abcdefghijklm abcde abc a Health Department NHS HDL(2002)1 4th January 2002 Dear Colleague

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1 NHS HDL(2002)1 abcdefghijklm Health Department 4th January 2002 Dear Colleague FAIR FOR ALL: WORKING TOGETHER TOWARDS CULTURALLY-COMPETENT SERVICES Summary 1. This letter provides draft guidance which sets out the responsibilities placed on NHS organisations by legislation, by policy, and by the results of a recent Stocktake exercise undertaken on behalf of the Scottish Executive Health Department. A copy of the summary report of this stocktake is enclosed with this letter and the full report is available at 2. The letter also provides a short background to these responsibilities, defines exactly what they are, and offers guidance on how they will be performance managed. It also provides information on the resources that will be available to help organisations meet these responsibilities. 3. The Race Relations (Amendment) Act 2000 develops the responsibilities previously laid down by the Race Relations Act of 1976 with regard to the elimination of race discrimination. These responsibilities include race discrimination in the fields of employment, facilities and services, training, education, housing, and public appointments made by Ministers and Government Departments. The 2000 Act places a general duty of race equality on all public sector bodies, including a duty to promote race equality. 4. The Scottish Executive has made equal opportunities for all a key element of all its work, as demonstrated by its Equality Strategy ( Addresses For action Chief Executives, NHS Boards Chief Exe cutives, NHS Trusts Chief Executives, Special Health Boards For information Chairs, NHS Boards Chairs, NHS Trusts Chairs, Special Health Boards Medical Directors, NHS Trusts Directors of Nursing, NHS Trusts Directors of Human Resources, NHS Trusts Chief Executives, Local Authorities Presidents, Royal Colleges Commission for Racial Equality Local Ethnic Minority Groups Local Health Councils and SAHC Enquiries to: Miss Laura Ross Health Planning and Quality Division Room 3N.04 St Andrew s House Regent Road EDINBURGH EH1 3DG Tel: Fax: Laura.Ross@scotland.gsi.gov.uk 5. In addition, the Health Department has underlined its commitment to this agenda by encouraging Chief Executives to follow the example of Mr Trevor Jones (Chief Executive of NHSScotland) in signing the Commission for Racial Equality s Leadership Challenge. abcde abc a

2 6. The Health Department will also be funding an Ethnic Minorities Resource Centre to provide support to the service. This Centre will operate from within the Public Health Institute Scotland. Action 7. Chief Executives are asked to circulate the attached guidance to executive colleagues. 8. The guidance will be discussed at a conference on ethnic minority health and NHSScotland, to be held on 22 nd January Chief Executives should attend this conference and ensure that appropriate members of their executive teams, and representatives of their local minority ethnic communities, also attend. 9. It is anticipated that local progress in adopting the final guidelines will be assessed by the Ethnic Minority Resource Centre after 31 st March 2003, as part of the Performance Assessment Framework. Yours sincerely TREVOR JONES Chief Executive Dr EM ARMSTRONG Chief Medical Officer ANNE JARVIE Chief Nursing Officer MARK BUTLER Director of Human Resources abcde abc a

3 How to use this guidance What follows is the main body of this guidance. This guidance has been written in such a way as to allow those charged with implementing it to treat each section independently. Immediately following this page is a short note setting out the background to the guidance. Elements 1 5 deal with specific deliverables that NHS Organisations are charged with under the Performance Assessment Framework. These will be performance managed by the Ethnic Minority Resource Centre in partnership with the Scottish Executive Health Department. These elements are subdivided into headings, listed below. Sections 6-8 signpost further background that may be useful to those charged with implementing guidance, or signpost further support that may be forthcoming. Deliverables Element 1 Energising the Organisation Statement of Organisational Intent; Executive Leadership; Action Plan Element 2 Demographics Surveying the local population; Needs assessment; commitment to research Element 3 Access and Service Delivery Access Audit; Personal Care; Food; Spiritual Care; Translation and Interpretation; Advocacy; Gender Issues Element 4 Human Resources Equal Opportunities; Improvement policies Element 5 Community Development Collaborative mechanisms; Developing the community 1

