman, A., & McMillian-Capehart, A. (2010). 'Establishing a diversity program is not enough: Exploring the determinants of diversity climate.' Journal of Business and Psychology, 25, 39-53.

Hobby, F. (2006). 'Diversity's next challenge.' Healthcare Financial Management, 60(5), 106-110.

Kalev, A., Dobbin, F., & Kelly, E. (2006). 'Best practices or best guesses? Assessing the eficacy of corporate affirmative action and diversity policies.' American Sociological Review, 71, 589-617.

Kotiranta, Kovalainen & Rouvinen., (2007). 'Female Leadership and Firm Profitability' Retrieved from:

<http://www.europeanpwn.net/files/eva_analysis_english.pdf>

Lusk, S. (2008). 'Why does government find it so hard to be strategic? An analysis of what stands in the way of strategic work in the public sector, and of ways to overcome the obstacles.' London. National School of Government.

Men's Health Forum (MHF). (2007). 'Is the NHS on gender duty?'. Retrieved from:

<http://www.menshealthforum.org.uk/gender-duty-compliance/19992-nhs-gender-duty>

Pitts, DW., Hicklin, AK., Hawes, DP., & Meltonl, E. (2010). What Drives the Implementation of Diversity Management Programs? Evidence from Public Organizations. Journal of Public Administration Research & Theory, Vol. 20 Issue 4, p867-886;

Pitts, DW., (2011). 'Representation of Lesbians and Gay Men in State, Local, and Federal Bureaucracies.' Journal of Public Administration Research and Theory. 21(1), 159-180.

Scott, T., Mannion, R., Davies, H., & Marshalls, M. (2003). 'Implementing culture change in health care: Theory and practice.' The International Journal for Quality in Health Care, 15, 111-118.

Storey, J. (ed.) (2001).Human Resource Management: A Critical Text, 2nd edn. London: Thomson Learning.

Thomas, R. (2010). 'The state of the diversity field.' Journal of Psychological Issues in Organisational Culture, 1, 88-94.

Vinz, D & Doren, M. (2007). 'Diversity policies and practices - a new perspective for health care'. Journal of Public Health vol.15:pp 369–376
**Chapter Five**

****

**NHS North West — An Evidence-Led Culture Change**

In the first four chapters of this book we examined the history of diversity in Britain; how different communities emerged or came to settle; how a legislative framework for discrimination arose; why equality matters; and some suggestions as to why it has proven so difficult to achieve and sustain.

Diversity is the default, not the exception. It's a fact of life. Human beings — like plants, fish, invertebrates and our fellow mammals — don't come in a single model. If we did, of course, then it's hard to conceive how anyone could justify treating any one person differently from any other. It's the differences that provide both the raw material for adverse treatment, as well as the framework for classifying them. This is why diversity and equality, although different concepts, are so closely linked.

**Diversity** describes a fact of life. People vary from one another on every axis you choose to measure: gender and gender identity; age; race or ethnicity; whether they are disabled or not; whom they are sexually attracted to; and whether they have a particular religion or belief. You can add to this social categories such as whether someone is married or in a civil partnership or not, whether they have caring responsibilities, and whether they have inherited or circumstantial disadvantages. Some people look on this diversity as a problem to be managed; others look upon it as a source of originality and being able to access the widest possible range of talents.

**Equality** expresses the idea that, in a world where people are diverse, we want to remove discrimination and prejudice and tackle the economic, political, legal, social and physical barriers that limit what people can do and be.

'A society which protects and promotes equality is one in which everyone can flourish. It seeks equality in the valuable things that people can do or be, so that everyone has the real freedom to live in ways that they value.'

The Centre for Analysis of Social Exclusion

As mobility increases, and as global mixing becomes more common, one might hope that everyone would become more aware that they are part of human diversity, rather than in some way separate and superior to it. Unfortunately that change of mindset doesn't come easily to some. It appears that wherever diversity becomes more apparent then it is all too often matched (initially at least) by a corresponding increase in inequalities.

We look upon the challenge of achieving equality as an effort at rebalancing a society whose diversity has increased or become more explicit. We are not so much trying to impose equality as restore it.

So much for the theory though. We don't wish to simply stare at the challenge and shake our heads in regret that it seems so difficult to solve. This is intended to be a book about practical solutions. And this part of the book is about our own methods, why they work, and how they can be applied to other organisational settings like our own.

**The setting**

NHS North West was created in 2006 as one of 10 Strategic Health Authorities (SHAs) within the English National Health Service System. SHAs were set up as regional management tiers, sitting between the Department of Health in Westminster and locally based Primary Care Trusts (PCTs), who commission (plan and purchase) health care in their localities, and in some cases, provide community services too. Although SHAs had many strategic roles, the ones that are most relevant here concern the responsibilities to exercise planning and leadership of the entire system of commissioning and provision on the one hand, and to measure and manage the delivery of those strategic plans on the other. This placed SHAs in the perfect position to pursue the achievement of equality on a significant scale.

North West England is also a challenging area for pursuing an equality strategy. It is geographically the largest of the English regions (5,500 square miles), and also one of the most diverse in population terms. The overall population is almost 6.9 million people. Figures researched for our strategic planning revealed that:

  * Just under 40% of the most deprived areas in the country were in the North West. 14 Primary Care Trusts in the region were in the worst 50 in terms of health inequalities and deprivation.
  * 9% (400,000 people) of the working age population in the region were on incapacity benefit, largely for preventable or manageable conditions.
  * 16% of people were on benefits.
  * There are higher levels of unemployment amongst disabled people and black and minority ethnic people.
  * Sickness absence in the region is the joint highest nationally for all groups of workers, with public service workers having the highest average number of days lost. The direct cost of absence (2008) was £517 per employee nationally.
  * One in three older people in the North West were unemployed compared with one in four of those living in the South. Although the age profile of the population is similar to the national one — with 20% children and young people, 60% in the working age group and 20% in the over 60s — the growth in the older population, and the apparent inability of the area to hold on to new immigrants, meant there was likely to be strong competition for workers.
  * Nearly a quarter of children in the region live in poverty.
  * 20.6% of the working age population is identified as being disabled.
  * The black and minority ethnic population increased from 5.5% in 2001 to over 7% in 2006. Future ethnicity projections for 2020 suggest a rise to 8.4% and, for 2032, a rise to 9.7%.
  * It is estimated that 420,000 of the North West population would identify themselves as lesbian, gay, bisexual or transgender. This is equivalent to the entire population of one of the region's major cities such as Liverpool or Manchester.
  * The North West (at that point) had the greatest numbers of dispersed asylum seekers in the UK.
  * There was a growing presence of gypsy and traveller families in the North West.

Migration flows from overseas were seen as one of the most visible trends impacting on the North West's population, labour pool and cultural mix. The number of foreign nationals registering for National Insurance increased to 51,500 in 2006/07 from 21,900 in 2001/2.

The Public Health system was also well aware of some of the key health challenges facing the the health service. Compared with the other nine English regions, the North West had (and still has) the highest rates for deaths from heart disease and stroke; long term mental health problems; alcohol related hospital stays; hospital admissions for depression, anxiety disorders and schizophrenia; drug misuse; self-reported violence; violent injuries serious enough to require hospital treatment; and for claiming incapacity benefits for mental and behavioural disorders.

When the programme began, we were therefore very aware of the immensity of the problem. We were also aware of many areas that the NHS could and _should_ take account of for particular groups or specific settings.

We knew, for instance, that organisations have glass ceilings for women and for black and minority ethnic staff. We knew that doctors from such groups are more likely to face disciplinary action in circumstances where their white British counterparts were more likely to receive just a quiet word. We were aware of the kinds of barriers encountered by staff and patients with disabilities. We knew about the prejudices faced by Lesbian, Gay, Bisexual and Transgender staff and patients. Indeed, we knew there was no shortage of this kind of specific information which it would be right to act upon in order to create a fairer working environment and better experiences and outcomes for service users.

At this point it would be tempting to start shooting from the hip; initiating programmes, sending directives or organising events. Those are all good actions in the right place and time. They are what you'd expect teaching institutions, service designers, hospitals, mental health services, ambulance services and all the rest to have been doing since the year dot. Except that, anecdotally, it was clear they hadn't. Was that because they didn't know? Was it because they didn't have the organisation or resources? Did they have bigger priorities? Indeed, when there are so many instances of these kinds of inequalities, how would you prioritise where to start?

The rest of this book therefore breaks down the elements of the evidence-led, strategic leadership approach which we elected to take. We call it an 'eco-system' approach because our contention is that, whilst any one part is important in its own right, all the components need to be present for the seeds of sustainable change to take root, grow and multiply.

We don't claim that our approach is 'rocket science'. The components are essentially common sense:

You begin by gathering evidence and distill an analysis of where the gaps and deficiencies lie.

You develop the analysis into a strategic plan with Board endorsement. The actions need to be Specific, Measurable, Achievable, Realistic and Time bound (SMART).

You provide the tools and personal skills development where the analysis indicates these are necessary, and where the absence forms barriers.

You then apply performance measurement to ensure that the strategy is followed through.

You measure outcomes. Not the amount of effort put in.

As we say, this is hardly rocket science. Management consultants would prescribe variations of this approach as a formula for targeting and achieving any kind of change. The devil (as they say) lies in the detail. It is a fact that nobody has (to our knowledge) ever before applied this approach rigorously within the Equality field or studied the outcomes systematically. We also believe that there are certain essential disciplines that need to be applied to ensure that such an approach doesn't slip into self-deception. Deciding what to measure, how to measure it, and how to apply course corrections along the way, are all parts of the learning that we want to share.

We sincerely hope that the detailed description of our approach, and the successes that we measured, will serve as an encouragement for others to strive for the same kind of transformative outcomes.

**Chapter Six**

****

**The need for evidence**

It's axiomatic that information is crucial to all rational decision-making. With so many possible actions that you _could_ take, deciding which one to do in preference to any others requires some sort of basis, otherwise you might as well toss a coin. And if you are going to embark on a particular course, without knowing it's the one most likely to succeed, you might as well set out with a blindfold.

So it is all the more remarkable that we see so many instances of managers (not exclusively in this field) deciding on individual actions — and sometimes entire strategies — on little more than received opinion, anecdote or 'gut feeling'.

Another common error is to be driven by events, or by whoever lobbies most effectively; taking actions in haste so as to be seen to act, rather than proceeding as the result of a rational analysis and prioritisation, on the basis of evidence.

The equality field is not unique in the tendency to be driven by crisis; when, for instance, a major fine has been levied for an egregious example of discrimination. At those times managers seem prone to say, 'This is dreadful... something must be done... this is something... therefore we will do it.' It's no way to run a coherent strategy or spend resources wisely.

Of course, it's important to take action as the eventual remedy for some wrong. The murder of Stephen Lawrence led, ultimately, to amendment of the Race Relations Act and the genesis of a system of public sector equality duties, plus many more actions besides. This wasn't an immediate knee jerk reaction, though. Before actions were decided upon there was a public enquiry by Sir William MacPherson, which took evidence, carried out a detailed analysis and drew conclusions. Only then, as a result of the conclusions and recommendations, were specific actions taken.

The impetus for embarking on evidence gathering, analysis and planning may not be as urgent as a murder or (in NHS terms) a Serious Untoward Incident. In our own case the process began as the logical first step after Shahnaz Ali took up her post, in an organisation which had previously not had anyone leading on equality, diversity and human rights, and which consequently had little assurance of compliance and no strategy.

We'll discuss the journey which our own evidence gathering and analysis led us on in this chapter. First, however, we should look at the different kinds of evidence.

**Types of evidence**

Evidence-gathering isn't a single one-off event. It is something you may do in many contexts, and can take many forms. Ideally it becomes a continuous process of refinement.

The biggest divide in categorising evidence is between _quantitative_ (things you can measure in various ways) and _qualitative_ (reports of how people say they feel or react to things). Both have their strengths, but are often most illuminating when combined.

A good rule of thumb is that quantitative evidence usually involves information that you could consider presenting as a graph or pie chart. You can also draw straightforward conclusions from it, such as 'a' is bigger than 'b'.

Qualitative evidence, by comparison, will usually be recorded in narrative form. You can't make graphs directly out of statements such as 'I felt bad' or 'we have a committee for that'. What's more, a value judgement is required to compare 'I felt bad' with 'I felt awful'. However, there may be occasions when, by coding qualitative statements like this, you can transform them into a quantitative form as well.

Quantitative evidence may include things such as counting how many staff you have in different organisations, at different grades, doing particular jobs. It can include all kinds of demographic data (how many people in each of the protected groups have used this service or reported this outcome); or things that reveal patterns only when categorised (for example, counting complaints and analysing them by gender, race, age, etc...).

Qualitative evidence can come from interviewing people, or by getting them to complete questionnaires.

**Sources of evidence**

Evidence can also be gathered from a variety of sources.

There is formal quantitative data collected as a by-product of operating an organisation or managing a system. Examples would be the numbers of staff working at a particular location, in a specific role, on a particular pay grade, and so on. The data may not have been designed for your purpose, but it is readily available from existing systems such as payroll and computerised staff records. This category also includes national, regional and local demographic data, collected and maintained by the Office for National Statistics (ONS), NHS Health Observatories and local authorities. These data are not necessarily tailored for your particular purpose, and they might not be broken down in just the way you require, but they are readily available.

This kind of accessible information might help support a strategic conclusion such as 'the profile of our staff doesn't match that of the local population'. Knowing what data like this is already available, and where, is part of the groundwork necessary to be a good evidence-based decision maker.

Next, there is formal analytical evidence of the kind that is published in peer-reviewed journals. This could be based on original quantitative or qualitative research by academics or clinicians, or it may be an analysis of other published works taken together (a 'meta study'). It may not have been produced for our purposes but the analysis and conclusions may suggest an area where action is required. A good example of this kind of research is public health reports (for example: 'five people in every 100,000 are likely on average to have this condition'), or studies which link a particular health outcome to a particular characteristic.

For instance, clinical research, published in this manner, tells us that people of South Asian and African-Caribbean heritage have increased susceptibility to Type 2 diabetes. However, such primary research may not have been linked to outcomes in a way that can help strategic intervention. The researchers won't have looked at whether screening is effective in your own area. Sometimes additional local evidence gathering may be necessary to arrive at the conclusion that a strategic intervention is necessary.

For example, you may need to combine local demographics (how many South Asians live here) with a potential issue (research showing increased susceptibility) and evidence of a risk (data about lower uptake of screening or increased incidence of avoidable morbidity) to arrive at data that indicates the need for prioritised action.

You'll note that this process — combining the likelihood of something happening with the impact it would have — is a standard approach in risk assessment. But although managers responsible for strategic planning should find it familiar concept, few (in our experience) seem to have applied it systematically to readily available morbidity and demographic data for specific groups.

For equality and diversity professionals there is a problem, however. Until recently there has been a dearth of properly-funded and reliable research on specific equality target groups. Stakeholder partners have told us that researchers have found it difficult to access funding to research particular groups, or to get it published in mainstream journals. This has happened for LGBT people, for instance. Traditional journals may also lack a patient focus, as in the case of taking a medical rather than social model approach to the experiences of disabled people.

Work of this kind is published, but not in the places where public health colleagues, clinicians or librarians may think to look. As an example, a great deal of research about lesbian, gay and bisexual people's needs and experiences is published by organisations such as Stonewall or the Terrence Higgins Trust. You won't find much by going to more conventional sources such as the Cochrane Library, Medline or EMBASE.

Such 'grey literature' may not be on the conventional radar but nevertheless it constitutes invaluable evidence for policy-making purposes. We'll discuss how we set about making this kind of evidence more accessible to managers in Chapter 8.

National organisations and external researchers may well publish information like this about the overall needs of particular communities, but they are unlikely to cover all topics and even less likely to provide local information. Another essential source of evidence in this field is therefore the information that can only come from consultation and engagement with local stakeholders. We cover this in Chapter 8 along with our discussion of other tools and techniques you'll require.

Finally, some kinds of evidence required for decision-making are simply not available from other sources. There are times, therefore, when you need to be prepared to go and gather (then analyse) your own.

**To sum up**

Evidence can be quantitative or qualitative

Evidence can come from official sources, such as the Census or health observatories; from academic and clinical research; from 'grey research' by NGOs; from partnership with other public sector organisations; and via consultation and engagement with stakeholders... and sometimes _none_ of these will provide the answers you need.

Research to inform strategy-making can either therefore involve searching through and cross-referencing any or all of the above, or occasionally having to start out from scratch to gather data yourself. This is where our own journey began.

**Mapping the landscape of an NHS region**

When we began work in January 2008 it would have been very tempting to try for an 'early win' simply by taking a few givens — such as the need to comply with the gender, race and disability equality duties, or the need to ensure all NHS staff are trained in 'diversity awareness' — and to impose an iron-fisted compliance regime to assure that these were being achieved. Strategic Health Authorities had the power to demand compliance, given that a large part of their role was to performance manage the NHS system in their region.

This would be a safe approach, ticking the necessary boxes, and it is superficially attractive. However, there would be no way of knowing whether ticking boxes in this way actually improves anything for anyone. It's clear, for instance, that if diversity awareness training were effective on its own, incidents of discrimination would quickly disappear and services would adapt naturally to eliminate unfair differences. As we discussed in Chapter 3, that doesn't happen and, as Einstein once said, 'doing the same thing over and over again and expecting different results is insanity'.

If you're a manager responsible for strategic leadership to bring about genuine changes in outcomes for people, it's worth pausing at this point to ask yourself a key question: 'What are you in the job for?' Staying safe, or bringing about genuine change?

If you're the latter kind of manager, you're more likely to want to know what's working, what's broken, and what is most likely to fix the latter.

Our initial groundwork therefore began with the most comprehensive questionnaire-based study we could concoct, covering all the measures indicating the health and effectiveness of the system whose oversight we were taking on.

The North West region consisted (then) of 63 organisations: 24 primary care trusts (PCTs) (the commissioners) and 39 provider trusts, including general, specialist and teaching hospitals, mental health services, and a regional ambulance service. (A new Community Health Trust was subsequently created, bringing the total of providers to 40 and the overall total to 64). Some of the provider organisations reported to the Strategic Health Authority whilst an increasing number had achieved Foundation Trust (FT) status, and were no longer as answerable to us on administrative and performance matters.

Rather than address our questionnaire to specific individuals, we addressed it to the organisation as a whole, via the office of each Chief Executive. To ensure this would work, we began by obtaining the support of our own Chief Executive and the Board, so that they understood the intended outcome and value of the data, and would back us up in obtaining it. This kind of insurance is vital, as organisations will occasionally try to circumvent surveys like this by appealing over your head. The questionnaire was sent out in March 2008 under cover of a letter from the SHA's Director of Workforce, to each of the 63 Chief Executives.

The distribution strategy was important to securing a good response and it certainly appeared to work. Overall we received back 52 fully-completed responses from the 63 organisations in the region... an 83% response. This included 22 of the 24 PCTs; 23 of the 29 Acute Trusts (including 7 of the 11 with Foundation Status); and 7 out of the 10 Mental Health trusts.

The survey, which was reproduced in full with our detailed analysis ('A Landscape of the Region') was divided into nine categories of questions.

**Part one** collected basic structural information, such as whether the organisation had an Executive Director responsible for Equality and Diversity; whether it had any sort of E&D governance committee reporting to the Board; whether there were specific operational leads and practitioner posts for E&D strategy and delivery; how senior those staff were; whether such staff were full time and/or dedicated to this function; and where they and the function reported within the organisation.

In the event, the questions in this opening section provided some of the most potent analysis, leading to an entire strategy for professionalising the leadership on this agenda, and ensuring that the people doing it were appropriately positioned, equipped and supported (the NHS Competency Framework for E&D Leadership described in chapter 10). The results tend to emphasise how important it is to ask the right questions.

**Part two** of our survey collected specific data about compliance, such as (in those days) whether the organisation already had the statutorily required race, disability and gender equality schemes, or a plan that combined these and perhaps some of the other main equality 'strands'. We also collected data about how this information was published and whether such a 'scheme' existed in isolation from or in conjunction with other organisational strategies or action plans, such as a workforce strategy, commissioning strategy, and so on. Evidence which this section provided about the leadership and performance weaknesses across the system supported many of the specific actions which we determined were necessary.

**Part three** examined evidence of whether and how each organisation performance managed the actions planned by the above schemes. There turned out to be very little of such basic governance going on. And, as we know, what isn't measured doesn't get done. It was the evidence from this section which led us to design the first-ever objective and consistent equality performance measurement framework for a health economy.

**Part four** contained a number of questions to assess whether each organisation had any coherent strategy or action plan to ensure that staff competencies relating to equality were being developed, and how this applied to (a) managers and (b) the Board. Evidence from this and other sections provided the case for developing the national NHS Equality and Diversity Leadership Competency Framework and associated personal development programmes.

**Parts five and six** examined how effectively each organisation handled the statutory requirement to undertake equality impact assessments, and how risks were identified and managed. Again, the weaknesses exposed by this helped support the 'why' element of the strategy that we developed.

**Part seven** asked questions about how organisations collected evidence themselves, including any staff and patient consultation arrangements; arrangements for obtaining data from patient contact (for example: appointments, complaints, patient advisory and liaison service work (PALS), and patient / public involvement (PPI), and so on); liaison with local authority planners (Joint Strategic Needs Assessments); and use of published sources (such as the census and regional analyses). Evidence from this section provided the rationale for developing a number of tools, including the first ever one-stop database and portal cataloguing available published evidence in a way that managers can easily find.

**Part eight** collected associated information about local arrangements for involvement and consultation. It emerged that this was very patchy. In several cases we saw parts of the population described as 'hard to reach', which also suggests those people found the NHS hard to access. Evidence from this section informed a decision to design and implement an innovative approach to ensuring sustainable engagement with expert equality stakeholder partners; an approach so successful that it continued to operate and deliver value, year after year. The evidence also spurred us to make a strategic financial investment to enable NHS organisations in the region to set up staff groups.

**Finally part nine** was left open for organisations to include any relevant detail which they wished to add, such as local best practice and their strategic vision.

It is worth noting that we deliberately refrained from asking questions about local needs, initiatives or priorities (other than what organisations might volunteer themselves in the last section). This was because the purpose of the survey was to measure the strategic strengths and weaknesses of the system. If organisations couldn't articulate a coherent vision for how they formulated strategy and prioritised actions to take, there was no point in knowing (at this point) the specific initiatives they were taking. By definition, they would not be able to explain why they were taking these steps and the outcomes they expected to obtain.

You will also see that we interleaved questions about straightforward compliance (the boxes which organisations would be likely to say they could tick) with queries that were more likely to diagnose the health of their decision making and governance processes.

**Analysing the results**

Fifty-two completed surveys covering nine sets of multiple questions produced a prodigious volume of data — a stack of paper about four inches thick — which we then had to condense into a more manageable form before drawing any conclusions. One learning point from this was that it would have been more helpful to structure the questionnaire as an online survey tool rather than issuing a paper format survey. We would always therefore recommend doing this online in future.

One advantage of the paper format, however, was the greater ease of correlating answers from a single organisation — which is usually harder to do with online survey tools. Since we were looking in some cases for causal links (do organisations with weak E&D leadership have poor statutory compliance?) this ability to really examine each response holistically (rather than simply counting which way everyone answered individual questions) was immensely important.

The questions were obviously planned with some idea of where the systemic weaknesses were likely to lie. Having an anecdotally supported idea of what you might find is important during survey design, so that you can ask appropriate questions to either prove or disprove hypotheses. It's a traditional scientific method. The results were even stronger than we thought we might see, however.

Our analysis began at the level of each individual question, examining the different responses quantitatively. The first level of genuine analysis was to then examine what those numbers told us across a whole section.

For instance, in the first section (which asked about the organisational structure for equality, diversity and human rights), we concluded: There is...

'a wide disparity in approaches among trusts in day-to-day leadership for E&D. At one end of the scale there are organisations with full time senior personnel, reporting to the Chief Executive and having regular meetings with colleagues from across the organisation and beyond'.

The opposite side of the coin was obvious.

We then broke this down into specifics. We found, for instance, that there were weaknesses in the way that leadership flowed from the Board and Chief Executive down to operational staff. The data meant we could highlight weaknesses in influencing capability, how the agenda was championed and whether accountability was clear. We also could evidence weaknesses in the career structures and working conditions for E&D teams, especially on relevant skilling and grading.

The corresponding data from the second part of our survey also enabled us to demonstrate that these weaknesses had measurable consequences, rather than simply being 'nice to have'. We could show that in some cases organisations had certainly ticked the statutory boxes, but in other cases there were real exposures that ought to be addressed as serious corporate risks. In the most serious of cases we were duty bound to write to the organisations to alert them to the corporate risk they were exposed to, and to recommend that the issues be progressed through their corporate risk register.

The third part of the survey demonstrated very clearly that, across the 52 out of 63 organisations who had responded, there was no common pattern for determining who was internally responsible for managing the equality agenda, let alone determining what to measure and how. We concluded that trusts in general would need guidance and direction about the kind of performance management they should be carrying out on a regular basis to manage fulfilment of the E&D agenda. We also concluded that, as nobody had taken any lead on this, it was an area which was ripe for us to provide strategic leadership.

When it came to our questions about the capability and capacity of organisations the responses showed again, quite clearly, that only a small proportion of them had any systematic plans for how to develop managers tasked to lead on this agenda. In particular it became evident that E&D leads did not benefit from the kind of structured career development and clear standards for competency that specialists in other fields could expect.

If we consider specialities such as Finance Manager or Director of Nursing, most organisations usually have a very clear consensus about the qualifications, experience and personal qualities that a leader ought to have for those roles.

By comparison, managers nominally responsible for leading on Equality and Diversity for their organisations may have come to work in this role from outside of the NHS, typically from activist roles or working for NGOs. They might be strong in specific knowledge of one or more diverse groups, but they would have missed the personal career development in leadership, and in the work of the whole organisation, that a career manager would have had. This would inevitably hamper their ability to work across multiple directorates and influence peers.

The alternative scenario was that managers made responsible for equality and diversity leadership may have worked their way through a career in the NHS but then found themselves responsible for the E&D brief without specific knowledge of the field. This is often exacerbated by the lack of common agreed qualifications for E&D management and leadership as a profession.

An organisation recruiting a Finance Director would know exactly what qualifications to expect as a minimum standard. The same would be true across almost every managerial area. Some desk research looking at the job descriptions and recruitment processes for E&D leaders and practitioners revealed very little of that standardisation. In the worst scenario, equality and diversity could be the post where people were assigned when there was nowhere else to put them. Hardly the standard for transforming outcomes.

The evidence regarding capability and capacity didn't supply all these answers on their own. However, as is often the case with good research, the data provided the information necessary to focus more detailed digging into this area. The result of this was our work to produce the first national leadership competency framework for equality and diversity.

The next section of the survey looked at equality impact assessment, governance and risk assessment across the whole NHS system in the North West. Here again we found that the quality of some of the answers from across the region raised cause for concern. There didn't appear to be much that could rigorously ensure that managers were competent to conduct equality impact assessments in the way that was intended, basing screening decisions on evidence, for instance, and regarding the lack of evidence as a red line issue. During training which we conducted one manager told us, for instance, that they assumed the impact of their policy area on lesbian, gay and bisexual staff and service users must be neutral because they had never experienced legal action from that group. (Legal protections had only just come into force under regulations that followed the Equality Act 2006).

The weakness in applying evidence to impact assessment was reinforced by responses to the next section of our research, which dealt with data gathering. The survey asked organisations to indicate the processes they had in place to collect service user and workforce data, broken down by all the protected groups. We asked this, in part, because previous national research (Men's Health Forum for the Department of Health) had pointed to systemic weaknesses in the way that information like this is broken down.

On the simple issue of gender, for instance, the superficial statistics would show that around three quarters of the workforce in the North West NHS were women. Organisations were often routinely poor at drilling down into that statistic, however. It would soon be apparent, if they _did_ disaggregate the numbers, that the picture was different across pay grades and professions. This points to another crucial aspect about evidence: ensuring that it is not so superficial as to be (at best) useless or (at worst) completely misleading.

Our questions about intelligence gathering also probed the methods (if any) that organisations used to collate quantitative sources with qualitative information of the kind resulting from Patient and Public Involvement (PPI) activities, local consultation and research.

Overall we concluded that organisations were reliant on incomplete sources of data for making decisions about both workforce and population issues. For workforce, they looked no further than what was available from recruitment monitoring and the NHS electronic staff record (which didn't cover all equality strands at the time and is optional personal data, often poorly completed). Monitoring for characteristics such as disability seemed almost non-existent, for instance. We confirmed this with the cooperation of our colleagues in the regional workforce team, who were in the position to analyse the same data across all organisations.

By this point you would probably not be surprised to learn that the responses to the next section of the survey, on systems for consultation and involvement, drew an equally patchy and disappointing picture. Overall, we concluded from our analysis of that area that NHS organisations in the region had a lot of work to do to develop sustainable channels for consultation and involvement. The lack of consistency in such arrangements raised concern over the compliance of the statutory gender, race and disability equality schemes which each organisation was responsible for developing and publishing. The picture appeared particularly weak in areas such as involving disabled people in policymaking (a statutory requirement) and developing consultation with LGBT communities (a requirement that was on the horizon). One of the outcomes from all this evidence was our decision to develop and demonstrate a robust and sustainable model for engagement with equality stakeholders ourselves. We then documented the method as a proven approach for other organisations to follow.

**Putting it all together**

It will be clear from the foregoing that the evidence wherever we looked in our survey was pretty damming. This didn't altogether surprise us. As we've said, the starting point for probing all these areas was a pretty good idea of where weaknesses probably lay. In some cases this was purely anecdotal, from our experience of talking to both managers and stakeholders. In other cases there were national studies (such as the desk survey of gender equality schemes carried out for the Department of Health by the Men's Health Forum) which evidenced a specific weakness that needed to be examined in more depth for our own region.

That last point is significant. Probing in this much depth shed an unfavourable light on our own region's ability to manage equality and inclusivity. However, this is not to say that the North West was in any way unique (or worse than) any other part of the NHS, or other parts of the public sector. The only difference was that we had made an effort to investigate suspicions about these weaknesses and provide a sound basis for planning to address them.

As we've shown, the results often indicated specific interventions that could be taken, either by finding or developing tools, or by requiring remedial action and following it through.

Our ambitions went beyond simply firing off individual projects to address obvious weaknesses however. It was clear by the universal nature of the weaknesses that a more strategic response was necessary. We will discuss how you turn data into strategy in the next chapter. However, we'll round off this chapter by discussing the overall themes which we extracted from a more holistic analysis of the data resource which we had created.

**Theme One **

****

**Underpinning management structure, capacity, capability and leadership by an appropriate body of knowledge.**

It will be apparent from everything we've said why this was the first, and largest, of the big strategic themes which emerged from our research. We concluded that several findings pointed towards the need for a strong body of knowledge on which to base a consistent vision for positioning, strengthening and professionalising all E&D activities for sufficient strategic influence and successful delivery.

We concluded that there was no consistency in the grading of E&D leadership or departmental roles — stemming from a lack of nationally-defined job roles and professional development paths for the specialism. To address this, we proposed several actions, each linked back to the evidence before us:

We determined we would work nationally with the Department of Health to develop a clear management structure and professional development pathway for E&D personnel. This would include a set of national job profiles; clearer skills profiling to support consistent grading of posts; and identification of the professional development necessary to generate the skills for leadership. Within this we also saw the need to give clear direction on how leadership should be championed from board level; how executive directors should work with senior E&D staff; and how these should all work to ensure that strategy and interventions could be coordinated across directorates.

To support this we also concluded that associated actions were necessary to define the role, competencies and liaison / leadership responsibilities of executive directors chosen to champion E&D. In turn this prompts consideration of which directorate the overall E&D function belongs in. Our research showed that it was often located in Human Resources, where it was unlikely to wield effective influence over commissioning or delivery or quality functions).

Likewise there was the question of how an E&D lead should be line-managed, and who else they ought to report to. Some of the best results appeared to come from organisations where the E&D function had a direct line of responsibility to the Chief Executive, as often happens when organisations really need to grasp a change management challenge.

We also foresaw the need to create personal development and qualification standards for E&D leadership and to distinguish this from the separate need for an overall equality and diversity training regime for staff. In particular we wanted to ensure that staff responsible for leading transformation were not bogged down by the minutiae of training their peers. We wanted it to be clear that strategic leadership required distance and detachment from day-to-day operational matters, and that organisations should support both levels of staff to act accordingly.

In the end we telescoped all of these requirements into a single programme of action to develop the national E&D leadership competency framework. The detailed contents of that framework (and the way it was linked into the NHS Equality Delivery System) reflect the quality of the research behind it. This was a product devised to meet a very accurately diagnosed set of needs.

**Theme Two**

****

**Impact assessment, risk management and standardisation**

It was apparent from the weaknesses which emerged from the survey that action was needed.

As a basic first step, of course, we knew that all trusts had to revisit their statutory equality schemes (or have them independently audited) to highlight risks such as insufficient granularity of data; insufficient consultation or involvement; incomplete consultation; and action plans which were fuzzy and which failed to seek specific, measurable, achievable, realistic and time bound (SMART) outcomes. It was clear much of this wasn't happening, except superficially, and that one major weakness area was the whole approach to information gathering and analysis.

To meet the demand for addressing these weaknesses in a strategic way, we concluded that we should support organisations to access the kind of evidence they needed to plan effectively. There was no existing tool that already addressed this well enough, so we went on to do more research and ultimately developed our Health Equality Library Portal (HELP): a publicly-accessible database bringing together and rigorously cataloguing the most recent and relevant quantitative and qualitative research and best practice information covering every equality target group.

The third proposed action within this second governance theme addressed the very clear lack of performance management in this field. It would be one thing to improve the standard of strategic planning, and to base it on appropriate evidence and stakeholder engagement; however, what isn't measured doesn't get done. As a Strategic Health Authority it was part of our remit to ensure that organisations performed well — and that extends to achieving measurable outcomes in improving the experience of diverse workforces and patients.

Again, therefore, two of our most notable achievements grew from this indisputably strong evidence of need at the outset of our programme.

The HELP evidence database was and remained the most comprehensive one-stop resource of its kind, used widely by teams and individuals across the country (and beyond) looking for the kind of information which they might otherwise struggle to locate. Access statistics confirmed that it grew in popularity and we continued to invest in the quality of the content. We cover in more detail how we designed this (with more research) in chapter 8.

However, it was our work to develop and implement the first consistent and objective Equality Performance Improvement Toolkit (EPIT) that stands as one our proudest achievements. t was based on the strength of the evidence showing why it was necessary. We will devote the whole of chapter 9 to this topic, as the approach and design are every bit as important as the evidence behind it.

**Theme Three**

****

**Partnership, Stakeholder Participation and Evidence based action**

We have already discussed one aspect of the quality and nature of data being used as potential evidence for decision making. The other clear indication from our research was that only patchy progress had been made to underpin such intelligence through consultation or involvement with stakeholders. There were notable examples of good engagement; however no single organisation had an effective model for engaging with all of the protected groups. The gaps were often referred to as 'hard to reach'. This phraseology has struck us as particularly problematic, as it points the finger in the wrong direction, blaming people outside the system for a problem which organisations should be on top of.

As a result of what the evidence indicated, we therefore resolved that another much-needed strategic intervention needed to be some kind of collaborative model for consultation and involvement with third sector (charitable and voluntary) organisations. As it was apparent that we needed this for our own work as well (the SHA had no established processes other than occasional general public consultation events) we decided to use ourselves as the guinea pig and develop a sustainable approach which we could then recommend others to adapt for local needs.

Developing our Health Equality Stakeholder Engagement (HESE) approach became one of the first distinct project work streams in our programme, resulting from our research. The other was the development of the HELP database.

Both HELP and HESE are described in more detail in Chapter 8.

**In conclusion**

It is inconceivable that you could set about developing a strategic change approach unless you have a strong underlying evidence base to draw upon. In this chapter we've explored the forms that evidence can take and where to get it. We've taken a journey through the research exercise which formed the basis for everything we subsequently did. In particular we've shown how all the specific projects we've undertaken have all had their roots in one comprehensive investigative exercise and the analysis from that.

However, we have not completely finished with the topic of evidence. In this chapter we've shown how evidence can drive the decisions to build specific tools or undertake specific interventions. That's a powerful enough exercise in its own right. We believe that's only half the story though. In the next chapter we examine how to take evidence from a variety of sources and mould the big picture into a strategy.

**Chapter Seven**

****

**One and One Makes Three** **—** **Turning Evidence into Strategy** ** **

**Using evidence to inform a strategy with measurable outcomes. Initiating programmes of work without these essentials can be so much 'shooting from the hip'.**

As the previous chapter demonstrates, you can get a long way by basing each action you take on sound evidence. However, individual actions may sometimes have limited effect. If all your resources are directed into specific interventions for one group (black and minority ethnic people, for instance) there is unlikely to be much crossover benefit for other groups, except to the extent that clearly BME people also have other protected characteristics related to gender, sexual orientation, disability and so on. This is the weakness in simply being driven by events and responding with ad hoc interventions.

Even the big cross-cutting initiatives, such as the national E&D Leadership Competency Framework (which we developed with the Department of Health), can be enhanced when they form part of a wider coherent strategy. Building that framework into the national Equality Delivery System helped to cement the place that it should have in corporate performance measurement. Building it into organisational change strategies, as an enabler of success, embeds it further.

This chapter is therefore all about ensuring that one and one makes three. This is a keystone of the 'eco-system' approach — the idea of creating an environment in which all the factors are conducive to good practice taking root and flourishing.

**Being part of core business**

Our concern as change agents within a large system of NHS organisations was to avoid becoming sidelined — of having our work considered 'worthy' and 'necessary for compliance' but in some way peripheral to the mainstream activity of the organisation.

Chapter 3 draws an analogy with the way that perceptions of the importance of information technology have changed in the last 40 years. In the 1970s and 1980s, technology (or Data Processing as it was called then) was seen by most organisations in much the same way as air conditioning and plant maintenance. It was 'important' in the sense that the organisation would notice if it failed to perform when required, but the people responsible for it, and the decisions about how to deploy computer equipment, were viewed as secondary to whatever the organisation did. It was hard (if not downright impossible) for a data processing manager to suggest to other managers that they should change how they did things. How dare someone like that tell a specialist how to do their job? What did the head of widgets have to gain from working with these people who knew nothing about widget making?

Now, equality specialists often find themselves in much the same position as IT experts in those days. They may have the potential to transform the effectiveness of commissioning, service delivery, public health or workforce relations; however, managers in the mainstream are, going by their previous record, unlikely to think of turning to them for help in making policy.

We tackled this by ensuring that the equalities team had a part in scrutinising the annual strategic plans drawn up by each Primary Care Trust (PCTs) in the North West region — a routine part of Strategic Health Authority business. Each year PCTs had to submit their operating and strategic plans for approval. The scrutiny was conducted by the main directorates in the SHA. However, in the North West, the equalities team inserted itself into that process, with the same power as any other to challenge (and if necessary reject) plans that weren't up to scratch.

This detailed scrutiny confirmed that most organisations were simply paying lip service to the idea of population diversity when planning investment in services that meet everyone's needs. The best that most of them would do was to restrict their planning to the geographical analysis contained in the Joint Strategic Needs Assessments prepared in partnership with local authorities.

That was a serious cause for concern. It meant, for instance, that North West PCTs were planning priorities on the assumption (at crucial points) that everyone's needs were the same — at least within specific council wards.

This would work where certain communities cluster in one place (as sometimes happens with particular immigrant groups); and it works for mapping areas of greatest economic and social deprivation; however it is useless for targeting needs on any other basis. Disabled and LGBT people don't all conveniently live in one part of town. In any case, even for towns with significant BME communities, the plans gave the impression that they were meeting the needs of people with the same profile as the planners — invariably white, middle aged and middle class.

This approach is faulty on two counts. It can lead to considerable financial waste, since services aren't targeted where they are needed (and the E&D team has access to information that could help target services more economically). The second problem is that groups of people start to notice that services aren't responsive to their needs.

For a commissioning body, whose central function is to allocate funding for services to meet local needs, the commissioning strategy defines what that organisation plans to do, and where priorities lie for the year ahead. If you propose to invest resources for a certain goal, but it doesn't address the aims of the strategy, then you're unlikely to get support. That's why equality needs to be at the heart of a commissioning strategy or else its advocates are immediately at a disadvantage. The organisation may understand that complying with equalities is a basic legal requirement, but it is much harder to influence priorities and practices to bring about better outcomes for particular service users.

Our analysis showed that, in 2008/9, most commissioning strategies in the North West region virtually ignored the kinds of health inequalities that commissioners (and providers) ought to be aware of and tackle. Equality schemes in those organisations tended to have documented lists of such inequalities and action plans purportedly addressing them. However, because the organisation had collectively failed to make the connection between the two, if the plans worked, it was in spite of, rather than because of, the organisation's corporate strategy.

Using the SHA's powers to reject such commissioning plans meant that organisations were forced to revise their plans and develop a more joined-up strategy. A distinct improvement the following year, when the exercise was repeated, showed that the message had got through.

A similar principle was applied to the scrutiny of plans for the reconfiguration of services and (later) to the process by which Primary Care Trusts divested themselves of their community services. In each case the SHA's equality team ensured that its powers of scrutiny and veto required organisations to do what they should have been doing themselves.

Embedding equality goals into corporate strategy obviously requires more than just inserting the right words liberally through a document. Plans were scrutinised for evidence-based reasoning. To pass muster, plans had to show how managers were acting upon cogent evidence of disadvantage, in an intelligent fashion, to eliminate disadvantage and/or promote equality of outcomes. This is what the public sector equality duties were asking of organisations. It is also a fundamental aspect of commissioning. We were adding quality to the scrutiny process which was a core part of the Strategic Health Authority function. Unless the strategic plans of those organisations showed how they would tackle those issues, no amount of ticking boxes and producing good-looking equality schemes would be approved.

This is another important lesson. When you are doing things right, when your mainstream plans genuinely embody the aim to ensure equal outcomes from everyone, and when you have the evidence-based reasoning to show you've thought about it, then compliance follows naturally.

**Applying our own medicine**

This chapter opens with a warning against taking action without strategy, but clearly flexibility needs to be built in: if you see your toddler about to fall down the stairs, you don't need to write a health and safety strategy before intervening.

Thus it was with the follow-up to the evidence gathering and analysis described in the previous chapter. The evidence showed that certain gaps needed to be filled, such as effective stakeholder engagement and a means to help people find evidence for decision-making. (See Chapter 8 for more details.) However, the research to produce such tools didn't need to wait for the ink to be dry on the strategy — it was clear that researching further on how to address these gaps could actually contribute towards the latter.

We think therefore that people shouldn't be too literal about doing things serially: research... analysis... strategy... action. There are clearly times where there can be an overlap, so long as you are clear that the actions you take will fit within (and not undermine) the overall strategy when it is complete.

This pragmatism is necessary to avoid interventional paralysis. With some discrete development underway there is less pressure whilst you think about the big picture of the strategy. With comprehensive research already undertaken, the development of the strategy, and aligning it with the business objectives of the SHA, was quite straightforward.

**Key information underpinning the strategy**

****

Several kinds of information contributed to our thinking:

  * Demographics and socio-economic factors affecting the health of the 6.9 million people in the North West Region (which were part of the SHA's wider strategic concern). Such information was available from the most recent Census, from public agencies, and from local government .
  * Data available from all sources (including stakeholders) about the specific inequalities experienced in health care delivery and outcomes. Some of these inequalities concerned health outcomes; some concerned the way services were accessed and experienced. Gaps in such information were another reason to involve stakeholders in the design of the strategy.
  * The national and regional policy context. This was perhaps the easiest information to obtain if you're a public sector body yourself. Such information is crucial for ensuring that the strategy you formulate is aligned with mainstream policymaking and can be seen to contribute towards business goals.
  * The evidence from our Landscape of the Region report on the strengths and weaknesses of the system we managed.

The North West, for example, includes almost 40% of the most deprived areas in the country. Fourteen (out of 24) of the former PCT areas in the region were within the worst 50 nationwide, in terms of health inequalities and deprivation. These facts alone emphasised the strategic relevance of our work.

In addition, 400,000 (9%) of the working age population were on incapacity benefit, largely for preventable or manageable conditions. Other indicators showed that there were higher levels of unemployment amongst disabled people (one in five of the population) and people from Black and minority ethnic backgrounds (BME) (7%). Each statistic highlighted the connection between the problems facing the system as a whole and the contribution which effective equality and diversity management could make towards addressing them.

Available public health sources also showed that the North West compared less favourably with other regions in England. For instance, the region had the highest rate for:

  * deaths from heart disease and stroke;
  * long term mental health problems;
  * alcohol-related hospital stays;
  * hospital admissions for depression; anxiety disorders and schizophrenia;
  * drug misuse:
  * self-reported violence;
  * violent injuries serious enough to require hospital treatment; and
  * claiming incapacity benefits for mental and behavioural disorders.

The region also had the second highest rate for:

  * deaths from cancer and smoking related illnesses;
  * deaths from suicide and injuries of undetermined intent in males; and
  * reported levels of feeling in poor health.

To add to this:

  * 23% of adults in the region were binge drinkers;
  * infant deaths were also significantly higher than elsewhere, as well as obesity in children, poor health in under-15s, child poverty and teenage pregnancy; and
  * the North West region had the joint highest rate of sickness and absence nationally.

Moreover, some of these factors could be linked specifically to particular protected groups in society, in a way that public health strategy has not always managed to do. It's easy to make the case that a one-size-fits-all prevention strategy could be less effective than one which takes account of the different needs and susceptibilities of sections of the population.

The strategy was linked to the SHA's overall corporate strategy, one of whose goals was 'to ensure people live longer, to reduce the impact of illness on people's quality of life and reduce the incidence of lifestyle-related illnesses'. The research unearthed many examples of how issues affecting various protected groups contributed to the challenge:

  * **Gender and Race** : life expectancy is significantly lower than the national average for both men and women and even lower for people in BME groups.
  * **Race** : ethnic minority groups have higher rates of diabetes, mental health and other health problems.
  * **Age** : infant deaths are also significantly higher in the region, as well as obesity in children, poor health in under-15s, child poverty and teenage pregnancy.
  * **Race and disability** : a quarter of all Gypsy and Traveller households in the North West have someone with either a disability and/or ill health.
  * **Sexual Orientation** : lesbian, gay and bisexual people have higher rates of smoking as well alcohol and drug addiction and are more likely to suffer mental health problems than predominantly heterosexual men and women.
  * **Transgender** : 34% of people with gender identity issues report having attempted suicide or self-harm one or more times when they have not been able to access support and treatment when they needed it.
  * **Gender** : men are much less likely to visit their GP than women yet are twice as likely as women both to develop, and to die from, the 10 most common cancers affecting both sexes.
  * **Gender** : three times more men than women die from suicide.
  * **Age** : depression is the most common mental health problem in later life. Of the third of older people with depression who discuss it with their GP' only half are diagnosed and receive treatment.
  * **Religion and belief** : more people in the North West identified with a religion compared with the rest of England. Religion and belief affect a variety of health matters such as blood transfusion, contraception, diet and medications.
  * **Sexual Orientation** : one in five lesbian and bisexual women had deliberately harmed themselves during 2007-8, compared with 0.4 per cent of the general population. Half of women under the age of 20 had self-harmed compared with one in 15 of teenagers generally.
  * **Transgender and Age** : young trans people report insecure housing, economic hardship, legal problems and difficulty in accessing appropriate healthcare. They have limited family support, high rates of substance abuse and high-risk sexual behaviours.

**From problem statement to strategic solution**

The risk in listing such individual challenges is that the action plan can become reactive to the specifics, rather than addressing the bigger picture... the overarching reasons the specifics are not already being tackled.

It makes sense that these specifics are tackled early on, in GP, community and hospital services. However, in a large region such as the North West, location can really make a difference to how these issues play out. That has always been the benefit in having autonomous local decision-making. The task of strategists is not to micromanage the whole system item by item but to identify the themes which, if addressed, lead to the desired results.

This is where the original Landscape research once again came into its own, as it helped identify such strong thematic weaknesses across many of the 64 NHS organisations in the region. These could be grouped into five interlinked areas:

**1. Increase the diversity, representation and improve the working lives of our workforce**

Recognising diversity means understanding how people's differences and similarities can be mobilised for the benefit of the individual, the organisation and society as a whole. Different groups of people offer different viewpoints, cultural knowledge and skills that can improve the NHS' ability to deliver services, adding value and sustainable competitive advantage. Workforce and delivery excellence can only be achieved and sustained by ensuring that the NHS recruits and develops the very best people for every job, regardless of their background or superficial differences.

**2. Develop data to monitor, information to manage and knowledge to act**

Readily available, up-to-date, accurate data, regularly analysed and presented, is vital for decision-making, support in planning and commissioning dialogues. It improves the focusing of provision, the evaluation of outcomes and supports innovation.

**3. Develop the right services: targeted, useful, usable and used**

Knowing who the population is and understanding the different health needs of groups and localities will improve precision of service delivery, lessen waste and could have a dramatic effect on the success of major health programmes. It will also facilitate the development and evaluation of focused development and pilot initiatives.

**4. Move beyond legal compliance to initiating best practice**

It is not sufficient to be legally compliant, although it is necessary at all levels in all NHS organisations within the system you're wanting to transform. Aiming for development and adoption of best practice will improve both working and service conditions; improving health outcomes whilst lessening wasted resources spent on litigation or high staff turnover.

**5. Develop our specialists and leaders**

To make best use of diversity as a lever for improvements in service delivery and workforce, and to have skills in managing both the benefits of improvement and the risks of poor practice, we need ready access to equality and diversity expertise at senior levels in the organisation so that these individuals are able to influence change.

A crucial characteristic of these five goals is the degree to which they are all linked in various ways to each other.

Leadership is a fundamental enabler of all change, for instance, and the best way in which to distribute the products of the innovation which good leaders promote is to recognise, document and share it as best practice. In a large system you don't want 50 or more organisations re-inventing the wheel. In turn, the underpinning for all leadership decisions and best practice is accurate, up-to-date data and the means to analyse and draw appropriate conclusions from it.

That business intelligence also then feeds into appropriate design and procurement activity for commissioning organisations, or fine-tuning of services for providers. Last, but not least, everything involves people — those who work in planning and commissioning services, as well as those who deal with the public at the delivery end. That is why it's important that that workforce should be representative of all the communities we serve.

Each of these five interlinked goals, were divided into sub-goals, analysing the present situation and weaknesses, the key deliverables required, and how success would be judged

This last point is vital - it emphasises a focus on outcomes. You may know the problems you face and feel that you're doing a lot about them. But a strategy must never lose sight of the ultimate objective, which is that changes and beneficial outcomes must be able to be objectively measured.

**Measuring success**

What isn't measured doesn't get done. It is all too easy to produce a strategy, and even to get it agreed and endorsed by everyone. However, it is also very easy for strategies to get pushed onto the shelf by events, or to confuse the inputs for results.

Our strategy was therefore designed to be measured and to become the touchstone for judging the relevance of any tools or projects we undertook. Any investment needed to address the gaps identified in the strategy, or to advance the achievement of the five goals.

The structure of the five goals, with their key deliverables and success indicators lent themselves very well to measurement like this.

Chapter 9 sets out an approach to measuring performance against the strategy, and the Equality Performance Improvement Toolkit (EPIT) which it led to.

**Chapter Eight**

****

**The Tools and Strategic Interventions Needed to Support Change**

We explained in the previous chapters the process of using evidence to inform a strategy with measurable outcomes — and why we believe that initiating programmes of work without these essentials can be so much 'shooting from the hip'.

In chapter 9 we will talk in detail about how to measure the outcomes in an objective and consistent fashion, and how that then feeds back into development and leadership. Before you can reasonably expect people to make progress, however, it is important to ensure that they have both the tools and competencies to do the job.

We will discuss the development of leadership competency in chapter 10. Before that, it is time to look at the question of tools.

**The need for tools**

Our 'Landscape of the Region' research showed that managers were very often struggling simply because they lacked basic resources.

Theme three of the conclusions in that research showed that NHS organisations in the region needed to improve:

  * the way in which data was derived and used as a potential evidence base;
  * the development of external stakeholder consultation; and
  * consortium-working with other agencies - for instance in joint consultation work or working together to develop common tools or develop joint strategies

Among the 10 proposed actions, two obvious requirements emerged for tool sets:

Proposed Action 9

'NHS North West will provide support and direction to help build data gathering and data disaggregation capacity within organisations — for instance by setting up a library of research reports and data from national and regional sources (both public and third sector) and by promoting techniques for collecting, collating and disaggregating internal sources'.

(Action 8, which dealt with sharing information about Equality Impact Assessments, also pointed to the same kind of functional requirement)

Proposed Action 10

'Develop a collaborative model for local and sub-regional consultation and involvement work along with other agencies and third sector partners. NHS North West should learn from the good practice examples of other agencies such as local authorities, police forces, prison and many in the third or voluntary sector'.

But what were the criteria for deciding whether to undertake an investment or development ourselves, or whether to encourage others to do this?

**What makes a tool or investment strategic?**

As the work of implementing and performance measuring the outcomes of the regional strategy progressed, many other kinds of gaps emerged, besides the two above. The approach to any of these was to consider first whether any particular need was fundamental to change or just a 'nice to have'; whether the need was widespread or local; whether it was capable of being met from within the system itself; and what form, therefore, any intervention by the SHA should take to remain strategically focussed.

The Equalities team made a particular effort to consider whether needs could be met first by encouraging collaboration between teams within the NHS system. This is always preferable where it can be achieved, as it encourages the culture of collaborative working and a sense of ownership of best practice. It also helps promote E&D leaders within their peer group.

A strategic goal was to make collaborative initiative-taking instinctive and automatic within the system; and, ideally, to render the SHA's equalities input progressively redundant. If people could identify gaps and organise themselves to address them then an E&D overview really would be unnecessary. It might seem strange to advocate that the goal of strategic E&D leadership is to change the culture so that it makes itself redundant, but it is the logical conclusion of the outcomes aimed for: a self-improving system. To envisage a situation where there is always a continuing need for your own presence is to aim low; to accept that equality and inclusion culture will always be lacking in some way. It also seems peculiarly self-serving.

**Facilitating rather than 'doing' where possible**

A good example of drawing the distinction about how far to intervene was when the opportunity arose to develop a new staff e-Learning module for basic Equality and Diversity awareness. The need had been highlighted by E&D leads themselves, who pointed out that existing material in the NHS e-Learning website was out of date. In response we discussed the need for a substantial update with the head of educational developments in Skills for Health.

However, when that discussion produced an opportunity to rewrite the existing training, we handed this back to the E&D leads who had raised the issues in the first place, and encouraged them to form a working group to decide the best form for the content. This worked because (a) it met the need they themselves had identified; and (b) no commitment other than time was necessary. It was a strategic development, meeting a widespread identified need which couldn't be done without some initial intervention from our level; however, the Equalities team only needed to facilitate and kickstart a process. The unique contribution was to find the right place to raise the issue and encourage a solution. From that point, it was something that the community of E&D leads could develop themselves, so it was right to then take a back seat.

**Investing to create; not for the routine**

Another related distinction is about how and when to strategically invest funds and, more importantly, when to identify that this is no longer appropriate.

One of the key enablers of the strategy over the course of five years was to ensure it was supported by the funding to employ a team and invest in strategic developments. Yet it wasn't a vast budget. The average annual spend on improving the outcomes of the whole NHS in North West England amounted to less than five pence per head per year for the region's population — and half of that was simply spent on the wage costs of a small but very specialised team. However, there is a definite budgetary limit below which it becomes impossible to fund the things which only a strategic team can lead. The key to achieving on a budget was to first secure the funds (by positioning the team in the part of the organisation which could stand such a budget) and then to be scrupulous about deciding what makes a strategic investment .

The best way to illustrate this is by means of an example.

The SHA's strategic stakeholder partners would occasionally present proposals for projects themselves. From these requests we began to identify the foundation for a good project: a well-evidenced systematic problem and a well-argued solution.

In the case of LGB patients, for instance, the Lesbian and Gay Foundation presented various forms of qualitative and quantitative evidence on the need for more welcoming and suitably knowledgeable GP care for lesbian, bisexual and gay patients; they also proposed a series of carefully-costed specific project interventions which would successively build to address the need. Each intervention also had built-in outcome measurements too, so at each stage of the investment it could be determined whether the solutions were working.

The attraction of these project proposals was that they were evidence-based and involved outcomes that could be measured. They were fixed cost. And the success measures of piloting one could be used to determine the advisability of progressing to the next.

Such a project was clearly a strategic one, since it could only take place with investment and influence at a regional level. The investment had to enable the development and promote it, but it would not require continuing support and investment from the SHA once launched. Instead, the investment should produce a tool that, once created, could sustain itself. The LGF's 'Pride in Practice' toolkit, which resulted, is well on the way to achieving that latter requirement. The investment was therefore genuinely strategic.

**Why this matters**

It is important to labour this point about strategic tools and investment since the Equality and Inclusion field is littered with the memory of good initiatives that are no more; projects that had worthy aims but which stopped when the funding ran out, or never developed beyond the local system in which they were conceived.

Such an investment approach wastes millions of pounds worth of effort, especially if essentially the same solution is simply reinvented elsewhere. Furthermore, whilst such schemes can help produce small changes for the duration that they run, the benefit is too often lost as soon as the money runs out or the initial sponsor moves on. From a strategic point of view that is not genuine change. It's a sticking plaster. And from an economic point of view it is extremely wasteful too. If change doesn't become permanent then the money spent on these projects is essentially being poured into the ground... constantly.

Suggested strategic investment aims, therefore are to:

  * invest judiciously.
  * facilitate projects that others can be helped to do for themselves and save the direct involvement for situations where others cannot be expected to succeed.
  * be clear on the evidence of need and the ability to measure genuine outcomes.
  * design solutions that will be self-sustaining and can therefore become embedded as permanent outcome-improving changes.
  * design them to have the widest possible benefit — regional rather than local; national rather than regional.

Investments like that, over the long term, have potentially open-ended benefits for fixed costs of investment. In value for money terms, the return is consequently significant. The rate of return keeps on growing. In equality terms, the outcomes are going to be real, and they will continue long after you've stopped having a direct input. That's investment for lasting change.

**The Health Equality Library Portal (HELP)**

We turn our attention now to the kinds of development which required direct project leadership by the equalities team to achieve. That is, developments which local teams would not be able to develop and sustain on the required scale, and which individual stakeholder partners could not bring to us as project proposals.The first of these stemmed from the evidence of our 'Landscape of the Region' research.

The case for HELP was very clear. Across the region, E&D leads and managers who were developing policies and plans, or attempting Equality Impact Assessments, appeared to have difficulties knowing where to go for up-to-date and reliable evidence on which to base decisions.

In diversity terms, this is a systemic problem. A 2009 comparative study undertaken by researchers in the Department of Public Health and Epidemiology at the University of Birmingham found that, for LGBT Health:

'numerous surveys on a wide variety of health aspects have been conducted since the early 1990s, almost always by volunteers from the LGBT community. Unfortunately, almost all of these have only been available as reports and have never been widely disseminated or fully published in peer-review journals, so the results have mostly not been accessible to healthcare decision-makers'.

The researchers also observed,

'Only 11 peer-reviewed and published quantitative research reports since 2000 were found on LGB health in the UK'.

(MEADS et al, 2009).

Similar patterns can be found for other equality target groups. Specific evidence of health needs tends _not_ to be published in the mainstream peer reviewed medical literature. In turn, although the information is published in _some_ form by charitable and voluntary sector bodies, it tends to be invisible to NHS managers unless they are already familiar with the organisations concerned.

Anecdotally the team knew of many other kinds of barriers to finding evidence too, often from direct experience. In order to design an effective solution, however, further specific research and evidence were required.

The primary research for designing a solution took two forms.

  * An online survey among a wide range of NHS managers on what kinds of evidence they needed and used, and how much they knew about where to look.
  * in parallel, research to look at what sources were already available, and what kinds of tools could be put into use to meet everyone's needs.

The managerial research covered managers in all kinds of organisations:

  * The Strategic Health Authority
  * Primary Care Trusts
  * Acute, specialist, ambulance and mental health provider trusts
  * General practice
  * Voluntary and community sector organisations
  * Local authorities
  * Education bodies
  * Regional agencies
  * Housing associations, ALMOs and RSLs

The online questionnaire was completed by a wide range of potential users or decision makers:

  * Equality and Diversity Leads
  * Managers
  * Chief executives, directors, and associate directors
  * Non-executive directors
  * HR managers
  * PPI managers
  * Administrators
  * Clinical staff

Research was carried out into the kinds of strategic, policy, evidence or advisory documents that respondents had an interest or hand in procuring or producing. This included:

  * Strategic plans
  * Policies and procedures
  * Equality impact assessments or equality schemes
  * Training materials
  * Complaints investigations
  * Commissioning plans
  * Public health plans
  * Procurement documents and contracts
  * Communications literature

All this information provided a comprehensive sample of users and needs.

A poll was then carried out among the 124 respondents to our online survey to identify the categories of evidence and advice material which managers in the sample said they most needed. Unsurprisingly, this showed that significant numbers of respondents recognised they needed information about the core diversity strands:

  * Deprivation (59/124)
  * Carers (57/124)
  * Transgender (75/124)
  * Age (48/124)
  * Religion or Belief (74/124)
  * LGB (69/124)
  * Disability (57/124)
  * BME (67/124)
  * Gender (52/124)

Small numbers of many specific areas were also listed in free format answers, including one that simply said 'Everything really'.

Respondents were also asked which areas they thought it was easiest to get information for at present. Predictably, the strongest responses were for the diversity strands which had been covered by statutory equality duties the longest: BME, followed by Disability and then Gender. Areas such as sexual orientation and gender identity scored low. Deprivation also scored low, which was surprising, given that this is one of the areas where Joint Strategic Needs Assessments have traditionally contained the most detailed analysis.

A more open question explored the most recent examples of areas where respondents had sought information. This produced a wide spread of topics, with most of the diversity strands mentioned several times, but also a much broader spread of needs. Many people were looking for best practice and legal information, for instance, plus pure demographic data.

The research made sure to check if any of the information being sought was 'sensitive', in the sense that it couldn't be made available in an unrestricted public database. The overwhelming response was that the information wasn't sensitive in this way.

Respondents were also asked how often they would access a resource if it met their information needs. By far the majority thought they would use it either once a week or at least once a month.

When respondents were asked what kinds of available resources they used already, the responses were revealing. They clearly indicated how few sources the average manager knew about or was confident in using. Out of 124 respondents, over half said they referred to sources such as government legislation, published codes of practice, the Department of Health web site, the ONS, EHRC and Healthcare Commission. Beyond those obvious candidates, however, very few cited other sources. Only eight mentioned using information from stakeholder organisations.

Finally, the 10-question survey asked what kinds of information respondents felt they would be able to share with their peers through a suitable platform. The commonest categories were Equality Impact Assessments and local demographic data.

The evidence from this simple survey was invaluable in drawing up a specification for what kind of resource people would find most useful, where to prioritise content acquisitions, and what SHA colleagues could contribute.

**To acquire or make?**

At the same time, extensive research for available tools drew a blank. This was not a surprise. If there was already an effective tool to meet this kind of requirement we would almost certainly have known about it. Also, the existence of such tools would have been reflected in the results of the survey, covering so many managers. Even looking at potential sources it was clear that most websites were difficult to search for the kinds of information which people needed. There was a huge unmet need. A resource that could meet this need would be of massive strategic value if we got the specification right.

Since there were clearly no suitable existing databases, we then looked for off-the-shelf software that would fit a demanding specification. Again we were not surprised, finding little that came close. It was clear that a brand new solution was required. That meant finding a suitable developer who understood our requirements, had a track record for producing effective software, could work with us, and was affordable.

In the end we struck very lucky with the developer we selected, Boilerhouse Solutions Ltd. They were able to tick all of those boxes, and furthermore understood what we were aiming for so well that they brought several new ideas to the table.

The specification evolved in discussions. In addition to the basic need for a way to catalogue a searchable repository for a wide variety of information, we recognised the value in making our HELP portal a more generally educational and information-driven site, by incorporating a facility to publish news stories of our own, and to list upcoming events related to equality and diversity.

An automatic digest of external news feeds was incorporated into the mix plus, later, a blogging platform and a bulletin board for staff to interact and discuss topics of shared interest. From a design perspective, adding all these features was an important aspect of building a resource which people would routinely return to.

Before it could be launched, in September 2009, we also needed to stock the system with content. For this we turned to the equality stakeholder partners with whom we had begun to build relationships, tasking each group to supply us with at least 100 good, up-to-date references for their specialist area. Subsequently we made continued updates a part of the Service Level Agreement we drew up with each organisation, ensuring a regular flow of new and relevant material.

**Measuring success**

HELP proved outstandingly successful as a strategic resource as soon as it launched in 2009. Gradually, the library grew to include over 1,600 fully catalogued information assets and over 300 catalogued specialist web sites, with coverage for every diversity strand fairly evenly distributed.

A key to the success of this area was the care in categorisation (and the success of the taxonomy in being able to accurately code the content of each item). A database is only useful if users can rely on finding what they want in one or two attempts. We are used to this in general search engines like Google, so people expect the same from a specialist tool too. The news, events and blog content were also tightly linked to the communications strategy. Constant updating of these portions reassured users that HELP was up-to-date. Users' confidence can easily be dented if the database looks as though it is not updated regularly.

Some statistics underline the immense success of the tool.

HELP was launched in September 2009. As at March 2013:

  * 1638 document assets had been added.
  * 170,216 copies had been downloaded.
  * The most popular document (our guide to the Equality Performance Improvement Toolkit) had been downloaded 2559 times.
  * Four other documents had been downloaded more than a 1,000 times each. These included our framework for E&D leadership competency (1648) and our methodology for sustainable stakeholder consultation (1341). A research report from Stonewall on Lesbian women's health needs had been referred to 2340 times and a report on healthy ageing had been downloaded 1004 times.
  * Another 19 documents had been downloaded more than 500 times.
  * More than 300 other documents had each been downloaded more than 100 times.
  * Over 650 people had followed the site's Twitter feed, which was linked so as to automatically notify people about new additions in each of the sections.

According to the site's Google Analytics in July 2012:

  * Over 13,800 unique visitors had been to the site more than 22,750 times, viewing 81,000 distinct pages whilst they were there.
  * Overall, 40% of visitors had been coming back for a second or subsequent time.
  * 91% of the visits had been from the UK and, of these, 33% were from NHS domains.
  * The site typically received around 25-30 visits per day.
  * 60% of visitors used the site for more than three minutes, with significant numbers spending far more than this.

By all measures, therefore, HELP achieved immense success. At the time of writing, it was still the only site of its kind meeting a real need at both national and local level.

**The Health Equality Stakeholder Engagement Approach**

Another very strong theme that emerged from the detailed surveying of the region's strengths and weaknesses related to engagement with equality stakeholders; that is, the voice of people from both inside and outside the NHS who possess one or more protected characteristics and whose experiences of NHS services or employment may differ from others.

The research had asked NHS organisations what processes they had in place for both consulting with, and involving, people in decision-making processes.

It asked about both levels of contact because 'consultation' (asking people what they think of something) is materially different to 'engagement' (involving people at a level where they can reasonably assume that their input has a material effect on the proposals being discussed). The various public sector equality duties in force at the time made a distinction between these two kinds of contact. The Disability Equality Duty called for 'engagement' whereas the Race and Gender Equality Duties called only for 'consultation'. It therefore seemed reasonable that, in the interests of levelling up the quality of outcomes for everyone, organisations ought to strive for 'engagement' as the common standard for all. What does it imply to stakeholders if you merely ask for an opinion on what you are doing without any commitment to take account of that advice and change what you're planning accordingly?

Additional questions asked NHS Trusts about:

  * What kind of formal mechanisms they had for consulting or involving each kind of equality stakeholder group in the development of strategic or operational plans;
  * What kind of specific staff networks they had set up;
  * What kinds of internal links they had set up between the E&D team and the Patient Advice and Liaison Service (PALS) officer, Patient/Public Involvement (PPI) team, and public health; and
  * Whether the organisation was represented on the region's Equality and Diversity group, set up by the Regional Development Agency and other public sector partners.

The results showed that there was very little consistency or best practice at all in this area, with most of the surveyed organisations failing to consult with external stakeholders on a regular and sustainable basis; most having few — if any — staff network groups; and no general pattern of effective matrix working with colleagues in the patient / public liaison fields.

One of the barriers cited most frequently was that some groups were considered 'hard to reach'. This is a problematic claim, as it seeks to place the blame for a lack of engagement with some communities on those groups' shoulders. Such language suggests such stakeholders are in some way to blame for being difficult to contact, rather than acknowledging that the job of organisations is to overcome such difficulties and ensure they _were_ engaging with every type of community that the NHS is there to serve.

Through the SHA team's membership of the region's overarching Equality and Diversity group we were also able to ask voluntary sector organisations representing all of the protected characteristics for their views as well.

The overwhelming message from such stakeholder organisations was that they were increasingly sceptical about the majority of public sector consultation or engagement efforts because they so manifestly failed to take account of the real world pressures being imposed. One common complaint concerned 'consultation fatigue' — the effect of continual unreasonable demands for short notice responses to detailed documents by dozens of organisations appearing to assume that stakeholders had resources to spare and could drop everything at a moment's notice to respond.

One look at the region's landscape showed how this problem could arise. In North West England there were 64 NHS organisations including the SHA; 46 local authorities; 46 local fire services; five subregional police forces; a Development Agency; a Regional Assembly; the Equality and Human Rights commission plus countless smaller agencies, all with a desire to be able to tick a box showing that they had consulted on their policies and plans.

Set against this, although there are in theory hundreds of voluntary sector organisations, very few of those were specifically focussed on the needs of particular protected groups. Most were very small, living from hand to mouth, without policy officers available to spend time reading often-lengthy consultation documents and preparing responses. Some equality strands were served better than others in this respect. In some cases there might be only one organisation which could fulfil this role; and they were unlikely to have the capacity to fulfil it for over 100 public sector agencies all asking for the same kind of input for free.

In these circumstances it was little wonder that some kinds of stakeholders might be considered hard to reach. We knew from anecdotal evidence that some were actively avoiding more engagement, just so they could get on with the work they were funded to do. They would avoid the one-sided effects of these kinds of demands for consultation, even though they knew that in some cases a nil-response could be assumed to imply they were happy with the proposals presented to them.

**The need for a respectful, realistic relationship**

Whilst sympathising with the pressures on such organisations, we realised that, as a Strategic Health Authority, we were in danger of becoming part of the problem in pursuing our own extensive needs to consult and involve. This meant we would need to produce a mould-breaker if we were not to repeat mistakes already being made and add to the undue pressures on the voluntary sector.

We also reflected at length on what we were really looking for in consultation, and how easy — or not — that would be to find.

One mistake often made by public sector organisations (the NHS included) is the assumption that general public consultation automatically covers everyone. The belief is that if such events are large enough, and held in enough places, everyone will automatically be covered. The most cursory discussion with equality stakeholders reveals how mistaken this is though.

To begin with, this kind of consultation tends to favour people who already feel engaged (hence their voices are probably already being heard). You tend to see the same kinds of faces in these events: people in a certain age group and social class; people who have no difficulties travelling or communicating; and people who naturally assume their experiences to be the norm.

People who are disabled or are perhaps gay, lesbian or transgender may not want to be identified as such if they do attend; participating fully would necessitate 'outing' themselves; you can't be sure they've been part of the process.

Where people from minorities _do_ engage, you cannot be sure that their experience speaks for everyone in that category. A disabled person who uses a wheelchair may not appreciate the different kinds of barriers which other disabled people may experience. Their experience may not even be typical of other wheelchair users.

Numerically, the minority participants in large, general, public consultations are also at risk of being drowned out by the majority. Their minority status is only amplified if care is not taken.

All these factors mean that open public consultation can produce skewed results if used as the _sole_ method to understand what diverse stakeholders think and need.

This is not to say that open public consultation should be abandoned. It clearly has a role, and the long-term goal of reaching out to others should include attempts to ensure that a more diverse audience can contribute and feel that their voices and needs are equally heard. However, it is not a solution that can be used in isolation.

This all brings us back to the need to select equality stakeholders carefully, and to engage with them in a way that then respects their needs as well as our own. As such careful selection takes time, in itself, it is obviously desirable to not have to repeat it because organisations have withdrawn or fallen by the wayside. It all points back to the need to make engagement of this kind mutually rewarding, and hence ultimately sustainable.

**Turning our own search for stakeholder partners into best practice**

We discussed above the factors determining a good strategic intervention. Simply setting up a consultation group for your own purposes is all very well, but is it strategic?

In this instance, it was clear to us that the challenges facing us in setting up a sustainable means of engagement with good quality expert stakeholders were not unique. To turn a simple local exercise into a genuinely strategic approach, we decided that we should aim for a method that was reliable, repeatable, and recommendable to others; in other words, genuinely best practice.

To achieve this we took a step back to consider both the process of finding the best possible partners; and to design a sustainable way of long term partnership with them. The aim was nothing more or less than a process that would build in value over time. Having consciously made these considerations a goal meant that we were also in the best position to reflect upon and document the rationale as we went.

****

**Seven steps**

We produced a seven-step model for managing the process of setting up such an arrangement: [taken from 'An Equal Partnership - Captured learning from setting up a health equalities stakeholder engagement model']

1. Decide on how you are going to embrace all diversities

Remember to include gender, transgender, all races and ethnic backgrounds, disabled people or disability, all sexual orientations, all religions or beliefs and every age group – plus all the combinations of these experiences.

2. Decide on the criteria for picking suitable partners

Don't limit your aims to what local organisations can currently achieve; set your sights on the ideal qualities in a stakeholder partner and decide how you might need to support organisations if necessary to get there.

3. Decide how much work is involved

Don't cut corners. Stakeholder consultation and involvement is not optional and requires serious organisational investment in time and effort. Remember that it is the stakeholders who struggle if you end up demanding more than you originally asked for. Think about different kinds of activities, such as research and day-to-day support, as well as consultations.

4. Commit to the philosophy that expertise has value

Recognise that the stakeholders you engage with are experts in local community needs. If they're not experts, revisit your criteria to ensure you find experts elsewhere. Expertise needs to be paid for, especially if it is to be developed and if engagement is to be sustainable, so decide on a fair rate to offer in return for serious contribution.

5. Pick your partners using a fair and objective basis

Conduct your selection process in a transparently fair, objective, professional manner. Shortlist and select strictly according to the criteria you established. Think of this like any other well-governed and transparent procurement exercise.

6. Put it all into a formal agreement

Nothing signals more clearly that you have a serious and businesslike approach to engaging in a committed partnership for the duration. Aside from the standard contractual clauses, pay particular attention to defining the skills and resources you expect each stakeholder to provide, the equality group/s and geographical areas you want them to cover, the named experts you want to work with, how you are going to pay, and how you expect to work together.

7. Invest in your stakeholder partners' skills and knowledge

Budget for time to share information with your partners about the health service and your organisation. The responses you get will benefit from this.

**Paying for expertise**

Perhaps the most radical idea in all of this was the decision, taken almost from the outset, to pay for the expertise we wished to call on. Immediately that decision was made, some of the other design ideas flowed automatically.

It was obvious that we would need to formalise the arrangement. You don't just hand over money without being very clear about the expectations on both sides. It was clear that we would need to design a Service Level Agreement (SLA) explicitly setting out each side's obligations and expectations.

It was equally obvious that we would need to decide upon a fair rate to offer the partners. Deciding this required quite a lot of discreet local research and sense-checking.

In order to budget for this and set boundaries for the SLA, it was important to estimate accurately how much resource was required.

Finally, in order to estimate that time properly, it was necessary to think about the structure of different kinds of consultation activity, and how much time should be allowed for them. It was soon apparent, for instance, that if we expected partners to provide good quality feedback on our strategies and plans, we ought to budget for the time they needed to digest the proposals and what we were asking for, discuss them with us and ask questions, and to research / present their recommendations, including evidence to back up their arguments.

This gave rise to the idea of a three-day 'set piece' format for major strategic consultations. Budgeting also gave rise to an allowance for ad-hoc telephone support for questions we might want to ask at any time, and an an allowance for a single research project every year by each partner.

It is notable how much all of this stems from the simple initial decision to put a financial value on professional consultation. To put that another way, it is also obvious how much can be missed by attempting to consult for free.

**Worth investing in**

Another consequence of designing for a sustainable relationship was that the next logical step was to invest in developing our partners to give of their best. As we knew how much work we wanted them to do, and could see a long-term future for the relationships, it made good sense to invest in training the representatives from each organisation for the purpose. The NHS is a complex system. If we wanted organisations to translate their observations into practical strategic analysis, it was worth spending time to train them in how the system worked, to enable them to make informed suggestions and responses.

The hidden benefit of a longer-term relationship is that this expertise also becomes more sophisticated over time. We budgeted time with the stakeholders to review how well the consultation processes worked for them and to continue their development.

At the end of the year we undertook a detailed review, including the experiences of the managers who had used the arrangement to get feedback on their plans, the views of the stakeholders, and our own observations on what had worked, and what had not.

We also invited stakeholders to become proactive as well, as part of the strategic partnership approach. Far from simply expecting them to wait until they were asked for input, we welcomed them coming to us with ideas of their own.

The result of all this is that we found the approach worth investing in for a second year, and a third, and a fourth. In the first year alone, six in-depth consultations took place, lasting three days each. These included:

  * Consulting on the SHA's 10-year workforce and education strategy. Significant changes were made as a result of the feedback received, and specific work took place in follow-up to address some of the identified barriers standing in the way of clinical training by some protected groups. The evidence also informed the design of a developmental programme for Black and Minority Ethnic managers.
  * Consulting on the SHA's communications strategy. This included many practical recommendations to improve the accessibility of corporate communications and new ways to reach specific sections of the public.
  * Detailed critical scrutiny and testing of the SHA's Single Equality Scheme.
  * A quick turnaround review of proposed changes to the NHS Constitution, to enable the SHA to respond back to the Department of Health
  * Cross-cutting research on age discrimination, as it affected each other protected group.
  * Provision of up-to-date research with which to stock the HELP system.
  * Critical review of the SHA's Stroke policy, providing input to ensure a rigorous Equality Impact Assessment, leading to appropriate policy adjustments.
  * A similar review and Equality Impact Assessment critique of the SHA's Mental Health Improvement programme.
  * Extensive detailed review and input towards the regional 'Healthy Horizons' strategy.

There are many other details we could write about on this approach; however, as the whole process was documented in a concise 'how to' guide as we proceeded, the best recommendation is that you read our guide, 'An Equal Partnership'.

**More tools**

Many other successful resources and approaches were developed under the programme to ensure that NHS organisations in the North West had the tools they needed.

To summarise the key headlines:

  * We created an E&D Leadership Forum, chaired by the SHA's Chief Executive and attended by leaders from all parts of the system, to oversee the strategy and its implementation.
  * We instituted a process of regular communications and development meetings with E&D leads from across the region, to ensure they were aware of what we wanted from them, and so that we had the opportunity to continually develop their knowledge.
  * We created a monthly newsletter and added regular blogs to the HELP web site, as a further tool for communicating news, ideas and best practice.
  * We created strategic educational resources in the form of touring exhibitions and accompanying web sites, films, and booklets, documenting the contributions made by Black and Minority Ethnic staff to the NHS in its first 60 years; about the relationship between LGBT people and medicine over the last 2000 years; and about the history of Disabled People.
  * We created a national resource to support responsible officers and HR managers to implement the new process of Medical Revalidation in such a way as to minimise the risks of inadvertent discrimination.
  * We set up a programme to offer opportunities for selected BME junior managers to be seconded into more senior positions and obtain experience plus visibility in leadership.
  * We developed a 70 minute training video to develop awareness of the ways in which NHS organisations could reach out and improve engagement with men and tackle avoidable causes of illness and early death.
  * With our strategic LGB stakeholder partners we developed and published guidance on how to conduct LGB workforce and service user monitoring.
  * We also invested in a self-sustaining developmental programme for GP practices 'Pride in Practice' to help drive up quality of care offered to LGB patients by GP practices.

This isn't an exhaustive list. In particular it omits the performance management and leadership competency development tools that are discussed next. However, the point is that all of these developments came about as the result of evidence; either from our own research or that presented to us. Our test in every case was whether it was strategic for us to develop the tools, whether they could not be developed better within the region's NHS system; and whether there was a lasting benefit to be derived from them beyond the initial implementation.

**References in Chapter Eight**

Meads, C., Pennant, M., McManus, J., & Bayliss, S. (2009). 'A systematic review of lesbian, gay, bisexual and transgender health in the West Midlands region of the UK compared to published UK research'. Department of Public Health and Epidemiology West Midlands Health Technology Assessment Group. Birmingham. Retrieved from:

<http://blgbt.org/downloads/LGBT_health_26.03.09_final_version.pdf>

**Chapter Nine**

****

**Measuring performance**

Chapter 3 set out why the kind of change required for progress on equality often fails, and how to make sure it doesn't. It has been that concern to ensure change _doesn't_ fail which lies at the heart of so much of our philosophy — our 'Eco-system' approach — with its underlying disciplines of basing what you do on evidence to begin with, and of being clear about the difference between mere _effort_ (inputs and processes) and genuine _outcomes_.

In practice, as we've already discussed, managers and staff are often very easily seduced by counting only what they are doing rather than the effect it has.

'Look how hard we are working' goes the cry.

'See how many committees we have'.

'Count up what we've spent'.

'Look at our initiatives'.

If any of these phrases sound embarrassingly familiar then take heart — it is a very human thing to seek recognition for effort. It provides a quick return and has long been considered an egalitarian form of motivation. Children are taught to look for recognition in that way. Parents and teachers offer praise for showing effort regardless of the outcome.

'It is not the winning but the taking part'.

'You worked very hard for that examination'.

Yet for each expression like this there is usually a question that's considered perhaps too impolite to ask. You might have studied and revised very hard but did you pass the examination? Did your team win the match?

Similarly, you and your team may undoubtedly work very hard; you may have set up and run many committees and workshops; you may have provided 'diversity awareness' training to everyone in your organisation; you may have spent a lot on posters and leaflets; you may have 'initiatives' coming out of your ears — yet does that cut the mustard in the eyes of an employee who is still discriminated against because of the colour of their skin or their disability? Have you achieved anything if lesbian, gay, bisexual or transgender patients routinely feel that your services are places to fear and avoid?

It cannot be repeated often enough. It is the _outcomes_ that matter. Not the input. Not the processes. Nor, sadly, just the goodwill and effort.

**A lack of performance measurement... or management**

The 'Landscape of the Region' research, providing the evidence on which our strategic approach was based, revealed very little performance management of equality work taking place in the region's NHS organisations during our survey in the Spring of 2008.

Within the 22 of 24 PCTs who responded to questions in this area, there was no consistent pattern for who was internally responsible for performance managing equality work, or on what basis. Answers included the Board, the Chief Executive or Chief Operating Officer, Director of Health Standards, Director of Strategy and Governance, plus various answers involving line managers or the organisation's E&D group itself. (Some of these answers clearly confused performance measurement of a function with appraisal of the individuals.)

A similarly confused picture emerged among the 23 (of 39) NHS provider organisations who replied to this section of the survey. Five of these cited their Board or one of its standing subcommittees. Another four cited their Chief Executive. And six (the largest category) referred to the Director of Human Resources or an HR committee. Answers like this were symptomatic of a widespread belief that equality and diversity in a public service organisation is a workforce concern, rather than also involving the quality and experience of the organisation's outputs: the services delivered or commissioned.

Overall, it was telling that there was no clear consensus about who was actually responsible for ensuring equal outcomes. It highlighted how little clarity there is on leadership responsibilities in this area.

This is only a small snapshot of our detailed observations. It was also apparent that few organisations had any clear idea of what should be measured in any performance assessment in this area. After all, if you've not got any clear outcome goals to begin with, it is not surprising that the question of what to measure would be confused.

Our conclusions were that NHS organisations would need guidance and direction about the kind of regular performance management that they should be doing to achieve their E&D agenda. We also concluded that, as a prerequisite, there needed to be a clear strategy and measurable actions on which to base any assessment process.

Initially, as conclusions to our 'Landscape of the Region' work reveal, we thought this was perhaps something we could facilitate organisations to do for themselves. All that we stipulated initially was:

Proposed Action 7

'The development of a clear and consistent framework for E&D performance management in the region...'

As discussions with leaders continued, however, and as the development of the overall regional E&D strategy took shape, it became apparent that we would need to lead on what to measure; and that it should obviously be tied to the five goals of the strategy.

**Performance measurement — where to start?**

Our evidence base on equality performance measurement was not limited to our own research and experience. The other obvious source was work already undertaken by the (now closed) Local Government Improvement and Development Agency (ID&EA). The agency was at that time developing a framework based on a number of structured measurement areas, rated in a Red-Amber-Green fashion as 'Developing', 'Achieving' or 'Excellent'. This much we borrowed as a good outline framework, although we had reservations about potential weaknesses in other aspects of ID&EA's design.

We definitely saw the advantage, if possible, of designing a broadly compatible approach to the one ID&EA were taking. The equality performance of NHS organisations has similarities to local government and other public agencies. This is even more relevant since the Health and Social Care Act 2012 came into effect, as local government assumes responsibility for public health and the integration of local Health and Social Care strategy. So, comparability of measures is desirable. However, it soon became apparent that such comparability was only achievable on the broadest of terms.

  * The ID&EA framework was based on priorities of importance to local government. The Equalities team priority was to objectively measure progress in ways relevant to the strategic advancement of equality in health service commissioning and delivery.
  * The ID&EA framework was rather loosely worded in terms of measuring processes and inputs — what local government was _doing_ as opposed to what it was _achieving_.
  * Also we were concerned about the loose governance of the ID&EA framework's self-assessment process. There appeared to be no mechanism to ensure assessments were objective, nor to ensure comparability between organisations. There was no challenge as to how an organisation might rate itself. (Sadly the same weakness has appeared in the initial implementation of the NHS Equality Delivery System, which partially implemented our own more robust approach.)

There is no doubt that representatives of ID&EA were keen for us to follow their framework. Equally, we were concerned to ensure that the framework to measure the effective achievement of our five year strategy should fit the bill. Reluctantly, therefore, we couldn't simply use the ID&EA framework as an 'off the shelf' solution. We needed a similar system more tailored to our own purpose.

**Linking strategy and performance measurement**

The project to design an approach (which we knew informally at the time as the 'E&D Performance Management Tool') took shape organically on the back end of developing and publishing our five year Equality and Diversity Strategy, 'Narrowing the Gaps'.

As set out in Chapter 7, the strategy provided five interlinked 'Goals' (high level strategic outcomes):

1. Increase the diversity, representation and the working lives of our workforce

2. Develop data to monitor, information to manage and knowledge to act

3. Develop the right services: targeted, useful, usable and used

4. Move beyond legal compliance to initiating best practice

5. Develop our specialists and leaders

As the basis for our strategic vision, they were developed as broad themes.

To take the design of the measurement framework to the next level, therefore, we needed to expand on the kind of outcomes we would see if organisations (or ourselves) were to claim successful achievement of those goals. These 'Deliverables' needed to express all the dimensions of what each goal meant and provide cues about what objective evidence would look like.

The first stage, therefore, was to give those 'deliverables' some short specific descriptions. For example:

Deliverables for 'Goal 1' taken from the EPIT 'Manual' issued to NHS organisations

Each of these deliverables represents a distinct group of outcomes which contributes in a different way to being able to say your organisation is genuinely making progress towards the overarching goal of increasing workforce diversity.

The first deliverable is the most obvious measure. Does the workforce demographic compare meaningfully with the community in which the organisation is located? So, for example, If the local community has a 30% BME population, how does the organisation look in comparison? Does the Board have a comparable BME representation? Does the next tier of senior managers? What does a patient see when they walk in the door of a service? Does at least part of the commissioning team bring local cultural understanding to the table when making decisions? If not, why not (given such a large local talent pool)? And, since historically it would be unlikely that this kind of result has been achieved (and the workforce statistics told us it hadn't), what progress (at least) is an organisation making towards being more representative at all levels?

You can see at once that a deliverable like this lends itself to being measured fairly objectively, and that a range of achievement might be expected:

  * Just starting to get a grip on the issue (Developing)
  * Making some demonstrable progress but not there yet (Achieving). The organisation might show where it started to tackle any disparities (a baseline) and the progress that it has made year on year towards improving the workforce demographic.
  * Able to demonstrate that this kind of outcome has occurred for *all* protected characteristics, rather than only one or two (Excelling)

We will come to the question of evidence for this in a moment. For now, just remember our desire to measure progress objectively and look at genuine outcomes, as opposed to plans and schemes and mere good intent or effort.

The second deliverable is concerned with one side of the picture within the workforce. For example, have they had the kind of development that will help them commission or deliver services with equal quality of outcomes and experience to all users, regardless of their own background and the patient's; and has that had a measurable effect? Indirectly this also influences how the workforce treat each other too, and the desired outcome goes to the heart of why we said a diverse and representative workforce is important to have.

Again it is clear that this deliverable can also have outcomes measured in terms of degrees of achievement.

Is the organisation just starting to get a grip on this? Perhaps they've identified the challenge, got the policies and processes set up, but it's too early to see the results? We'd call that 'Developing'.

Is there some demonstrable evidence to show? Again, we'll come back to the question of acceptable evidence in a moment, but remember that it is _results_ that matter; merely counting the number of people who've attended training is about process, not outcomes. If the evidence covers more than one protected group we'd call that 'Achieving'.

The reason for wanting progress for more than one group is that 'Achieving' should be a stretch. Also, if you were a disabled person and an organisation was scoring 'Achieving' purely on the basis of progress being made for Black and Minority Ethnic people, we doubt you'd be impressed or think the assessments credible.

Is the organisation really on top of this across the board? Are they the kind of beacon of best practice achievement that their peers would recognise this? Are people beating a path to their door to find out how they did it? These kind of criteria are what we would recognise as 'Excelling'. Anything less would just be a degree of 'Achieving'.

'Excellent' should be the ultimate stretch target. It is not something you would award lightly, as in any walk of life.

The third deliverable recognises the reality that it may be all well and good that you've trained and developed people to be more culturally competent in their thinking and actions; however that alone doesn't fulfil the overall goal if discrimination is continuing.

The first step on the road in this case is for organisations to know whether there are problems or not. That begins by acknowledging the possibility and thinking about what the indicators would be. In our time we have encountered people prepared to assert that there is no problem simply because they've not heard of it, rather than as a result of digging for the evidence. And certainly the facts are there when you dig.

Wider research indicates that there _can_ be problems of this kind. The indicators are that in some instances (such as BME clinicians) people from protected characteristics are disproportionately represented in processes such as grievances, disciplinaries or capability reviews. These can sometimes be proxy indications of bullying or harassment taking place. To be able to measure such indications requires an organisation to have already decided to analyse these processes against protected characteristics. If they are only at that point then this would be an indication of 'developing'.

Notice how the measurement criteria imply things that should be in place to facilitate that measurement — in this case routine equality monitoring of processes such as grievances, disciplinaries or capability reviews. If you're not measuring it you can't claim to be on top of it.

If such data shows there is no disproportionate impact taking place for two or three groups then that would be, reasonably enough, an indication of 'Achieving'. Similarly, if the data shows that there _was_ a problem in some areas but the incidence has been decreasing since steps were taken, then that would count as 'Achieving' too.

As before, 'Excelling' is reserved for organisations who can show that discrimination has really been eliminated across the board.

**Pride comes before a realistic assessment**

We stress the importance of outcomes, and for objective evidence of those, because it is only through such a rigorous approach to evidence that you can overcome the natural corporate tendency to avoid uncomfortable scrutiny and overestimate performance.

Even in the public sector, it is evident that immense pride attaches to how organisations perceive themselves and how they _want_ to be perceived. Even though equality performance is sadly not one of the criteria on which organisations will automatically volunteer that they want to be measured and compared, it is still something they will get very defensive and competitive about when someone else is measuring them.

Some organisations responded very positively to our announcement and launch of the EPIT system in October 2009. Some providers, in particular, said they were actually grateful for the opportunity to demonstrate the good things they were doing because (tellingly) they felt the PCTs commissioning them were not giving direction or challenging them in this area. This kind of feedback was immensely encouraging. Many more organisations exhibited trepidation but were nevertheless prepared to go along. Sadly, however, a small minority of organisations were far less pleased about the whole idea.

The first negative reaction you can expect when launching any kind of performance framework is resistance to taking part in it. The amount of authority behind what you're doing therefore matters a great deal. We expected resistance, so our strategy involved obtaining the full buy-in of the SHA Board from the very start, at the point when the Board endorsed the five-year strategy 'Narrowing the Gaps'. In particular, we ensured that both the Chief Executive, Mike Farrar, and the Director of Workforce, Dean Royles (the latter now heading both the NHS Confederation and NHS Employers) understood and were supportive of our aims.

EPIT was launched by letter from our Chief Executive to the Chief Executives of all 64 NHS organisations in the region in mid-October 2009, with a completion deadline of 31st January 2010. This gave organisations four months to prepare for and complete the process. Short of coming from the Chief Executive of the NHS or the Secretary of State for Health, this was as strong an endorsement as you could expect. Despite that authority, organisations still attempted to resist the introduction of the system. This is when it is really important to ensure that your leadership don't just pay lip service but genuinely 'get it'. The appeals over our heads were therefore not going to get anywhere.

The next stage of resistance, if an organisation can't avoid a performance measure, is to look at what they can do to subvert it. This is where the corporate ego comes in. We believe that the failure to factor this in has proved the Achilles heel of the subsequent Equality Delivery System. We'll come to that in Chapter 12, when we compare both systems.

The subversion is probably not conscious. We don't think people approached EPIT with the specific intention of deliberately rating themselves higher than they deserved. It is more, we think, a combination of corporate ego and a genuine cultural failure to grasp what the required outcomes look like.

The corporate ego factor is obvious. What Chief Executive doesn't stand before their organisation and tell them how great they are, and paint a vision of excellence? Indeed, we know from recent news events that this tendency can extend outside the walls of the institution to include those who are supposedly there to regulate quality and safety.

The stock response of some organisations was therefore to determine the result in spite of (rather than because of) the available evidence. In these cases we felt a lot of sympathy for E&D leads (especially the more junior ones) caught between the Strategic Health Authority demanding an evidence-based assessment of their actual outcomes, and senior executives inclined to say, 'There's no way our organisation is going to admit to being anything short of Excellent or Achieving.'

The only way you can possibly challenge that mindset is on the actual evidence. This is why the objectivity of the evidence-seeking process is central to the outcome of the whole process. If you give in to corporate pride, or allow the principle of seeking outcomes to be diluted, then you are no longer measuring genuine performance. You end up measuring corporate chutzpah instead.

**Upping the stakes**

As if the stakes were not already high, we decided to raise them higher by making a decision, early in the design, to make the whole EPIT process public. To support this we designed a dedicated website.

The public face of this web site presented the results from each organisation in two ways so that anyone could compare them. One view showed all the performance measures (the five goals and their 13 deliverables) for a selected organisation. The other view allowed all organisations of the same type (commissioners or providers) to be compared for a single goal. So, for example, you could dial up any of the five goals and immediately see how each organisation compared against their peers. One intended benefit of this was that if some organisations were really doing well then others could see this and would know where to network for good ideas.

The other side of the EPIT website was not public but allowed us to manage all the information involved. Imagine the complexity: 64 organisations providing written evidence to back up their performance claims in 13 separate deliverable areas: a potential logistical nightmare. We solved this by allowing organisations to log into the site privately, enter their self assessments, and upload the corresponding evidence. The site also had facilities to manage the process of checking and approving those assessments (see below).

We found the EPIT web site so valuable to the process that we repeated the idea when we eventually came to implement the Equality Delivery System. The original design needed very few tweaks. Interestingly, the NHS Equality and Diversity Council (EDC), who launched the EDS, decided to go without a website to manage the process and make it transparent to the public. Part of the reason may have been the mixed messages being given out about whether the EDS was compulsory or not. Whatever the reasons, as we'll discuss in Chapter 12, the result is that it is very difficult to pin down EDS results nationally, and even less feasible to be sure that the results are genuinely comparable.

With our implementation of EPIT there were no such grey areas. Our Chief Executive had made it clear that the process was compulsory. The website made the assessments a public affair. It is little wonder, therefore, that organisations would see the process as challenging.

**Strong governance for heavy obstacles**

As we've said already, you cannot allow the rigour of a system to go slack. The intended purpose of measuring outcome performance was to describe accurately where organisations really stood and to identify gaps so that we could then genuinely work with people to close them. None of that can happen if you allow people to (consciously or unconsciously) avoid harsh realities about their real performance.

With that in mind, the governance process was perhaps the most crucial aspect of EPIT to get right. At the heart of this are some key principles

**Being clear about what you are measuring.** As we've said, we look for genuine outcomes — those things that an external stakeholder would recognise as tangible improvements. Patting people on the back for simply working hard doesn't cut it. Counting the number of processes, policies, or even the number of people trained, doesn't cut it either. Processes don't necessarily work. Policies may sit on the shelf. Training doesn't necessarily lead to behaviour changes. The most compelling sorts of evidence are simple numbers. A line between 'then' and 'now' data points, Preferably pointing upwards. Organisations who are really doing well will usually have these numbers available, as they would know they need them to objectively measure where they stood before (a baseline) and where they stand now. Indeed it became apparent when we examined our first batches of evidence that the more documents we were sent, the less likely the organisation concerned really had a grasp on the outcomes that matter. This is not an area where you _weigh_ the vote. People who really have a grip on measuring outcomes can state the evidence succinctly. Volume suggests prevarication.

**Being clear what good looks like.** A good performance measurement process isn't trying to catch people out. If we thought organisations were performing well to begin with we wouldn't have placed so much emphasis on accurate performance measurement. An important part of the process is the development: helping organisations get a clear understanding of what outcomes look like when they're unsure. That way the guidance doesn't merely help elicit the evidence required; it also paints an overall picture of what sort of outcomes should be occurring in a healthy system. It is a teaching opportunity.

A very large part of developing the EPIT tool therefore involved writing the guidance in a tutorial fashion, to suggest what example kinds of evidence would meet the requirement. The guidance was there to help people recognise which evidence was relevant, and to learn through that.

As if to emphasise the need for clarity in this respect, it's worth saying that this was by far the hardest part of the whole design process for ourselves. Time and time again we would find that we were writing down measures and then realising they were about inputs or processes. We would go through sections of the draft guidance repeatedly and challenge ourselves to refine the suggestions we had written there. This underscores how difficult the discipline could be, and it meant that we understood very well the journey we were trying to take organisations on as well.

**You must have a second set of eyes.** We designed the initial stages of EPIT to be based on self-assessment. Armed with our guidance defining the kinds of evidence required, we expected organisations to conduct an honest assessment of where they stood. The first of the checks and balances was that managers in those organisations needed to be realistic. If the evidence wouldn't support 'Achieving' for instance then there was no point in claiming it. However, this was only the first step. We designed the process so that, having settled on their own self-assessments, somebody else would then _verify_ them. For practical reasons we broke this down.

We required commissioners (Primary Care Trusts) to verify the assessments made by the NHS provider organisations for which they had lead commissioning responsibility. NHS provider trusts often take referrals from several PCTs. The PCTs all commission those services individually. However, there is almost always _one_ commissioner who takes the lead. This balances out so that most commissioning bodies would have lead responsibility for at most one or two providers. The requirement to verify the EPIT assessments of providers would not therefore be an onerous task.

In any case, this kind of review of the evidence of outcomes each provider was achieving ought to already be part of monitoring contract compliance. We knew it was not necessarily the case. However, one of the spinoffs from delegating this responsibility was that we hoped commissioning organisations would become accustomed to routinely reviewing the performance of providers in this respect. It was understandable that they might not have done so before, when they weren't sure what to measure; however EPIT was providing them with a script.

Having delegated the responsibility to verify providers in this way we were then left with the task of verifying the commissioners ourselves. This was no trivial task. The North West had 24 Primary Care Trusts and we were setting ourselves up to verify the evidence of performance provided by each of them in 13 'Deliverable' areas. That's 312 separate sets of evidence to verify. And there were just two of us to do it. However, we felt that taking on this workload was worthwhile, as it meant we would have an unprecedented opportunity to understand the strengths and weaknesses of our commissioners in depth.

**Assessing the outcomes**

EPIT was launched in October 2009 and we allowed organisations a full four months to complete their first self assessments. During this time we spent a lot of time in explaining why we were introducing the process and in answering questions about how to complete it.

In particular we wanted managers in organisations to understand that assessment was a collective responsibility, not something which should just be handed to the local E&D lead to complete. E&D leads certainly had a big part to play, but that was in supporting their leadership colleagues to provide the evidence required. Questions about workforce needed to be answered by workforce directors and their reports. Questions about commissioning needed to be answered by commissioning directors and their teams. For many managers this would be a valuable learning exercise. Some said that thinking through the requirements and the evidence suggestions meant that they understood (for perhaps the first time) just how their own role could impact on equality for everyone.

We were also at pains to point out that the assessment process was looking for evidence that was already to hand. Whilst the evidence gathering process might identify gaps for organisations to tackle over the medium term, the process was really about identifying what information they already had and putting it into a succinct form. Some organisations complained that four months wasn't enough; however that was to miss the point. Many organisations told us that the process had the unexpected benefit of getting managers to share data they had not thought of sharing before. This kind of 'show and tell' activity was a revelation, leading to new insights.

In spite of localised resistance, the majority of organisations rose to the challenge and submitted their assessments and evidence on time for the end of January 2010.

For PCTs, the next step was to then begin verifying the evidence that their providers had submitted. Our EPIT website was designed to act as a clearing house for this information. PCTs could only access the evidence pertaining to the organisations for whom they had lead contractual responsibility. For ourselves at the SHA, the corresponding task was to scrutinise the returns from the 24 Primary Care Trusts.

It was immediately evident that the verification process would be far from straightforward. Firstly, although we had given extensive advice (even offering individual advice surgeries) during the four month preparation, it was apparent that some organisations had not heard the advice and were assessing themselves higher than other indicators suggested they had the right to do.

**Triangulation and corroboration**

We weren't conducting this process in isolation. The SHA was also scrutinising commissioning plans from these organisations at the same time. As our commissioning colleagues were often criticising these bodies on the way they conducted evidence-based planning and took account of local needs, it was hardly likely that we would agree with an organisation's self-assessment that they were 'Achieving' or 'Excelling'.

A top-slice through the evidence submitted for EPIT also indicated where organisations were not really reading the guidance. Tens of megabytes of 'evidence' were submitted for some areas, but it was clear that the relationship between the volumes submitted and what we were looking for was often tenuous at best. Seldom did the evidence come close to demonstrating any clear outcomes. The prevailing tone was 'look at how much we've got', rather than demonstrating what it meant. There was also the occasional evidence that senior managers or Boards had intervened to force realistic self-assessments higher than they deserved. For instance, the headline claim might be 'Achieving'; and yet the evidence document had not been amended from the previous conclusion of 'Developing'.

It was apparent from all this that we couldn't simply operate the verification process at arms length, handing down verified assessments remotely. Instead we re-planned our schedule and invited almost all of the Primary Care Trusts to join us in focussed face-to-face meetings or teleconferences to discuss their submissions. During these meetings, which each took about one to two hours, we went through each of the 13 deliverables and discussed the evidence. Managers had the opportunity to explain better what they had, in the light of our challenges and explanations of what was required. Various outcomes resulted from this:

  * In some cases organisations explained their evidence better and we agreed with their assessment of a deliverable.
  * In other instances the managers felt that they could submit more appropriate evidence, having discussed their situation. In these cases we agreed a deadline for the new evidence.
  * In many cases the organisations conceded that their initial self-assessments could not be verified and that they should be downrated. On these occasions we documented the agreement and asked managers to provide an action plan for closing the gap.
  * On a few occasions we felt that the organisation was perhaps 'borderline'. For example, they had assessed as 'Achieving' and, if we were generous, we could just about accept that claim. However, in those cases we also discussed where the organisation hoped to get to the next time around, when EPIT was repeated. We expected progress on that future occasion. If we awarded 'Achieving' now then, although they might consolidate this next time, it was perhaps making a rod for their own back. On occasions, therefore, we allowed organisations to choose to downrate themselves to 'Developing' at this time, so that they could come back with a really strong story about progress to strong 'Achieving' next time.

In every case we took extensive notes and then wrote to the organisations after our meetings to remind them of the advice we had given and what we required from them. This was important, not only in backing up managers who would need to explain the outcome to their Boards, but also because our goal throughout was to lift and develop performance via constructive critique. EPIT was a tool to help organisations look realistically at their performance and address their shortcomings. It wasn't a stick to beat people with.

**Moving forwards**

There was very much more to the EPIT process than this. For instance, after scrutinising PCTs' own returns we realised we would have to pay a lot more attention to how they in turn were scrutinising their providers. If PCTs were struggling to grasp what genuine evidence of outcomes looked like, then it was likely that (a) their providers were having the same struggle and (b) the PCTs would need some support to be as tough but constructive. Helping commissioning organisations to better manage what they wanted out of their providers in this area was support worth investing in.

We will examine the overall verified outcomes from the first round of EPIT in Chapter 12. In that chapter we'll also examine how the second round of EPIT compared, 18 months later in July 2011, and how we then migrated to the new EDS framework which our work had prompted. To round off this chapter, however, we want to touch on the process that took place between the two rounds, and how we sought to use the objective evidence we had gained in order to drive up performance.

**A learning exercise**

As we've said before, we didn't design EPIT as a stick with which to beat people — although the process of coming to terms with the realities of their under-performance was undoubtedly a painful experience initially for some. Our goal was to measure genuine outcomes within our system, objectively and consistently. Objectively because the process had clear evidential criteria based on outcomes achieved. Consistently, because the verification process ensured everyone was being objectively measured against the same yardstick.

Nevertheless, at first sight the initial verified results from the first round of EPIT looked a little bit like a battlefield the morning after. All around was the evidence of false assumptions slain. Some organisations had gone off vowing they would find the better evidence we said they needed, only to come back a fortnight later and concede they weren't doing as well as they had imagined. Our 'state of play' matrix went from a sea of optimistic 'Achieving' scores, to an almost uniform display of 'Developing' (and in some cases lower than that). It was now time to build.

For all the shattered illusions, there were some really good examples of achievement in a handful of Primary Care Trusts, and across almost every deliverable. The lesson therefore was that 'Achieving' was not unobtainable. The score sheet showed that PCTs need look no further than their neighbours for examples of managing it.

To capitalise on this we organised a 'Master Class' event in the summer of 2010, specifically for the E&D leads of PCTs. Instead of us presenting to the group, we asked the leads with Achieving scores to present to their peers on how their organisations had qualified for them. We also brought in outside speakers, such as the Equality and Human Rights Commission (EHRC) and a motivational speaker. The emphasis was on sharing. The benefit was that it gave kudos to the leads who were demonstrating the kind of achievement we were looking for, and it instilled a mix of hope and competition in their peers.

We supplemented the one-off 'Master Class' by introducing a regular quarterly series of communications and development events. The aim was to build up the competence of both PCT and provider managers in areas suggested by the most obvious gaps. We also introduced a monthly newsletter at the same time.

The underlying message, therefore, was that, having put the whole system through a tough test, we were now going to help develop them. In the autumn of 2010 we announced the intention to re-run EPIT the following summer. And, in the intervening 12 months, people could see a developmental programme stretching ahead and see the whole strategy in action.

In Chapter 12 you will see how effective the development turned out to be.
**Chapter Ten**

****

**Building Leadership Competence**

The previous chapter details the ways in which progress on meaningful outcomes can be objectively and consistently measured. In this chapter we look at the need for developing E&D leadership competency to deliver the necessary transformative changes in outcomes (regardless of who leads in this area). Before getting into the theory and practice of how to develop such leadership, however, it is worth just consolidating what we've already said about measuring progress objectively.

The particular outcomes we looked for in the Equality Performance Improvement Toolkit (EPIT) related to the achievement of our overall regional strategy 'Narrowing the Gaps'. The need for such an approach was grounded in the evidence from our research 'A Landscape of the Region'. And the approach itself was based on a structure already developed by the Local Government Improvement and Development Agency (ID&EA). Our significant additions were a rigorous focus on measurable NHS-specific outcomes and a strong governance approach to maintain realistic and consistent assessment.

The NHS Equality and Diversity Council, keen to capitalise on our success, produced a national derivative approach called the Equality Delivery System (EDS), which was launched in the Autumn of 2011.

In Chapter 12 we present our outcomes using both systems and discuss our regret that crucial aspects of EPIT's governance were not taken up in the national framework.

Crucially:

  * The EDS was not made mandatory in the way that EPIT was applied by us in the North West. The effects of that decision are clear in the EDS results of other NHS regions that we compared.
  * The EDS contained _some_ outcome measures of the kind we sought to measure in EPIT; however the committee putting the tool together unfortunately also allowed in many more 'process' measures too, allowing organisations to assess their achievements or excellence on the basis of how hard they think they are working, as opposed to what they are meaningfully changing. This encourages a culture of complacency rather than a culture of self-critique.
  * The EDS also applied a far softer governance model than EPIT, supposedly empowering local stakeholders to hold NHS organisations to account (which is a good idea in principle) but failing to provide the kind of back-up which such stakeholders would need in order to really challenge the egos present in such NHS Trusts.

In our approach the results claimed by commissioning organisations (the Primary Care Trusts) were scrutinised and challenged by our own team, using the SHA's statutory powers to performance manage those organisations. In turn we developed PCTs to scrutinise and challenge the provider organisations whose services they commissioned, using their powers of contract performance review. The process provided us with detailed insights into the nature and shortcomings of E&D leadership in those organisations.

The EDS as implemented in 2012, by comparison, placed all the responsibility for challenge in the hands of local stakeholder organisations (Local Involvement Networks [LINks], charities, voluntary organisations and groups of individuals) without giving much direction on how these stakeholders would be supported to provide robust challenge. Given that we, with all our insider knowledge and statutory powers, found it difficult enough to challenge large NHS organisations, it is hard to conceive how small patient groups, with possibly very little knowledge of NHS politics and organisation, could achieve the same thing.

A completely external governance process, with no scrutiny of the evidence by NHS leadership, also denies that leadership an important means of assessing in detail the competence of the managers presenting evidence of achievements. This is an immensely rich vein of detail on exactly how managers are thinking about outcomes and where the system, or they, may be falling down. It seems a strange thing to miss such an opportunity.

Far from being _against_ involving stakeholders in performance scrutiny, however, we introduced it with our own strategic partners in the second round of EPIT. As the NHS Constitution says very clearly, 'The NHS belongs to the people'. It's an important ambition, therefore, that the people should be involved actively in performance assessment and critique. However, we were very clear about the need to extensively develop those stakeholders for the role they were being asked to fulfil. Effective patient and stakeholder-driven governance is an outcome in itself — something requiring a concerted effort to achieve, not something which we can assume will just happen spontaneously.

An umbrella concern we had about the Equality Delivery System lay in the choice of name, which might seem to imply (falsely) that a tool (however strong or flawed) for measuring performance on equality would, in itself, _deliver_ results. Remember that it is only a measurement framework, although (as we discussed in the previous chapter), the hunt for evidence may deliver many valuable insights and prompt process changes.

**Leaders deliver improvement: tools can only measure it**

EPIT proved to us beyond doubt that NHS organisations were in general failing to achieve the equality outcomes that patients and staff have the right to expect. We subjected only one English region to this degree of scrutiny; however, it is safe to assume that the North West was pretty typical of the rest of the country in its failure to demonstrate much tangible achievement when we started the process. This was clear because, as regional leaders in this area, we talked candidly to each other all the time.

The proposition that change was necessary was also well-evidenced in the 2008 research that has underpinned all of our strategic work. As discussed in Chapter 6, we found gaps of many kinds, some of which could be helped by developing tools and resources, but some of which also required more concerted forms of development.

It was clear that organisations were not achieving equality. But the first serious concern we had was that they also lacked even the most basic objective data to tell them that fact, or to measure any progress towards more equitable results.

The second concern was that they lacked the managerial and leadership competencies to do something with the data and bring about change in their organisations.

Imposing a performance measurement approach served two purposes and addressed the first of these concerns. EPIT measured progress for our own strategic ends. It also directed managers towards using measurement approaches which they had so far failed to develop for themselves.

It does not follow, however, that managers could necessarily go the next step on their own. Provided with the evidence that their organisations were under performing, could they change that? Another aspect of our research suggested they probably couldn't, at least not without help.

**A gap in leadership competence**

We examined managerial and leadership capability and capacity in some detail during our 'Landscape of the Region' research. And we found not just one weakness but an entire system of them.

Organisationally it was clear from our investigations that there was very little clarity on how to position, line manage and champion leadership on equality and diversity in organisations. We discussed some of this in outline in Chapter 6. What really stood out, however, was that there was widespread confusion in many organisations between the concepts of _leading_ on E&D strategy, _managing_ it, and simply _understanding_ some of it. This led to some organisations having only relatively junior personnel trying to act far beyond their pay grade (or focussing only on minutiae such as classroom training rather than strategic planning). Some organisations did not understand the difference between the working Equality and Inclusion knowledge you need to impart to _all_ staff, and the broader in-depth knowledge and experience which a practitioner or manager should have in the subject.

This lack of clarity was aggravated by the absence of clear experience, knowledge and qualification criteria for an E&D management or leadership role. For the NHS this was remarkable. The NHS has a very comprehensive structure for defining job roles and career progression through different grades. The NHS Knowledge and Skills framework spells out levels of competency and attainment required for practically every kind of role to be undertaken — administrative, managerial or clinical. The Agenda for Change pay grading framework documents each standard type of job role in extensive detail, in order to ensure staff are recruited and promoted at consistent levels nationally for the same and comparable kinds of work.

Having said that the oversight is remarkable, it is also understandable given that (a) E&D roles only began to be created in quantity with the arrival of the Race Equality Duty in 2002; (b) expertise was often parachuted into the NHS from outside (therefore bypassing more conventional career development); and (c) neither academic institutions nor professional bodies had sufficiently addressed the need for professionalisation of the function. It is only very recently that organisations such as the Institute of Equality and Diversity Practitioners have been set up; and these are still creating professional accreditation processes.

**Confused positioning and championship of roles**

There was no clear consensus on where leadership on Equality and Diversity should be positioned within organisations and how it should be championed. A significant proportion of those designated as 'leading' on the agenda found themselves working in a Human Resources directorate, where it is not usually expected that they would have much say in commissioning of services or management of quality and patient experience. This reflects the idea that equality is somehow just a staffing issue.

Big transformative change needs strategic influencing skills across divisions and the support of the Board and Chief Executive; however we weren't often seeing that reflected in the grading, line management, reporting lines and championship of such roles. Simply reporting to a single manager implies an organisation thinks the role is mainly an operational one.

People were not necessarily dedicated to the role. In some cases they were simply working part time; in other cases the E&D responsibility was only an adjunct to some other role (such as HR manager, Head of Nursing / Quality)

Organisations also seemed to have hazy (or non-existent) plans for developing people placed in this kind of role. We didn't see any evidence that NHS trusts were identifying how the equality lead (or the Board) might need to be developed in order to be effective change agents. Of course, that links to the issue of whether organisations perceive that there is a strategic change to be achieved. In the absence of strong data to demonstrate performance failings it was perhaps not surprising if organisations concluded that equality and diversity was simply a compliance or risk management issue for junior managers to handle.

It is very instructive to note how the appreciation of the importance of E&D leadership in our region increased after so many organisations had had their performance failings exposed by the EPIT process. As the NHS reorganised between 2011-13, many other regions made substantial numbers of E&D staff redundant because leaders could see no strategic imperative in retaining them. In the North West, post-EPIT, there was very little attrition of this kind; organisations knew full well why E&D leadership was vital to retain.

**Developing a framework for leadership competence**

The 'Landscape of the Region' research which we undertook at the outset of our programme provided a rich vein of evidence in this area. Indeed, the research indicated that the weaknesses were so systemic that half of all our proposed actions related to addressing the various facets of the problem.

Theme 1 of our research-based recommendations concerned 'Underpinning Management Structure, Capacity, Capability and Leadership by an appropriate body of knowledge' and broke down into five related action proposals:

**Proposed Action 1**

Work nationally with the Department of Health to develop a clear career management structure and consequent professional development pathway for E&D personnel. The work should include:

a. Development of a set of national job profiles for different roles within a model E&D structure,

b. Clearer skills profiling to ensure roles are appropriately and consistently graded, and

c. Identification of the corresponding professional development necessary to provide horizontal and vertical development of skills for leadership.

**Proposed Action 2**

Develop guidance to define the role, competencies and liaison / leadership responsibilities of Executive Directors chosen to champion E&D.

**Proposed Action 3**

Develop clear guidance on the appropriate positioning of the E&D function and leadership within the structure of organisations. This needs to be related to the management skills and seniority of E&D leadership (see Proposed Actions 1 and 2 above), to ensure that their sphere of influence is sufficient across all business areas.

**Proposed Action 4**

To develop a Training Framework for organisations to develop and embed all-round staff capability in E&D through a systematic development programme in their organisations. Training should be related to Core Dimension 6 (CD6) of the [NHS] Knowledge and Skills Framework so that a consistent and appropriate syllabus is being followed in all Trusts. The various tiers in CD6 can be used to cover the needs of staff at different levels of responsibility. Guidance should be provided to Trusts on the necessary capacity to carry out and sustain this function, to ensure that E&D Leads can remain strategically focussed. Performance management measures in this area should also be specified, to ensure that organisations are able to monitor both the number of staff trained, and also the degree to which the training has achieved the desired behavioural changes.

**Proposed Action 5**

Develop guidance on the role of an E&D Lead, reflecting the needs of both commissioning and provider organisations. The roles need to address the balance between operational and strategic activities such as influencing, research, consultation, developing baseline data and measuring effective outcomes.

**Setting to work**

It was clear this work was not something that could be done piecemeal. All the areas of weakness would need to be addressed at the same time for any single one of them to have any prospect of achieving change.

It was also clear that this was not simply a local requirement. This was an issue affecting the entire system nationally. Indeed, the issues were not unique to the NHS; we were confronting a strategic issue with implications for the whole public sector.

The essential first step was to therefore engage with the Department of Health and turn this into a national level undertaking. The Department agreed to 50/50 funding on the work that was necessary and to a joint management committee, involving the National Director of Equality and Human Rights and leadership figures from several Strategic Health Authorities. Development responsibility sat with our own team, however.

Development began by initiating some further research examining organisations where particularly good outcomes were being achieved. We then examined what it was about the leaders in those organisations which seemed to enable this.

It was from this detailed research that 5 distinct competencies were distilled:

1. Operate from a Human Rights, equality and inclusion context

2. Apply a robust equalities analysis to service planning and improvement

3. Build capacity to respond to diverse and changing community needs

4. Communicate a compelling business case for Equality, Diversity and Human Rights and influence strategically

5. Influence and lead change to improve equality outcomes

In other words, in order to bring about organisational changes which would lead to consistently reliable equality outcomes, the leadership of the equality, inclusion and human rights agenda should embody all of these competencies.

**Building on the framework**

On their own, these statements could be interpreted many ways. The next step, therefore, was to flesh out a complete framework centred on what these competencies mean in practice; how they relate to the competencies developed within mainstream NHS staff, managerial and leadership development programmes; how to build job descriptions that are fit for purpose; how to position and manage such leaders and provide career progression; how to build Board and executive leadership support for the function; how to identify skill and competency gaps; how to fill those gaps; and how to certify achieved levels of competency

When constructing the framework we had three potential audiences in mind:

  * We wanted staff interested in working in Equality and Diversity to be able to use the framework to identify the transferable skills and competencies they already have or need to develop. This supported our view that Equality work should not be a career cul-de-sac reserved for enthusiasts. It ought to be capable of being seen as a post any career-focussed manager could consider taking as a promotional or sideways step.
  * We also wanted existing Equality and Diversity leaders to be able to use the framework to inform their performance management and career development conversations. By defining best practice in terms of career development paths and the grade at which people with particular responsibilities should be expected to operate, we also provided subtle support for appropriate regrading where people were already performing above their grade.
  * Finally we wanted the framework to support senior managers responsible for managing Equality leads, by providing the templates for appropriate job descriptions and guidance on the kind of support and professional career development they should be offering. Again we saw this not only in terms of producing better E&D leads but also in terms of developing the means for talented managers to progress onwards and upwards (taking their E&D experience with them to new roles).

In addition to these personal dimensions, we also wanted the framework to support organisations in a practical sense, in areas such as workforce planning, recruitment and selection, performance development and succession planning.

**Anchoring E &D leadership competency in the everyday**

In designing the framework we were very clear that we didn't want people to think that E&D leadership competencies were in some way completely divorced from the knowledge, skills, experience and personal qualities required for other management and leadership roles. Quite the reverse, in fact. Our mission was to show how the majority of the competencies are part of what goes to make any well-developed and rounded leader. The secret lies in identifying key elements and bringing them forward.

To underline this, a major part of the framework was designed to show how each of the five core competencies can be identified and strengthened for leaders doing other work. This means that organisations can use the framework to bring out E&D leadership strengths in their entire senior management team. This need not be a speciality requiring a specific hiring. The latter is vital for smaller organisations who can't necessarily support a dedicated specialist post but want to embed the right kind of competency into their overall corporate decision making.

There are several career frameworks in the NHS and so, for each of the five core competencies, the framework identifies the relationships to:

  * The NHS Knowledge and Skills Framework (KSF)
  * The NHS Leadership Qualities Framework (LQF)
  * The NHS Leadership Framework

Another key feature of the framework concerned grading and positioning the leader's role within their organisation. Our research highlighted this area as a common weakness and why it was vital to tackle this.

Perhaps the most crucial recommendation in the entire framework concerned the definition of the minimum level of seniority for managers in this role to have any hope of both operating at a strategic level and influencing the operational aspects of their organisation. Our research showed how many very competent specialists were struggling below this point, in positions where they could have little hope of influencing and bringing about change.

**Developing and implementing the framework**

We engaged an external specialist developer by open competitive tender to develop the content of the framework with us. There was an enormous amount of detailed work required to give the framework a robust underpinning. We wanted to avoid potential criticism that, without that degree of foundational work, the framework would simply be based on opinion. The contractor we engaged also had extensive senior level consultancy knowledge on the NHS Agenda for Change system and how job evaluation worked.

Our other insurance policy was the steering group — comprising senior leaders from the Department of Health and NHS workforce leadership; strategic leads from four of the 10 Strategic Health Authorities from around England; NHS Employers; and successful E&D leads from a selection of large NHS Trusts.

**Push back**

As it happens our fears were well-founded. We were not surprised that there would be resistance. The framework called on organisations to professionalise an area of management which many evidently preferred to see as low-priority and low-status. We knew that one of the red lines would be the strong recommendation about the minimum grade requirement for E&D leadership in various-sized organisations. For that reason the framework contained a lot of job evaluation detail and templates for writing professional job descriptions.

We and our developers went out of our way to cover potential objections by thorough gold-plated analysis. Ironically this then became the criticism of choice by those senior managers who didn't want to adopt the framework's recommendations. The message fed back to us on several occasions via intermediaries was that the framework was 'too complex'.

In reality the bottom line of the framework was not complex at all for competent workforce professionals. We set out the argument that this was an area of work that needed to be professionalised and why certain competencies were fundamental to successful leadership in the area. The detail was there for those who wanted to understand how we had arrived at those competency definitions through researching the qualities of successful leaders; and our tables of analysis showed how the acquisition of such competencies could be achieved through mainstream development processes; however these details were not essential to implement change. They were just there to show we had done our homework thoroughly.

**The Framework in a nutshell**

The core recommendations of the framework, based on that analysis are essentially two-fold.

Firstly the framework provides specific recommendations for how to grade and position an Equality and Diversity leadership role depending on the size and complexity of an organisation. We approached this in the knowledge that the NHS was set to change radically within the next few years.

We foresaw the question of how E&D competency might be defined within the new Clinical Commissioning Groups (CCGs). These were expected to be lean organisations where much actual footwork would be contracted out to service providers. Our main concern here was that leaders in such organisations should understand that we weren't proposing the need to employ a specific individual labelled 'Equality and Diversity Lead' — the function could exist among the Senior Management Team of a CCG provided those leaders, collectively, had the necessary core leadership competencies.

We made it clear, however, that whilst such organisations could outsource the ' _doing_ ' part of equality work (training, data gathering, outcome monitoring) and they and those providers might buy in research and specific sector knowledge, the ultimate responsibility for setting strategic goals and assuring the achievement of equal outcomes should remain with the CCG and their local authority partners. The public sector equality duty doesn't permit organisations to outsource their obligations.

At the other end of the scale were the big strategic bodies: organisations such as NHS England, Health Education England, and Public Health England. The system-wide strategic responsibilities of such organisations mean that anyone leading on equality strategy at this level must be more experienced and senior; their responsibilities require a different level of the core competencies to be effective influencers among their leadership peers; and they have a wider range of responsibilities.

**One framework, several levels of use**

These differences meant that we set out to provide the basic framework of a skills and responsibilities specification which could be applied to different levels of seniority in leadership. These are not completed job descriptions, since a job in any particular organisation would have elements that are specific to roles at those levels. For instance, a job description for an Associate Director level post would include sections about participation in leadership committees, management of junior staff, deputising as the organisation's point of contact in 'on-call' arrangements and so forth. We couldn't specify these. What we set out to provide was a consistent definition of the specific elements relating to strong, effective leadership in this field.

We also provided guidance on how career progression should work. This should permit a manager to progress from (say) a Band 7 entry role in Equality and Diversity leadership to Band 8 and Band 9 responsibilities. We felt it essential that progression should also permit managers from other areas to migrate (with all their acquired managerial experience) from another role (e.g. in commissioning or organisational development) _into_ equality leadership, and for a manager working in equality leadership to be able to progress sideways or upwards into any other kind of managerial role given the appropriate personal development.

This kind of horizontal progression is common in other areas of NHS management. It is how rounded and experienced senior managers develop. At the most senior levels the advantages of a broad experience of running an organisation are obvious and such development is therefore encouraged. Young managers who have been talent-spotted may move rapidly into a number of different disciplines as part of their development. However, traditionally, this seems not to have been the case for Equality and Diversity professionals. Some may have been recruited from outside the organisation and therefore have little knowledge of how the rest of the NHS works outside of their speciality. Others may have been shunted into E&D in order to protect their employment with the organisation, without any particular knowledge (other than perhaps their own protected characteristics). Whatever the case, we wanted to provide a developmental route to prevent the area becoming a career cul-de-sac, where the only prospect of promotion was to move up into 'dead men's shoes'.

**Professional development**

It follows from all of this that another essential component of the overall competency framework was to provide the means to support the acquisition of competencies and facilitate career progression.

The creation of a developmental pathway spun out of the work which we and our contractors undertook during the framework's development to road-test the definition of the core competencies and determine how accurately we could measure the gaps for individuals.

During this evaluation phase we sought approximately 50 volunteer E&D managers from across four Strategic Health Authority regions in England, taking care to select a representative mix of managers from different size organisations — commissioning and provider bodies — and in different parts of the country.

Our contractors, who had extensive experience in career evaluation work, devised a battery of tests including classwork, assignments and individual interviews, to identify the levels of each of the five competencies in each candidate and relate these (as in our original pathfinder research) to the kinds of outcomes those managers were achieving as change leaders.

When the results were analysed they showed a very clear distinction between candidates.

  * A proportion of the candidates had skills in the competencies which related to general management and influencing. By and large it was found that these were the managers whose careers had developed along the conventional NHS management path and they were therefore products of the mainstream career development process. Most of these candidates tended to be weak on the competencies relating to specific knowledge of diversity (except perhaps their own diversity) and their experience with the details of equality law and practice examples. This group knew how to influence their leadership peers but not how to develop an effective equality strategy.
  * A second substantial group of the candidates had skills in the areas that the first group were lacking: they were confident describing the needs of different diverse groups (besides their own) and had a good working knowledge of equality law and best practice. This was usually because they had been recruited into the NHS for this knowledge. But these candidates tended to be weak in the core NHS managerial and leadership skills. So this group knew all the problems and challenges but typically lacked the experience and skills to develop a strategy in NHS terms and influence their peer group to embrace it.
  * A very small number of the managerial test sample had skills in both areas.
  * And a more worrying number of the test sample were weak in both.

The results of this research bore out what we already knew about the different backgrounds of E&D leads from our initial research. Some had been recruited into the NHS for their activist and sector knowledge. Others may have ended up within these roles for personal reasons (such as returning from a career break), There they had remained, with managers who had no clear idea about how to develop them.

**Tailored personal development**

It was obvious therefore that there could be no 'one size fits all' approach to professional development. What we and our developers devised instead was a tailored approach, beginning with a personal training needs assessment for each candidate, identifying their strengths and weaknesses across the five core competencies. We then designed modules to tackle each candidate's own areas of weakness.

To give the process additional credibility, we also arranged for the training to be structured to provide candidates, on completing the assignments that were part of the training, with the evidence necessary to obtain a Level 4 qualification from the Institute of Leadership Management.

To pilot the whole development package we invested in the cost of putting several of our own E&D leads through the evolved training needs analysis and development programme.

To begin with we already had 12 volunteers in our region who had taken part in the exercise to test the competencies and evaluate the training needs assessment process. Relatively little additional work was required to help these managers achieve ILM 4 awards as a positive mark of their leadership competency. Five candidates already had all the necessary competencies and needed only to complete written assignments to submit for evaluation. The other seven candidates had specific weaknesses of one kind or the other and therefore needed some tailored development before they too submitted assignments.

**Rolling out the development opportunity**

After investigating the volume/cost tradeoff for developing another cohort of candidates from our own region from scratch, we decided we could afford to offer the opportunity to another 16 people. We advertised these places among the region's E&D leads on a first-come, first-served basis. The only main criterion was that candidates must be employed on at least Band 7 of the Agenda for Change pay framework. This was because the skills and seniority of a band 7 manager are the minimum to be able to complete the practical assignments. The only other requirement was obviously that candidates must be working actively in E&D leadership roles.

The Band 7 requirement provided an immediate reminder of how many Equality 'leads' were languishing in jobs which graded them below this level. The oversubscription of the offer also demonstrated how keen managers in this area were to have an independent qualification evidencing their leadership skills.

**Taking the programme to a national level**

With 28 candidates from our region at various stages of development and submitting assignments, we also then discussed with the NHS National Leadership Council (now the Leadership Academy) how to roll this scheme out more widely. In the end the Academy earmarked the funding for another 100 candidates from around the country: 10 from each SHA region. What had begun as an exercise to test the competency definitions and evaluate typical training needs had developed into the first ever concerted push to develop the professional capabilities of this group of managers throughout England.

There were a few who dropped out before completing the qualification. In our own region we had three candidates who, having been selected, failed to register or complete the training. In two cases this was because of serious long-term illness and in one case the candidate was offered early retirement as part of a workforce reduction programme. Two very capable managers, who would have had no difficulty completing the assignments, also failed to submit in spite of attempts to support and counsel them through the process. This was a great shame but highlights the kinds of pressures that managers in this field can be under. There were lessons to be learned here for the future.

Overall, however, one of the proud legacy outcomes of our work in the North West, with its 64 NHS organisations, was a total of 36 managers achieving ILM 4 qualifications, documenting their leadership and E&D competency. It marked a genuine change in the self image and confidence of this group of managers; evidenced most clearly in the significant improvement in EPIT scores when we repeated that performance management process 18 months after the first round.

**Conclusions**

Our experience with creating the competency framework and developing the competencies and confidence among our own region's staff shows that this is an important part of the overall formula for improving the quality and outcomes of equality work in a system like the NHS.

Were we to approach this again we might undoubtedly present the framework in a simplified form, and perhaps do more to sell the purpose and advantages to sceptical HR Directors concerned about having to promote and pay more for properly skilled practitioners.

Regardless of that minority of opponents, however, the process showed very clearly that formal professionalisation in this field is an essential part of achieving results. If you don't equip managers to be able to win over and lead sceptical colleagues in time- and financially-pressed organisations, then you should not be surprised that equality (despite the lip service it receives as being 'important') fails to get the resources and attention necessary to achieve it.

The creation of a professional development pathway and personalised training towards recognised qualifications showed the immense spread of capability among incumbents. This should not be seen as a failing on their part but a failure of the system to have hitherto identified their needs and develop them.

And we saw in many ways the positive effects of providing a development opportunity for a group of very dedicated managers who had been starved of such chances. We saw it in the confidence of managers to initiate programmes of work. We saw it in the increased authority with which they talked about their vision. And, most importantly of all, we saw it in the objectively measured outcomes when we came to repeat our EPIT appraisal and the national Equality Delivery System processes subsequently.

These outcomes are not solely the result of the training we provided. They also result from the broader programme of communications and development, and the resources which we talked about in Chapter 8.

We contend, however, that the Competency Framework is one of the most important legacies of our work in the NHS.
**Chapter 11**

****

**Making change sustainable**

Πάντα ῥεῖ καὶ οὐδὲν μένει

'Nothing endures but change'. Heraclitus (5th century BC)

Variations on the theme include :

'There is nothing permanent except change';

'The only constant is change'; and even

'Change alone is unchanging'.

Whatever your preferred translation, the idea expressed by Heraclitus 2,500 years ago could have been written with the NHS in mind. It could also be said to apply to many other public sector enterprises which have been subjected to increasingly frequent reorganisation by successive UK governments. However, the NHS has arguably suffered most.

**Endless redisorganisation**

In its first 25 years, from 1948 to 1973, the structure of the NHS remained relatively unaltered. All that changed in 1974, however, when regional, area and district health authorities were introduced to replace regional hospital boards and took over control of public health and ambulance services from local authorities. The next change came in 1982, when area health authorities were abolished and district authorities were restructured. New general managers were appointed throughout the system in 1984 and an NHS Management Board was created in 1986. The Ministries of Health and Social Security, which had been merged in 1968 to create the DHSS were separated in 1988 and the NHS Management Board was reorganised into the NHS Policy Board in 1989.

****

That same year also heralded perhaps the most significant reorganisation of all, when the Conservative plan 'Working for Patients' created the so-called 'internal market'. This created self-governing NHS provider trusts to run hospitals and separate 'commissioning' organisations which contracted services from them. 1991 saw the creation of the first 57 NHS Trusts, followed by more in successive waves, rising to 270. In 1994 the NHS Management Executive moved from Whitehall to Leeds. Then in 1996 the 14 regional health authorities were reorganised into eight larger administrative bodies.

481 new 'Primary Care Groups' were introduced in 1999 and then the NHS Executive was abolished in 2000. New regional directorates of health and social care were introduced in 2001 and then, in 2002, the NHS regional offices were abolished; 96 health authorities were reorganised into 28 Strategic Health Authorities at the same time. In 2006 those 28 SHAs were reduced to 10 and the Primary Care Groups were condensed into 151 organisations now called 'Primary Care Trusts'.

Following the 2006 reorganisation, there was a period of relative stability until 2011, when preparations began for the major reorganisation planned in Andrew Lansley's Health Bill. The Strategic Health Authorities were telescoped from 10 into four supra-regional 'quads' whilst PCTs were grouped together into around 50 'clusters', shedding 80% of the system's governing boards and senior management teams in the process.

The final reorganisation (for now) followed on April 1st 2013 when the Strategic Health Authorities and Primary Care Trusts were all disbanded, to be replaced by 212 'Clinical Commissioning Groups' and shared 'Commissioning Support Units', plus new national bodies including NHS England, Public Health England and Health Education England and an array of local and national scrutiny and regulation bodies.

**The effects of constant change**

Heraclitus would probably be pleased to see that his mantra still holds good. But, for anyone attempting to bring about lasting culture change, the constant inconstancy of the NHS is a nightmare. Key managers leave or are made redundant. Relationships are severed. Documents are lost or destroyed. Teams are dismantled. Funding ceases. Years are lost whilst new incumbents establish networks all over again.

Chapter 8 discusses the importance of sustainability in relationships with stakeholder organisations and of facilitating change in a strategic fashion. This includes pump-priming funds and encouragement for best practice ideas to be developed within the wider system, in order to encourage wider ownership of initiatives. This is a good idea for the obvious reasons; but it was also based on our observations of what has so often otherwise happened to initiatives. The NHS has a long and sad history of great initiatives that have come and gone without trace because sustainability is not built into them.

The typical profile is that someone decides that it is important to develop good practice in a certain area. Some money is found, along with an enthusiastic project team. A pilot is proposed, for all the best risk management reasons. The pilot runs. It is perhaps enormously successful. It is written up. Maybe there's a conference. But, as it turns out, nobody has the clout or budget to elevate the innovation from the status of local pilot to regional or national practice. The fixed-term funding runs out. The team moves on. Without leadership the pilot falters. Next thing it is gone and forgotten. In a year's time people talk wistfully of trying something similar. 'As a pilot, of course'.

This is why, wherever possible, we conceived our strategic interventions with either a national adoption plan or independent self-sustainability in mind. Both of these are options. As it turns out, one has proven to be a better insurance policy than the other.

**The 'start at the top' approach**

The Equality and Diversity Leadership Competency Framework is an example of aiming high to begin with. We saw from the outset that the needs discussed in the previous chapter were not unique to our own region of England. The evidence came from research in the North West; however it was pretty obvious that the challenges of professionalising E&D management and leadership were universal. This is why we partnered with the Department of Health from the beginning, with shared funding (even though we carried out and supervised the research and development work) and a national steering group. This increased (but couldn't necessarily guarantee) the likelihood of national buy-in. We sought to embed the framework further by making it one of the features of the Equality Delivery System when this was launched.

To that extent the theory was sound. In reality, looking back, we underestimated resistance to the framework from parts of the HR Directors community, especially because of the framework's heretical suggestion that Equality and Diversity managers should be developed and in some cases promoted. We were touting this idea in a system which was perhaps more inclined to see such managers as an expendable luxury; among the first to go when the demands were coming to slim down workforce numbers.

This is part of 'chicken and egg' problem. Developing and elevating the status of E&D leaders would enable them to convince Directors that E&D is central to the core business objectives of the organisation. With that understanding, the leadership would readily support the development of professional skills and competency in the area. Many organisations seemed to be stuck with the reverse, however. In other words: senior managers seeing E&D management as a more junior operational function; junior managers lacking the competencies, credibility and senior level championship to convince the leaders otherwise. A vicious cycle.

Whether you agree with that analysis or not, we could see from soon after it was launched that the Competency Framework's adoption depended largely on our presence to advertise its existence, to proselytise the benefits, and to counter the arguments of the naysayers. In the previous chapter we acknowledged that, given the opportunity, we would have learned from the valid elements of criticism and improved the clarity and utility of the product. The objections were easy enough to overcome. However, we were under no illusions about the likely fate of the framework after our organisation and team was disbanded.

The lesson from this example is that even if you aim to embed your innovation from the outset you can still become unstuck if you don't have the _time_ to support it through the turbulent stages on the way from 'new' to 'established'. In this case the constant flux of change in the NHS eventually meant that we ran out of time.

This is not to say that if the NHS goes ahead and quietly forgets the Competency Framework there is nothing that figuratively 'stuck to the wall'. A successful spinoff of the competency framework project was the development programme for more than half of our region's E&D leads (and 90 in the other regions, funded by the NHS Leadership Academy). All those managers had their sights raised. They received tangible proof of their expertise through earning Level 4 certification from the Institute of Leadership Management. Some have since been made redundant in the latest and biggest NHS reorganisation; however others have found work within the system; even if not still working in an E&D function. In many corners of the NHS system there are therefore people who, whatever they now do, are more likely to do it with equal outcomes in mind. They are like seeds carried on the wind. It is impossible to know how that kind of knowledge will germinate and spread.

**The 'start local and work up' approach**

The alternative to aiming high to begin with is to develop an idea locally with the intention that, when it is successful, it can become a national initiative.

Even though a project is more achievable if you start out within the boundaries of the system that you can directly influence, you also need to keep the final objective in mind: that the initiative can be scaled up.

With most of the projects we developed, we aimed for this a matter of course. The Health Equality Library Portal (HELP) was developed initially for the needs of the North West region, although we planned from the outset that it should be accessible to everyone. Very little effort was required for the word to spread. It happened by word of mouth from the start. The service became a national and international hit because it fulfilled a very real need in an effective way and had no direct competition.

The sustainability challenge for HELP was to keep the site constantly updated and fresh. In order to do this we needed both internal resources and a constant stream of research. To launch HELP with a credible supply of relevant research content, we had first engaged our stakeholder partners in a one-off project to each provide at least 100 up-to-date and catalogued research documents and web sites. To maintain the flow we then added a responsibility to carry on supplying fresh material in the annual Service Level Agreements which the partner organisations signed.

To back this up we employed a project worker with librarianship skills, whom we set to work maintaining the library, and ensuring the consistency and reliability of the digital catalogue. Later, when that employee moved on, we absorbed the function into the rest of the team, including our Communications lead and the PA. The key to sustainability was to ensure we had a continued supply of new material and the resources to insert it into the library.

Three months after the April 2013 reorganisation of the NHS, HELP nevertheless disappeared from the World Wide Web, suffering the same fate as countless other online systems, as the managers charged with shutting down the old system's resources pulled the electronic plug. It disappeared silently. One day it was there. The next day all references to the site's 1700 evidence documents and the portal of over 300 equality-related web sites were redirected to a standard corporate web page. Some organisational changes are so big and so far-reaching as to go beyond normal concepts of sustainability.

**Some changes are too big to survive**

The disappearance of HELP after our departure provides an object lesson in how difficult it can be to plan for the survival of any corporate initiative.

HELP didn't disappear because funding stopped (though the third-party hosting costs would have become an issue eventually). The website was paid for and capable of remaining online for long enough for the new NHS system to establish itself and pick up the running.

HELP didn't disappear because the management team had left or moved on. Certainly, it would have rapidly become out of date without someone to own and maintain it. However, much of the material in the system had enduring value for reference. It was still a useful resource without new content. It could stand a period of non-maintenance whilst the NHS sorted itself out.

HELP didn't disappear because the need for it had gone. People still need to search for the kind of resources which the system was designed to make easy to find.

HELP disappeared because it was not seen as a critical enabler for achievement of the system's goals by the sort of managers who were going to survive such a massive disruption.

**Being part of 'core business'**

This returns us to a point we've made in earlier chapters about how Equality and Diversity must be seen and understood as central to the organisation's core goals.

  * 'How do we achieve quality without understanding diversity?'
  * 'How do we guarantee patient experience without understanding diversity?'
  * 'How do we assure a workforce where all staff are valued and which reflects the population we serve without understanding diversity?'

A management which instinctively asks those questions (and means them) at every turn would not figuratively leave a box containing answers on the kerb as the moving van pulls away.

This is why culture is so central to ensuring that improvement (and the tools to drive it) survives the most disruptive of organisational changes. The challenge is to distinguish between the kind of leadership which talks the talk because it sounds right, and the kind that walks the walk because they believe these ideas are central to the outcomes they are there to achieve.

In our work we did our best to develop managers like that. What we didn't bargain for was a change so enormous that it swept away even those people we had cultivated, and handed power to others who were yet to be reached.

But does that mean all efforts are ultimately doomed if another Armageddon-sized change comes along? Not necessarily, as our third example will illustrate. However, it shows that you should not put all your strategic eggs in one basket.

**A third way**

Pride in Practice was an initiative suggested to us by one of our strategic equality stakeholder partners, the Lesbian and Gay Foundation. We talked about it earlier in chapter 8. It was based on earlier research that we had funded them to carry out, examining how prepared, equipped and friendly our region's GP Practices were towards Lesbian, Gay and Bisexual patients.

The research, carried out in a reasonable sample of practices, had verified previously anecdotal evidence that some surgeries and their staff were directly hostile towards patients who shared that they were Lesbian, Gay or Bisexual. Some refused to even put up posters signposting support services, or came up with excuses why they had been rapidly taken down.

However, the research had also highlighted a much larger number of GP practices and their staff who recognised that they were perhaps not providing a good service to their LGB patients, either because they themselves lacked knowledge, or because the practice as a whole had not examined how they did things and the unintended barriers they might be creating.

We felt there was an open door opportunity among this second group of practices, which we could help to address. However, we also concluded that the best and most sustainable strategy for addressing this was to come at the problem from outside of the NHS itself. We asked the Lesbian and Gay Foundation to develop a proposal to address the needs highlighted in their research. And then we helped the charity to produce an effective toolkit which they would then own and promote.

Pride in Practice is a developmental approach to helping GP practices examine and tackle their own weaknesses; develop an LGB-friendly clinical environment; and then have their quality recognised by external assessment. Practices can earn Gold, Silver or Bronze accreditation, with a plaque that they can then display in their premises and on literature.

We were clear from the outset that we would not fund the _running_ of Pride in Practice. We helped with the one-off costs of developing the resources and producing an initial set of the materials. This was sufficient to get the initiative off the ground with a local launch and gain initial results and publicity. The rest, however, would be up to the LGF.

It would be the LGF's responsibility to promote Pride in Practice after the initial launch. It was their responsibility to make the running of the benchmark an economically viable proposition, whichever way they thought that was best achieved. And, ultimately, it will be the responsibility of the LGF to update the system as necessary over the course of time, to ensure the Gold, Silver and Bronze standards remain ambitious targets for practices at different stages of development.

Pride in Practice was launched in February 2012, more than a year before the latest reorganisation in the NHS. As planned, we put no further money into the initiative post-development. And, as planned, the charity continues to run the benchmark system after we were gone.

Time will tell whether Pride in Practice is sustainable for the long term. GP practices may balk at the idea of paying to take part. However, other benchmarks such as Investors in People operate on a chargeable basis, so it is not unreasonable to hope this could work. The alternative will be for the charity to seek funding in the NHS system. For instance, the NHS Greater Manchester Primary Care Cluster determined that it would be a good idea for all GP practices in their catchment to undergo the development and assessment programme. It is to be hoped that this will continue among Clinical Commissioning Groups and nationally.

At this stage, at least, it would appear that initiatives like Pride in Practice, which were set up to be independently sustainable, have had better prospects of surviving disruptive change than those which have relied on corporate continuity. We've noted also that local initiatives which we encouraged to flourish within our region have generally survived in the NHS provider sector (which has seen less disruptive change) whereas those set up by Primary Care Trusts in the commissioning sector have been far less likely to survive the transition to Clinical Commissioning Groups. However, one doesn't always have the luxury of choice over how to set up an initiative, and time will tell whether the independently-run initiatives really are sustainable in a difficult economic climate.

**Culture eats strategy for breakfast**

There is a saying in management science that 'Culture eats strategy for breakfast'. The phrase is attributed to the Austrian-born management consultant Peter Drucker, who is credited with inventing the concept of 'Management by Objectives'. And 'culture eats strategy' was popularised by Mark Fields, the President of the Ford Motor Company, where the words continue to hang in the corporate war room. He observed that no matter how far reaching his vision or how brilliant his strategy, neither would be realised if not supported by the culture.

And this is surely the lesson of our own experience in the NHS. For, no matter how well we had underpinned our strategy with evidence and analysis, and no matter how relevant our tools and initiatives may have been, the sustainable long-term influence of our work relies on whether the will to advance equal outcomes becomes an embedded part of the values and culture passed from leaders to organisations and from managers within those organisations to staff.

Leadership and Values are key terms in the liturgy of the new NHS management. Some top managers at national level are said to 'get it' about equality. It would be ungracious to question whether that is the case so early in the life of a structure which may (if lucky) survive politically-driven reorganisation long enough to achieve stable running. Those who survive the longest and ascend the highest are adept at changing their stated outlook to suit the needs of the moment. The ultimate tests will be whether the organisation really, honestly, orients itself towards the pursuit of genuine, measurable, equal outcomes and whether the culture really does evolve to preserve hard-learned lessons of equality best practice the next time the merry-go-round starts up.

And it is the honest, genuine measurement of equality outcomes that we turn to in the final chapter
**Chapter Twelve**

****

**Measured outcomes at NHS North West**

We come now to the final chapter of this theoretical and practical examination of why equality should matter in a public sector institution, how you promote it, and how you can set about measuring it through tangible outcomes.

**How this book came to be written**

The germ of the idea for creating this text began long ago, at the publication of the Equality team's five-year strategy in 2009. This gave a commitment that, as well as beginning an evidence-led programme of work, we would assess our success through measures of what had changed. This was a routine approach we took for individual projects, as one ought to do when investing public money to produce results. At the end of the first year of running the Health Equality Stakeholder Engagement approach to consultation, for instance, we undertook and published a thorough benefits analysis as part of the justification for continuing to invest in it. All of our developmental events had audience surveys. Access statistics for our Health Equality Library Portal were regularly checked as a means of establishing that it was meeting its design objectives. So it was envisaged from the outset that we would at some time publish the outcomes of our overall strategy, which was intended to play out over five years. The logical time for this would have been in 2013/4.

We envisaged two principal approaches to measuring the outcomes. The first and most objective test was going to be whether we achieved the intended year-on-year improvement in performance scores across the 24 commissioning and (by then) 40 provider organisations in the North West.

The 2008 'Landscape of the Region' research demonstrated where the weaknesses lay, while the 2009 strategy targeted those deficiencies. The EPIT performance measurement framework was to measure those areas in depth. The first run of EPIT was to provide a baseline for where organisations stood on their equality outcomes. And subsequent annual runs of EPIT (or the new EDS system) were to provide snapshots of progress.

EPIT was designed to be a tough and objective benchmark so that progress year on year could be honestly assessed and compared. Commissioners and providers would use their own performance measurements to make an evidence-based judgement of their corporate progress. And we would look at the regional 'big picture' of all those measurements taken together as the most obvious indication of whether the strategy, tools and development interventions were working in the intended way to drive up the quality of outcomes for all.

The second and more qualitative measure of our influence was going to be the emergence of examples of best practice initiatives started autonomously by organisations in the region. These served not only as the evidence for specific claims in the performance framework; they also provided more general evidence of a culture shift. They showed how organisations were applying the principles we were trying to inculcate and coming up with novel ideas for how to improve outcomes. Examples of some of the case studies are provided in Appendix 1 and many were originally published through the HELP system and our monthly newsletters as they came to our attention.

In our original plan, the simple numerical evidence of repeated EPIT performance snapshots, coupled with the narrative examples of organic best practice springing up in the region, would have been the best evidence that our strategy and methods were working. However, that was before national events took over. To us it is a tragedy that we were unable to complete the programme as envisaged, especially (as we will show in a moment) the indications were that the medicine was working effectively. One cannot ignore events though. Our philosophy was always to adjust our course as best we could.

The dramatic changes announced for the NHS in Andrew Lansley's White Paper of July 2010 made it clear that we would never be able to see our programme through to the end as originally envisaged, whatever place we might have in a future organisational structure. All 10 Strategic Health Authorities, including our own, and the whole existing structure of commissioning, would be disbanded at the end of March 2013. Indeed, the original proposals were for change much faster than that. What is more, the piecemeal changes inflicted on the structure of the NHS between 2010 and 2013 meant that we couldn't continue with business as usual until the end. We would continually need to adapt.

In 2011 we were invited to write a peer-reviewed paper for the Journal of Psychological Issues in Organisational Culture (JPOC) for publication in 2012. We approached this as a joint team effort and it was immediately apparent that in order to explain our ideas and interim results we would need to step back and provide a theoretical framework for how the understanding of equality has evolved in Britain, and how that related to running institutions that provide public services.

We had already researched and published a unique history of how Black and Minority Ethnic migrants had contributed to building the NHS from 1948 onwards. We had also just researched and published a uniquely comprehensive history of how Lesbian, Gay, Bisexual and Trans people had been seen by and influenced medicine in the previous millennia. We planned to follow-up with something similar about disabled people and medicine. Researching these publications and our academic paper made us aware that, whilst parts of our subject area were covered in the literature, nobody seemed to have ever pulled these threads together in one coherent whole. In particular, nobody writing from a theoretical standpoint seemed to be in the privileged position to be able to describe a practical methodology in detail alongside objectively-measured results.

Finally, as if any further encouragement were necessary, the last 12 months leading up to the biggest NHS reorganisation in 65 years also made it increasingly clear that very little good practice might survive the event. In chapter 11 we discussed what steps one can take to make changes sustainable, and we acknowledged that some changes are so Armageddon-like in their scale that nothing may survive them. In this context, with our organisation and our efforts wiped out by forces beyond our control, a book like this seemed the only remaining method to try to ensure that our ideas of what works could be preserved for future managers to learn from and apply. We might not still be able to apply them ourselves, but at least documenting our philosophy and our evidence of effectiveness could benefit others.

So, we come to the results...

**EPIT One: the baseline**

As explained in Chapter 9, we launched the Equality Performance Improvement Toolkit (EPIT) in October 2009, six months after the strategy was published and just weeks after the first of our big enabling tools (HELP) came online. The research behind our strategy indicated that the results would not be promising and the evidence coming through our online EPIT submission portal in late January 2010 showed that we were not wrong.

As discussed in chapter 9, one of the first and most tricky problems about the evidence and self-assessments submitted to us by the 64 organisations in the region was a combination of poor quality and an unrealistic belief that they were achieving equality outcomes. The most fundamental issue was that, in spite of repeated explanations and one-to-one sessions and telephone support, most organisations failed to grasp the difference between a genuine outcome (what difference did it make to patients, staff or the public?) and measures of the effort being put in.

Evidence on offer varied from the irrelevant (minutes of meetings held) to the totally impenetrable (entire 100-page strategy documents from which we were expected to deduce the outcomes). There was certainly no lack of evidence of _trying_ , so we could see why people wanted recognition for 'excelling' or 'achieving' in some way. However, the purpose of our framework wasn't to make managers feel good. It was there to provide an honest appraisal of how their efforts affected people on the receiving end of NHS management, whether patients, families or staff.

Our plan was to verify the evidence supplied by the region's 24 Primary Care Trusts. They in turn would verify the evidence provided by the provider organisations for which they had lead commissioning responsibility. The latter merely encouraged organisations to performance manage contracts worth millions of pounds as the public might expect. In other words, determine local needs and then design and purchase suitable services to fulfil them according to a contract. Performance managing the fulfilment of that contract was an official responsibility. And one of the reasons we introduced a performance measurement framework was because we knew from our initial research that managers had no apparent basis for either setting or measuring the achievement of equality targets in that process — a massive missed opportunity.

As we discussed previously, the process of verifying EPIT self-assessments by commissioners to an objective standard was fraught with political difficulties because so much of it involved getting managers and their Boards to appreciate that they weren't holding themselves to any meaningful standard of quality. What seemed to be happening was that organisations were congratulating themselves on effort rather than results. Some tried appealing over our heads to the SHA's Chief Executive and Directors. Some became abusive. Some burst into tears. What was originally meant to be a straightforward exercise in checking evidence turned into a lengthy process of individual sessions, patiently explaining where organisations needed to provide objective evidence of results and then painstakingly writing guidance for each one.

Some managers simply accepted our regrading of their evidence and went away to explain to their bosses. Some gave the impression that they thought the system was rigged to produce the results we wanted. This reinforced the impression that they still had not really understood about where they were going wrong. Others took the advice and, having grasped what was expected, asked for more time to collect the evidence. Interestingly, in the latter case, some then came back two or three weeks later confessing that they really couldn't assemble the kind of evidence required. The lesson in that case was well learned.

Organisations were starting to understand that if they didn't have the wherewithal to measure what matters, then they had no basis to claim they were being successful or making progress. It was a tough but necessary shock to the entire system, after which we set out to build and encourage.

The initial results from the first run of EPIT on the 24 Primary Care Trusts were therefore quite bleak, albeit with some individual islands of good practice.

EPIT measured 13 so-called 'deliverables' across the five broad goals set out in the strategy.

1. Increase the diversity, representation and improve the working lives of our workforce

2. Develop data to monitor, information to manage and knowledge to act

3. Develop the right services: targeted, useful, usable and used

4. Move beyond legal compliance to initiating best practice

5. Develop our specialists and leaders

Taken across 24 Primary Care Trusts, the 13 deliverables meant that there were a total of 312 measurements overall. Of these, 280 (89.7%) came out as 'Developing'; 27 (8.6%) were 'Achieving'; and none were 'Excelling'. In the case of one Trust, the evidence was so weak, and the support for the managers concerned so problematic, that we realised the need for a whole new category of 'Insufficient Evidence'.

Viewed from the perspective of the public who pay for and use NHS services, especially those in any of the protected groups, this result was a shocking indictment. From our point of view it was no more than we expected. We knew our work was cut out. EPIT provided the wake-up call to others and the essential baseline against which we could measure progress in the future.

This exercise showed us that we could not altogether rely on the accuracy of PCT efforts in verifying the providers they commissioned. If an organisation could not quantify genuine outcomes for themselves, how well could they hold to account large provider organisations with multi-million pound annual budgets?

It was also plain that many providers had never been performance-managed in this area before. Until EPIT there was no basis on which to do it, and some PCTs lacked the provisions in their contracts to force providers to the table on this. Yet some providers told us that they welcomed the conversation; they were bursting to tell us and their commissioners what they did.

The initial run of EPIT among the providers therefore left a lot to be desired. Three providers effectively refused to take part (one in direct terms). In some areas the data was weak. In other places the PCT never completed the verification of evidence to the standard required. We volunteered, where necessary, to help the commissioners to hold their providers to the same standard we had held them to but, eventually, we still ended up with many gaps. We also realised, in practice, that two of the deliverables we had constructed could not be applied to providers as they related mainly to the commissioning process; though some tried and succeeded in supplying evidence.

The result was not a pretty sight. Once again, 40 organisations each providing evidence and self-assessment on 13 'deliverables' means 520 separate measures in total. Of these, 372 (71%) were definitely verified as 'Developing'. Another 24 Developing claims were made but not verified. In 13 cases (2.5%) the PCTs and ourselves accepted the evidence of 'Achieving' outcomes. Seven more Achieving claims were advanced but not verified. In 34 cases (6.5%) there was insufficient evidence on which to grade and in 65 cases (12%) no response was given; however 25 of those were in instances where the organisation didn't feel able to rate itself on the two commissioning-related deliverables.

The promising thing in all of this, for both PCTs and providers, was that we found some evidence of genuine 'Achieving' outcomes across all the deliverables. It underlined that it was perfectly possible to meet the expected standards and that there were leaders in the system who knew how to do so. One PCT demonstrated 10 'Achieving' scores out of 13 whilst another managed four. Three more organisations got three each. Even among the providers, one organisation had five verified 'Achieving' scores and two of them managed two 'Achieving' scores each.

The overall conclusion from our EPIT baseline was that we had constructed a tough framework, but that it was do-able. Furthermore, there were people within the system who were able to demonstrate successful outcomes in nearly every area. The challenge would be to spread that knowledge around. This was why our first response to the completion of the first EPIT exercise was to create a 'Masterclass' workshop, in which managers who had demonstrated 'Achieving' outcomes explained how they had done this to their peers. Our programme of regular quarterly development meetings and educational releases, plus our leadership competency work, then aimed at building expertise and confidence.

**Preparing for EPIT 2**

The first EPIT measured performance in January 2010. With the launch of our educational programme, we then announced that there would be a second round of EPIT in June 2011. Eighteen months seemed to us a good interval for measuring progress. Ideally we would have liked to have run annual assessments; however, one of the things we learned was that January was not a good time for people, with many other reporting deadlines falling at that time, for the last quarter of the financial year. The timing was also influenced by our desire to give people more time. Furthermore, we knew that the Equality Delivery System, based largely on our EPIT work, would be launched in the autumn of 2011 and there would be an expectation to complete this by the following April (2012). For all these reasons June 2011 therefore made sense logistically.

We used the intervening time to provide education and encouragement, including being prepared at any moment to talk to colleagues across the system about what their previous evidence indicated and the problems they faced. We also applied learning from the whole previous exercise to avoid repeating pitfalls. We decided, for instance, that if organisations were reporting the same level of self-assessed capability as before, we would take that as read without verifying the evidence in detail.

This allowed us to concentrate on verifying organisations' claims to have improved. It also allowed managers to focus efforts on their best areas. In addition, we introduced the idea that our equality stakeholder partners would be involved in the verification process this second time around. Organisations would be invited to present their evidence in teams, with managers presenting on their own areas of responsibility and with both ourselves (the SHA) and the stakeholders asking questions and deciding the outcome together.

The involvement of stakeholders in this way was a planned development; however it was also a staging post to how the Equality Delivery System was intended to run, with organisations having to present entirely to their local stakeholders. We felt that EPIT 2 was therefore a useful transitional exercise for everyone.

**EPIT 2 results**

The landscape of the local NHS had already changed by the time the June 2011 assessment time came around. Primary Care Trusts were being reorganised from 24 individual bodies into five clusters. This was to take effect from October; however in one region the process was already advanced. A pair of PCTs asked to be assessed as a single organisation, so that now there were just 23 sets of 13 deliverables to assess (299 data points in total).

Of these 248 (82%) were accepted as 'Developing' — mostly by default as their assessments hadn't changed. However, the number of verified 'Achieving' scores had leapt to 51 (17%), compared with 27 (8.6%) before. This represented a doubling of the areas in which genuine 'Achieving' results could be demonstrated. And these were results accompanied by very good examples of innovative working practices demonstrated before the sceptical gaze of the leading equality stakeholder organisations in the region.

The results among providers, who now faced the same method of appraisal from much more savvy PCTs, were equally promising. Some PCTs were still struggling, although now the struggles were increasingly because they weren't satisfied with what the providers were offering as evidence. They were even challenging the 'Developing' evidence, with the result that the number of verified 'Developing' scores dropped to 175 out of 520, with a further 126 not verified. Overall, however, that represented 301 likely 'Developing' scores (57%). The drop from the previous time was a combination of more 'Achieving' scores and an additional 3 organisations (6 in total) who declined to take part. The headline result, however, was 70 verified 'Achieving' scores (13%). That is more than five times the number (2.5%) measured in the previous exercise. A further 31 'Achieving' scores were claimed but not verified. However, the fact that these were not pushed back to 'Developing' means they were considered credible.

What this means is that although there were still worrying gaps in the region, there were distinct and measurable improvements in genuine outcomes on both the commissioning and provider sides of the system. Among the commissioners, we had seen a doubling in the number of 'Achieving' deliverables. And among the providers there had been a five-fold improvement. The numbers were all still much poorer than we would like. However, this was the result of just 18 months of concerted development. This is why we felt it such a tragedy to disrupt and eventually disband parts of the region's NHS organisations when we evidently had a formula that was capable of producing marked improvement. The strategy was for five years. The evidence hinted at what more could be achieved, given the chance.

**Comparatively measuring EDS results**

For now, in the autumn of 2011, it felt as much as we could do to hold the system together and prevent a loss of focus as organisations merged and new leaders came into position with different ideas. However, we were committed to implementing the Equality Delivery System with as much diligence as EPIT. The two systems were not the same. In particular we worried about some of the measures being about processes rather than genuine outcomes, and about the ability of stakeholders to contain the instincts of organisations to rate themselves higher than they perhaps deserved.

We helped organisations to prepare for the EDS by holding workshops where we demonstrated how the EPIT deliverables mapped on to the EDS requirements. The wording may have changed but the purpose was to show how organisations could move their existing data and documentation to the new system. We also held sessions for equality stakeholders to prepare them for the system too.

The EDS system was now organised under the management of the new telescoped 'clusters' of five super-local Primary Care Trusts. Within these we were also able to ensure that the strongest of the region's E&D managers was in key leadership positions to coordinate the process. We focussed on regular meetings with those five leaders, in addition to the regular developmental events for everyone, with the result that those five took it upon themselves to ensure that the same kind of EPIT-grade governance was applied.

The EDS results for the region, collated by us through a new dedicated website in June 2012, were a slightly different format, with commissioners and providers grouped together in each cluster. The assessments were also for slightly different things, although overall they covered almost all of the areas mapped by EPIT. It is for that reason we felt that we could draw some outline comparisons, so long as we limited ourselves to overall percentages.

The EDS has 18 measures, which were completed by a total of 51 NHS organisations in the region. That makes a total of 918 data points. Of these, 665 (72%) were agreed with stakeholders to be 'Developing'. 207 (22%) were agreed as 'Achieving'. And one (in an admittedly good PCT) was agreed to be 'Excelling'. 25 (2.7%) fell into the new classification of 'Under developed'. This was reminiscent of the 'Insufficient Evidence' result in our first round of EPIT. Only one of the 51 organisations failed to complete the assessment.

It would be risky to read too much into any comparison between the EPIT results and the EDS ones. For one thing, the sample had markedly changed. In four of the five clusters there was only one combined measured for the whole commissioning process; this meant that the sample leans more towards the profile of the provider organisations. However, what reassured us was that the spread of results between 'Developing' and 'Achieving' was still similar.

There was a risk of loss of governance with the SHA out of the equation but the PCT cluster E&D teams assured us, in deeds as well as words, that they had learned well from their experiences. Providers fed back to us that the process was every bit as tough and objective as we had led them to expect.

**Comparing other NHS regions**

The benefits of the learning from our regional equality measurement system were borne out by a short exercise we conducted, comparing our EDS results with another English region.

The national nature of the EDS meant we could compare ourselves in a way that had never been possible before. Consequently, when the EDS deadline had passed we informally asked our opposite numbers, the Equality and Diversity Leads in the other nine English regions, if they could let us see some of their own statistics. The result was very revealing. We received a majority of negative responses. It was not that the leads weren't prepared to share their data. It was simply that their data was too chaotic. One lead attempted to provide the data but it was apparent that they couldn't assemble it. The take-up of the national system in other regions was evidently weaker because there had never been an exercise like this before. Another region was able to send us some data but the results were erratic.

In the only region to supply fairly complete data, the median for completion stood at around 60% and the percentage of 'Achieving' or 'Excelling' scores varied wildly between 88-94% at one end of the scale and 11-20% at the other. For the region as a whole, the number of 'Achieving' and 'Excelling' scores stood at around 40%; however the erratic values cast doubt over how meaningful that might be. It was highly reminiscent of the original submissions from our own organisations, before the reality check we carried out. With leadership and discipline we might expect the numbers to settle down in a more realistic fashion in a second exercise; however there were no indications of how that necessary governance could be developed within the system.

**Summing up**

We come to this point with a degree of pride but very heavy hearts. These statistics, coupled with all the examples of good practice developed by increasingly confident and capable managers, show that our intensely rigorous, evidence-based and strategy-led approach to transforming equality outcomes across 60+ autonomous NHS organisations was showing strong signs of success just as it was cut short. If we had constructed a less rigorous regime then we would not be so confident. However, we know it was tough, but fair and accurate. We were successfully changing the culture.

Our framework for developing appropriate leadership competencies among Equality and Diversity Leads was not universally popular, especially when it pointed to the need to promote real talent to a level where managers could be effective. Nevertheless, the spinoff of training and external examination brought a much-lacking culture of professionalism and meant that 36 E&D managers earned national qualifications to boost their credibility and morale.

Our methods of engaging with equality stakeholder partners proved to be sustainable for the duration and developed the kind of relationships which brought excellent and workable ideas for innovations to our door. Our evidence database, HELP, exceeded all expectations in terms of popularity and our newsletters and educational resources found national readerships, filling the gaps in other regions.

We set a tough standard and we put many noses out of joint in the process. We made enemies, but these were more than outnumbered by friends and supporters. We put the pursuit of Equal Outcomes on the map within an NHS region that employed 220,000 people and served 6.9 million citizens.

The research says we were beginning from a low and chaotic starting point, with many deficiencies; not least a widespread lack of focus on outcomes. But the evidence also shows that we were making genuine strides in the right direction. We can see the measurable effect we had in just 18 months, but can only speculate where we could have got to given more time and a stable system to continue managing.

Equality matters because we all pay the same taxes for the same NHS, which was conceived to be free at the point of need to _everyone_. Not _some_. But _all_. The data says the NHS has often failed to measure up to that standard. It means that some people don't receive the same standard of care as they should. And a lack of attention to this disparity lies at the heart of wider discussions about the quality of care. An NHS which feels casual about the care experienced by members of minorities such as Black and Minority Ethnic, disabled and LGBT people is not thinking about quality at the most fundamental level. The result can be a lack of quality for everyone.

We complete this book as NHS outsiders. We are not there to continue our work in the new organisational structure, and many of the people we developed, and the tools we created, have been swept away. Redundancies were widespread. In many respects the system returns to Year Zero in terms of the attitudes and cultures we set out to address. We hope that by documenting our knowledge and philosophy, and showing that it worked, there is some chance that those approaches will once again have the opportunity to be applied.
**Postscript**

**Making Equality Work In The New NHS**

Aside from the theory chapters, the substance of this book has been about our practical experiences of making equality work within the context of the NHS in England as it existed between 1st July 2006 and 31st March 2013. This was one of the longest stable periods in the NHS structure in recent times.

Our strategic approach was conceived and executed within a hierarchic management structure that had particular advantages for what we set out to do. The Government and Department of Health were at the top of a pyramid, with ten (regional) Strategic Health Authorities (including our own) at the next level, each one having considerable statutory powers to manage local organisations. In the North West that included 24 local Primary Care Trusts (PCTs) and a majority of the region's 39 (later 40) provider trusts (those which had not achieved autonomy through Foundation status). We could even indirectly influence those latter Foundation Trusts, by how we managed the PCTs commissioning them.

The structure was particularly conducive to the kinds of transformation we had in mind. A Strategic Health Authority was effectively a regional arm of the Department of Health, but with a great deal of autonomy. SHAs channeled finance to the PCTs, who then used it to commission and contract provider services. In the North West that spending amounted to around £12 Billion per year — about an eighth of the budget for the NHS in England. As part of that funding process, the SHAs had a significant amount of power in terms of performance management.

Performance management, as we have explained, is a significant part of driving up equality outcomes — so long as 'the stick' is accompanied by support and encouragement ('the carrots'). Practically everything about this model of the NHS was performance managed by SHA staff. It was just that there had not been much attention to how to performance manage equality.

And the scope of SHA concerns was almost total. It included responsibility over Public Health strategy and the commissioning and quality management of Education at the regional level, as well as the aforementioned PCT/Provider oversight.

**All change**

The NHS structure has now changed considerably. The 151 English PCTs are replaced by 212 Clinical Commissioning Groups (CCGs), who exist in a local health and social care economy where strategic planning and monitoring are shared with Local Government and there is local stakeholder scrutiny by new Health Watch organisations.

(Poster by NHS Employers)

The PCT responsibilities for commissioning general practitioner, dentistry and pharmacy services plus specialised commissioning have been transferred up the chain to the new NHS Commissioning Board (NHS England).

The SHAs are gone. Their public health function is taken over by local authorities under the eye of a national body (part of the Department of Health) called Public Health England. The SHAs' education commissioning responsibilities are taken over by regional level 'Local Education and Training Boards' (LETBs), which come under the control of a new national body (Health Education England).

What this means is that there are few places where a leader can stand in the new structure and have a complete view and the opportunity to change things directly.

The nearest equivalent to that pole position in the new structure lies in NHS England, which arguably has far greater power over the parts of the NHS that it manages. Unlike the Department of Health in the old structure, it doesn't have a layer of ten autonomous SHAs between it and organisations at the local level. And, the statutory powers of NHS England, along with its directly controlled structure of 27 Local Area Teams (LATs), provide a lot of opportunity to peer and scrutinise should the leadership wish to do so.

NHS England's pedestal doesn't afford _total_ control. It doesn't have direct powers to integrate public health strategy and the planning of education for doctors and nurses — for that it needs to collaborate with other bodies. The determination of the Government to develop every provider into a Foundation Trust means that a strategic leader planning equality transformation also can't directly tell the organisations running general and specialist hospitals, mental health and ambulance services what to do. Aside from guile and persuasion, those organisations (a big part of what the public experience) can only be controlled through financial and quality regulation (Monitor and the Care Quality Commission) and through the CCGs which have contracted them.

Otherwise it has pretty extensive levers of control over a substantial part of the system — particularly the commissioning of GPs, dental and pharmacy services; the commissioning of specialised services; and the over-the-shoulder scrutiny of CCGs.

**Applying our principles**

In theory, therefore, a lot of what we are teaching in this book can still be applied, albeit tailored to the situation.

Clinical Commissioning Groups, though individually small, should be applying the principles of evidence-led management to everything they do in any case. Where they share the services of local Commissioning Support Groups, a lot of that evidence gathering can be shared between organisations. There is no sense in everyone reinventing the same local wheel.

For activities like stakeholder engagement it makes sense for local commissioners to team up with other agencies such as the local authorities and Health Watch to create effective consultation structures. Sharing like this avoids putting excess stress on the (often small) bodies being consulted and it means that the costs of genuinely sustainable engagement can be shared.

Provider organisations can likewise be included in these types of local strategic engagement consortia. They can also derive their own evidence through which to prioritise development, or work with local commissioners and the new NHS Clinical Reference Groups (CRGs) and Clinical Senates.

It still makes sense to have one national Performance Measurement Framework for equality outcomes in commissioning and provider organisations. Indeed, as we complete this book we hear that NHS England is updating the Equality Delivery System (EDS) for just that purpose. Local shared engagement bodies of the kind we've mentioned would be tailor made to engage with EDS participants for performance evaluation. Our recommendation would be that the new EDS tightens up on governance though — eliminating 'fuzzy' and process based performance measures; supporting stakeholder organisations to challenge and rein in excessive performance claims effectively; and providing a national hub to store, display and compare performance measurements for the public to see.

It makes sense to develop and press for the establishment of rigorous competency definitions and developmental programmes for people managing equality strategy at all levels. This doesn't just apply to NHS England's own small team of around a dozen managers, but the leaders with responsibility for equality outcomes in all the organisations at the coal face.

Many other tools would apply at a national level too. Our HELP system has disappeared, despite its enormous popularity and success. It leaves a void for a National Equality Evidence Database of some kind though.

**In summary**

It would be wrong, therefore, to write off our proven methodology for driving up equality outcomes just because the structure of the NHS system has altered. As illustrated, the principles still apply, although the places where they need to be applied may alter.
**Appendix 1 — Case Studies**

**Examples of development by NHS Trusts**

**Salford Royal Foundation Trust**

**The Equality and Diversity team at Salford Royal NHS Foundation Trust ensured that equalities work was seen as 'core business' by linking the outcomes from their work to other key quality standards and outcomes in the organisation's business plan. Tammy Pike, Salford Royal's Equality and Diversity Lead, explains:**

'We developed a comprehensive report showing how equality standards relate to other quality indicators (for example, CQC's) and this provided a benchmark across all parts of the organisation The report also showed how Equality Delivery System (EDS) outcomes linked to other important outcomes such as medicine management. For example, ensuring prescribers have the knowledge to advise and prescribe medicines that meet the cultural needs of the patients.

'To improve awareness and understanding of the EDS and make sure that patients and staff were able to carry out their scrutiny effectively, the team provided training sessions on the new system for thirty-six members of staff and members of the public/patients.

'This engagement of staff and patients in the process also helped us to identify areas of good practice and where we could improve. This information then helped us put together meaningful equality objectives for the organisation.

'The final report was presented to the Patient/Staff Experience Committee to sign off the Trust"s Equality Objectives and endorse the report. They were also invited to make recommendations for future work.

'Key to the success of this included linking the outcomes from service delivery and employment strategies to equalities, and training key staff and community groups in the EDS process.'

Here are some 'top tips' from Salford.

  * Present the information in an 'easy to digest' format.
  * Work with service managers to ensure that EDS outcomes are embedded in their annual plans — you may need to provide them with support and additional training.
  * Show clearly how equality outcomes support and improve service delivery.
  * Don"t assume that staff understand what is meant by 'improving outcomes for protected groups'. You may need to check on levels of understanding within the organisation.
  * Leave plenty of time to deliver the training sessions on EDS (it took longer than we expected).
  * Send your EDS evidence out prior to the event to give people time to digest the information.

'The process showed us that we needed to work more effectively with the Trust"s Membership Engagement Manager to develop a more comprehensive engagement plan in relation to all protected groups.

'By putting patients and staff at the heart of our work and fully involving them in the scrutiny of that work, we have been able to identify priority areas for us to improve and deliver on across the organisation. Through feedback from both staff and service users, we could see that the staff need support to understand how equality can deliver improved access to services users.

'It also helped us address gaps in the our own team"s knowledge of the key issues staff face in delivering equitable services.

'The E&D team has been "walking the talk" in the hospital and the community to see at first hand how front-line staff work, and what they view as the most important areas for the Trust to work on in the short and long term.

'Because managers can see the links between improving equality outcomes and the patient experience, it has given the report we produced much more attention and focus from the organisation.

'I've been asked to attend a series of senior management meetings across the organisation to present our findings and to discuss how each directorate can set key equality objectives to improve both outcomes for staff and patients.

'Involving staff in the process has made the equality team re-evaluate the level of understanding of equality and diversity within the organisation.

'Listening to staff and their interpretation of E&D has allowed us to reconsider how we deliver the equality agenda. Once we have collated the information from our frontline "walks", we will be producing a training needs analysis to ensure that we can align the delivery of equality training to the needs of the staff and local community groups.

'Clearer links between equality and other external standards such as the CQC have enabled managers to understand and identify with equality approaches.

'The performance review process has enabled the Staff Equality Forum to:

  * develop their understanding of equality and diversity and how it can support improved service delivery and employment outcomes;
  * feel fully involved in the process and enabled them to identify, as a forum, clear future work programmes;
  * help service users and carers to be fully informed of the work that has been undertaken in an easy-to-understand format; and
  * highlight how future engagement should be structured and the support processes needed to work effectively.

'As one member of the local community said: "I have been involved in this work for many years but for the first time you have enabled me to really understand what 'equality' means". '

At a glance – Salford Royal's EDS objectives

**Objective 1:** Evaluate the level of understanding of issues facing protected groups relevant to the organisation and improve the training and development of staff to ensure that they can better support the patient experience and outcomes across all these groups.

**Objective 2:** The Trust takes steps to ensure that it actively engages with protected groups to identify barriers to accessing its services; develop a patient panel/forum with representatives across protected groups in conjunction with Membership Manager.

**Objective3:** Patients are informed and supported to be involved as they wish about their diagnosis, treatment and care; review areas for improvement on the patient survey results by protected groups to develop action plans.

**Objective 4:** Improved engagement with staff from all protected groups to identify priority issues; recruit, train and develop work plans for the staff forum.

**Objective 5:** Improve support for staff in relation to bullying & harassment Objective 6: Benchmark staff profile against the local population; improve recording of staff within protected groups within data recording systems.

**Helpline for gay farmers in Cheshire**

**One of the main problems the farming community faces is isolation, and this can be exacerbated for gay farmers who may not feel safe to be 'out'. This has led to them being at very high risk of suicide — but a helpline set up in Cheshire has proved to be a lifeline. The project, initiated by Keith Ineson, a Methodist agricultural chaplain, received financial support from Central and Eastern Cheshire PCT, as part of its equalities improvement work.**

****

**Nearly everyone who contacts the helpline thinks they are the only gay farmer in the world — but far from it! Keith explains how the project came about.**

'Clive is a farmer's son, and enjoyed nothing more when he was a youngster than going around the fields with his father at night, checking the stock and the snares. He was out with his father one evening when they found a car in the gateway. A hosepipe was connected from the exhaust to the interior of the car and the engine was running. Clive's father smashed the window and dragged the man out of the car. He was still alive. At the subsequent inquiry it turned out that the man was gay and could not cope with the situation, so was trying to kill himself. Clive's father said that if he had known he would have left him to die.

'Clive grew up in the belief that if his father ever discovered that he was gay and he were in that situation, his father

would leave him to die. Obviously it was very unlikely that this would be the case, though Clive didn't look at it

that way. He lived with this knowledge for over 40 years before he told me the story and admitted that he was gay.

'One of the main problems the farming community faces is isolation. Many farms are now a "one-man band" and the pressure is on to do the work as quickly and efficiently by yourself. So working in the fields, ploughing for example, can mean that you see no-one all day. And although farmers always used to be the mainstay of the local church and village community in general, now, because of exhaustion and lack of time, this is very often no longer the case. This, combined with the difficulties that farming has faced for several years, means that depression is an industrial disease and that farmers are at the top of the occupations facing the risk of suicide.

'The chaplaincy started 11 years ago and I became very used to dealing with cases of depression and people verging on suicide. Over the course of three to four years, I found that I worked with a small number of farmers who were gay. Their sexuality was causing great concern for them — even more so than if they had been in "ordinary" occupations. It seems as though attitudes in rural areas on matters tend to lag behind behind those in urban areas so it isn't always seen to be as acceptable to be gay as it is in urban areas.

'I'd already realised that mental ill health is an industrial disease, but mental health problems for gay people are also a huge cause for concern. I suspected that I was only seeing the tip of the iceberg and so started doing some research. In rural areas, it isn't always seen to be as acceptable to be gay as it is in urban areas.

'Government statistics identified that there are 8,744 farmers and farm workers in Cheshire, which sounds a lot, but if you add on all the family members who work in other jobs but are expected to help out on the farm as well, the figures make sense. Using the generally-accepted statistic that 8.4% of men are gay, that meant that there were about 367 gay farmers in Cheshire. I trawled the internet and other agencies to see if help was available but could find nothing, so I set up a helpline and a one-page website, supported by a three-line advert in Farmers Guardian during Christmas week, which has run ever since.

'In the first six months, 52 people called me: some were one off and some developed into cases where I would speak to them every day for weeks on end. Nearly all the callers have been over 50 and, for them, homosexuality would have been illegal when they were younger. About half of those who got in touch are married since, in the farming world, the pressure to marry and produce an heir is immense.

'Nearly everyone feels that they are the only gay farmer in the world. Far from it! A large percentage have either tried or considered trying suicide. Depression is very common. Statistics among gay men show that at some time or other one in four will attempt suicide. Combine this with the high suicide rate generally among farmers and it is obvious that there is a huge problem. Funding is a huge challenge — it costs about £7,000 a year to run the helpline, and until recently finding extra help seemed almost impossible. Farmers clearly find it easier to confide in other farmers, so helpers need to be farmers or have a farming or at least a rural background. In addition the helper has to be gay and preferably understand depression at first hand. A tall order to say the least!

'After a publicity drive which resulted in both local and national coverage, people wanting to help started to get in touch, so we now have four volunteers to staff the helpline plus someone to arrange the rotas. Calls still come in to my mobile phone, but they are diverted at intervals to other responders. We arranged pay as you go phones for the volunteers, so that they can be kept completely separate from their personal numbers.

'Many of the callers were looking for social contact as they were extremely lonely. I decided to arrange a secret Facebook group and this is proving very popular with a steadily growing membership. Over the past months the helpline has proved its worth time and time again — some callers have said that without it they would have "topped themselves", which speaks for itself as to the need.'

_This is an example of an intervention where the NHS organisation didn't need to contribute much directly, other than to see that financially supporting a local initiative would contribute towards their health objectives for the community. The obvious outcome lay in reduced suicides and (although this is difficult to attribute directly) a reduction in A &E cases resulting from self harm. The next example, from NHS commissioners in the same county, illustrates more of a hands on leading approach._

**Shedding new light on an old problem: the Men in Sheds project**

**Men are one of the hardest groups for healthcare services to reach. A project in Cheshire — based on a similar scheme in Australia — has found a novel way to break through the barrier.**

Many men are reluctant users of traditional health services, such as GPs and even pharmacies. They do not always respond to mainstream health awareness campaigns and a lot of men will only go to their GP when nagged by their wives. So for those who are single or widowed — and especially men who have retired or are unemployed — this is a real problem. With no immediate regular social interaction, no one to discuss niggles or pains, many men will dismiss anything that could be a potential health problem. And as any healthcare professional will attest, early detection is often the route to a faster and lasting cure.

It"s known that a lot of men like being practical and find it far easier to do something with their hands than, say, take part in discussions. Men from traditional working class backgrounds can be especially difficult for healthcare professionals to reach. But they love their sheds, or the idea of having one. Not just because they want to make something but because it"s _their_ space. A crucial place that"s male orientated, strongly masculine and where women tend to leave them alone — or may even encourage them to go so they can have some peace in the house!

And so on the basis that if men won"t come to a health centre but they will go to something that offers them a chance to meet other men and do something with their hands, the project "Men in Sheds" was born in Australia, a notoriously macho culture where men find it hard to express their needs. But they _will_ talk to other men in a shed, across a lathe or workbench. Ask many men to talk about their health with a professional and they'll run a mile or make all sorts of excuses not to attend. A shed however, with lots of opportunities to make things, be practical and mix with other men who are doing the same, has proved far more attractive.

The same kind of need was identified at a men"s health event in Central and Eastern Cheshire. It was decided that the Men in Sheds project, co-ordinated by Age Concern Cheshire, seemed to be an ideal group to access men. And Age Concern was keen to work in partnership with the PCT in Cheshire to enable them to gain the views of men through the project.

The Men in Sheds project began in Hartford, a village near Northwich. But there are now four such sheds across the county. The shed in Hartford is an industrial unit converted to house wood-working machinery. The project runs four days per week, Monday to Thursday from 10 – 4pm and the men can come and go as they please. No prior booking or commitment is required. Nor is it necessary to stay for an entire session. Some men turn up for a few hours once or twice a week. Some attend for one or two days a week. And some go all week. It"s entirely free.

What they all get from it is camaraderie. A place to go. Some are using skills they've used all their lives, at work and at play. Some have never picked up a saw, power tool or operated a lathe. It"s a chance to learn new skills — or just to pop along for a brew and a chat! Men find it far easier to chat around doing something, and with other men, than they do in the formal setting of a surgery.

Stephanie Lawley, the Equality and Diversity lead for Cheshire, Wirral and Warrington Commissioning Support Service, is very enthusiastic about the Men in Sheds project and has witnessed it making a huge difference to the men's health. She commented: 'The men get a great deal out of going to the sheds and we know that social ties and a sense of belonging is vital for health. But there"s another dimension. Men will talk to each other about things they find embarrassing. And this could lead to exploration of a health issue they'd have otherwise tried to ignore. For example, one man in the shed in Crewe said as a throwaway remark that his wife was having a go at him about the number of times he got up in the night for the loo. Across the workbench another man, hearing this, said, "I wouldn't ignore that if I were you. I had that and it turned out to be prostate cancer." The man did indeed have the early stages of prostate cancer. He went to the doctor — urged by his fellow shed men — and received treatment.'

Men face isolation after finishing their working lives, or if they've been unemployed for a long period. Several men at the sheds in Crewe and Hartford report that the project had quite literally saved their life. BA, 53, freely admits he was an alcoholic. The shed at Hartford helped him to stop. 'It gave me something to do, somewhere to go. I'd worked as a French polisher then became a full-time carer for my father who is disabled. I still do the French polishing here and I also work as a volunteer for the project. It gives me a sense of purpose. You really need that if you're to kick the drinking, which I have. I've been free of the drink for three years now.'

At a further end of the age spectrum is EJ, 81, a former craftsman who welcomes the chance to continue making use of his hands while making friendships. 'I've made new friends here and I see them outside the sheds now. We help each other. That"s what the shed is all about.'

Alan, 52, (not his real name) went to the shed to help him recover from depression, not helped by being unemployed. Single, he was isolated and needed somewhere to go. The shed, he says, has been a tremendous help and benefit. 'I worked in IT before so didn't do anything practical with my hands. I retrained after redundancy but became very ill with depression. The shed saved me. It's like a working men's club here. Except we do work! Okay some days we don"t get a lot done. Some guys just come here to paint or have a chat. That's the beauty of it. You can make whatever use of it you like.'

There"s a lot of banter in the sheds too, perhaps of the kind that a more mixed crowd might frown on or find awkward. GB, 69, has Parkinson"s but his shake disappears when he"s planing wood. 'The guys joke and say if they need some glue mixing, they can just stick my shaking hand in it. I don"t mind the banter though. It makes me feel better and I give as good as I get.'

GB used to make model airplanes as a hobby but since his diagnosis can no longer manage the intricate level of work needed. 'There is always something we can do in the shed. And it sure as hell beats watching daytime TV,' he adds.

This sense of getting away, of avoiding being stuck indoors, comes across very strongly from the men using the sheds. And while the main aim is to give them somewhere to go and something to do if they want to, there is a practical application too. They can make bird boxes and garden furniture for local charities or their families.

PH, 77, is a former joiner and carpenter who reckons he"d turn into a cabbage if it weren't for his regular attendance at the Crewe shed. 'I think it"s very good for your mental health to come to a project like this. We joke that it keeps us off the streets, stops us mugging teenagers, but the banter is part of it. It's what you miss when you stop working. I would recommend it to anyone.'

**Cervical screening for disabled women in Salford**

**How NHS Salford set about tackling the issue of lower use of cancer screening amongst different groups of women**

More women in Salford are now able to use cervical screening services thanks to a number of new services developed by NHS Salford.

The organisation found that there were differences in uptake of cervical screening services between the deprived areas and the more affluent parts of Salford. Since the new services have been introduced, uptake has increased by 2% and patients have been giving positive feedback about the new approach.

Particular groups demonstrated significant differences in uptake, including disabled women, those with learning difficulties, the Orthodox Jewish community and non-English speaking women.

The Trust now runs a customised service specialising in the needs of disabled women and those from vulnerable communities. It also offers weekend and evening clinics for working women, a culturally sensitive service in the Jewish community providing creche facilities and leaflets have now been translated for Polish patients.

The new look service for disabled women includes transport to and from the clinic, hoists and specialist beds and volunteers to meet and support patients upon arrival. Staff are also trained in handling patients with unique physical needs, sensory impairment, learning difficulties and those with mental health difficulties.

A working group has been set up to make further improvements to the cervical screening service for disabled women. The group includes healthcare professionals and a patient who had previously experienced problems in accessing the services.

**Mosque Radio Project in Bury**

**Primary care staff can often find it difficult to reach specific communities with messages that apply especially to them. This is an example of engaging with a local community's own networks to get important health information to exactly where it is required.**

South Asian people have particular genetic health risks, such as a higher than average incidence of diabetes. Asian women also often develop breast tumours at an earlier age than the average population and are less likely to be detected in time for early intervention. Unmanaged diabetes can have serious complications, including permanent blindness.

These are difficult health messages to get across by conventional techniques, aimed at the whole population. It's especially problematic where communities aren't traditionally used to seeking help until symptoms are already evident, or there are language or cultural barriers.

In circumstances like this, using a community's own channels can be both cheap and effective. Staff from Bury Primary Care Trust organised a screening campaign for over 50's in the muslim community, checking for the signs of visual damage connected with untreated diabetes. Rather than a conventional approach, the sought the help of the local Mosque Radio service, and direct appeals from mosque leaders, to not only advertise the screening opportunity but also explain and endorse why it was important to people.

The approach resulted in a 70% take-up of screening, compared with just 30% when letters were sent out in the normal way. This is attributed to offering the screening within the familiar environment of local muslim community centres, along with peer encouragement.

This is a good example of the creative, beneficial and cost saving initiatives that can arise when NHS commissioners and public health managers engage with diverse communities and work with them to address specific health inequalities. The amazing thing is that these approaches quite often cost nothing and yet are so much more effective than firing messages indiscriminately at the whole population as though they will all react in the same way.

Such initiatives are not hard; however, they _do_ require managers to understand the diversity of their local population, have evidence of what the health inequalities are in their area, and to develop strong stakeholder relationships where ideas like this can be brainstormed.
**Appendix 2 — Publications**

**Publications produced by the programme**

**A Landscape of the Region**

****

Research, findings and proposed actions for progressing equality and diversity in North West NHS organisations. Published October 2008.

****

**Narrowing the Gaps**

****

Better health outcomes for all. Equality and Diversity Strategy for 2008-2013. Published Spring 2009

**An Equal Partnership**

Captured learning from setting up a health equalities stakeholder engagement model

**Equality Performance Improvement Toolkit**

The comprehensive implementation and requirements for NHS North West's performance measurement system.

****

**Guide to Monitoring for Sexual Orientation**

A detailed step by step guide for public sector organisations to plan and implement effective statistical monitoring which incorporates lesbian, gay and bisexual people. Developed by the Lesbian and Gay foundation for the NHS North West equalities team, with an expert consultative panel from NHS providers, commissioners, other public sector agencies and the LGF.

****

**NHS Equality and Diversity Leadership Competency Framework**

In two parts — the reference and the resource manual — a comprehensive reference work to enable organisations to plan the development, positioning, and board-level support for managers to be competent leaders on equality.

**Timeline of Black and Minority Ethnic Contributions to the NHS since 1948**

A comprehensive educational resource consisting of a mobile exhibition, a video, a booklet and web pages explaining the significant role that Black and Minority ethnic people at all levels had in building and still running the NHS. Following the closure of NHS North West, the exhibition is now managed by 5 Boroughs Partnership NHS Foundation Trust.

**LGB &T History, challenges and successes**

A comprehensive educational resource consisting of a mobile exhibition, a video, a booklet and web pages explaining the relationship between lesbian, gay, bisexual and trans people with medical science and practice, and the many contributions which they have made and are still making to medicine and the NHS. Following the closure of NHS North West, the exhibition is now managed by 5 Boroughs Partnership NHS Foundation Trust.

**A Disability History Timeline**

A comprehensive educational resource consisting of a mobile exhibition, a video, and booklet explaining the struggle for equal rights through the ages, in ways that contextualise disabled peoples' contribution to and relationship with the NHS today. Following the closure of NHS North West, the exhibition is now managed by 5 Boroughs Partnership NHS Foundation Trust.

**Equality and Diversity in the Health Service: An Evidence-Led Culture Change**

A peer reviewed paper in the Journal of Psychological Issues in Organisational Culture. (3) 1, 41-60. The paper covers some of the themes expanded greatly in this book.

**Pride in Practice Workbook**

Written and designed by the Lesbian and Gay Foundation with strategic funding from NHS North West and endorsed by the Chair of the Royal College of GPs. The workbook serves as the central component of the Pride in Practice benchmarking tool for GP Practices.

**Understanding Male Health**

A 70 minute DVD featuring expert speakers, explaining how health inequalities for men arise and can be addressed. The video was designed and produced in conjunction with the Men's Health Forum (MHF) as a tool to aid a national teaching programme. The development project covered planning, filming and editing the film and duplicating an initial stock of DVDs for the MHF to use and distribute.

**Monitoring and Promoting Trans Health Across the North West**

Detailed report on a preliminary study aimed at providing an evidence base for future work, improving the all round experience of trans people accessing health services.
**Appendix 3 — Online Resources**

**Online resources produced by the programme**

**The Health Equality Library and Portal (HELP)**

****

Described in detail in Chapter 8, this online database grew to contain over 1,700 catalogued references to evidential matter on all topics relating to each of the protected characteristics. It also contained a separate catalogue of links to over 300 relevant web sites; an events calendar; up-to-date news; a blog; and a discussion board. HELP also supported sub-sites containing online versions of the BME Timeline; the LGBT Timeline and the guide to sexual orientation monitoring (see appendix 2)

<http://www.help.northwest.nhs.uk>

**The EPIT Dashboard**

The EPIT dashboard provided a means for anyone to see the verified or unverified performance measures by every NHS organisation in the North West. The public could view the results for an individual organisation or comparatively across all organisations for a given performance measure. NHS Trusts could also log in to enter their self-assessed performance scores and upload the evidence to support those assessments.

<http://www.epit.northwest.nhs.uk>

**A Fair Route to Revalidation**

This site was created to provide comprehensive guidance to help responsible officers and HR directors ensure the new process of 'revalidation' for doctors was not operated in ways that might lead to direct or indirect discrimination. The site is still online at:

<http://fairroutetorevalidation.nhs.uk/>