4 FAIR FOR ALL: WORKING TOWARDS CULTURALLY COMPETENT SERVICES Introduction 1. Our National Health: A plan for action, a plan for change laid down NHSScotland s commitment to ensure that ' NHS staff are professionally and culturally equipped to meet the distinctive needs of people and family groups from ethnic minority communities. This specifically linked in with the wider Scottish Executive drive for equal opportunities, as laid down by the Executive s Equality Strategy. 2. NHS Scotland has more recently supported a comprehensive stocktake of how the organisation is performing in this area. Chief Executives were provided with copies of the full report; summaries have been distributed to the wider community. 3. This guidance is provided to outline the responsibilities to be placed upon NHS Organisations in delivering a culturally competent service. The specific measurables laid out in appendix A are designed to reflect five major strands of policy; demographic profile; access and service delivery; community development; human resources; energising the organisation. The main body of the letter provides contextual information. 4. Achieving these deliverables by March 31 st 2003 will be easier for some organisations than for others. Organisations will be held accountable on the basis of their relative improvement through the period. 5. Of greatest importance to the Health Department will be evidence of a culture change within NHS Scotland that results in awareness of and responsiveness to the needs of minority ethnic communities. 6. It should be noted that improving the health of ethnic minority health service users extends to improving the health of all communities. Competence in this area indicates capacity to be sensitive to distinctive requirements of all groups. 7. The requirements laid out in this letter extend to all Trusts and Health Boards, including the Scottish Ambulance Service and the State Hospitals Board. It is also relevant to the Common Services Agency. For ease of understanding these are referred to as NHS Organisations throughout this letter. Definitions of major strands of policy 8. A culturally competent service is defined as a service which shows respect for the diverse beliefs and consequent needs of each and every individual coming into contact with the service. This includes, but is not limited to, making provision for religious and cultural beliefs such as worship, diet, and hygiene requirements, catering for communication and language diversity, and involving users in service development. 2

5 9. The heading demographic profile relates to the level of demographic intelligence held by an NHS Organisation concerning their catchment population. This includes geographic concentration and relative socioeconomic positioning. NHS Organisations must have adequate levels of intelligence to facilitate effective planning of services. 10. Access and service delivery relates to the level to which NHS Organisations are active in acknowledging and overcoming barriers to access by ethnic minority populations. 11. Community Development relates to the engagement of NHS Organisations in consultation, dialogue and support for minority ethnic communities. 12. Human resources covers the extent to which NHS Organisations are integrated into HR strategies relating to the recruitment, development and retention of staff. 13. Energising the organisation relates to the extent an Organisation deals with ethnic minority health issues positively and actively. Role of Trust Management Structure 14. Responsibility for delivering the ethnic minority health agenda rests with Chief Executives of organisations. However, it is the view of the Health Department that the issues herein cut across all areas of NHS Scotland. Hence, Medical Directors, Directors of Operations, Human Resources and Operations will all be expected to take roles in delivering the agenda. Resources 15. The Department acknowledges that this is a challenging task. To this end, it intends to fund, under the auspices of the Public Health Institute Scotland, an Ethnic Minority Resource Centre. This centre will be expected to be active by March 2002 to provide support for NHS organisations in meeting the expectations laid down and making positive changes to the culture of these organisations. A paper detailing the work of the centre and its role in performance managing this process is forthcoming. NHSScotland Ethnicity awards 16. It is suggested that the Centre establish an annual Ethnicity awards ceremony, to recognise publicly-nominated outstanding contributions to the ethnic minority health agenda by NHS staff and organisations. Reporting mechanisms 17. The deliverables included in the appendices will be appraised as part of normal organisational structures through the Performance Assessment Framework. 3

6 Element 1 - Energising the Organisation To what extent has the organisation come to terms with the challenge of ethnic minority health? Notes 1. NHSScotland Organisations are expected to ensure that they have achieved the following deliverables in Year One of their Fair for All programmes. 2. Organisations achieving these deliverables will be expected to move on to tackling deliverables from years two and three, within this strand, on their own initiative. 3. Achievement will be noted during the PAF round. 4. Advice and support on these issues will be available through the Ethnic Minority Resource Centre. Statement of Organisational Intent Each organisation will be expected to draft a policy statement covering how it intends to deal with all aspects of providing a culturally competent service. In particular, each statement will be expected to include: The organisation s statement on ensuring that its services will be provided appropriate to need to all elements of the community it serves, and will be of a consistently excellent standard; The organisational position on racism, including the handling of racist behaviour; The organisation s commitment to consistently improving access to its services; The organisation s commitment to gathering an appropriate evidence base for all future decisions in this area. The organisation s commitment to learning from and sharing of evidencebased good practice in this area. The statement should also cover all other aspects of this document. The statement should outline the organisational commitment to mainstreaming all ethnic minority issues into decision-making and reporting processes. The statement should be consulted upon with local communities and then published publicly. 4

7 The statement should be disseminated throughout the organisation, at induction and at appropriate training points for all staff. Executive Leadership Each organisation will be expected to appoint a senior member of the Executive team to take responsibility within the organisation for delivering a culturally competent service. This individual should hold a position allowing them to remain abreast of all major potential problem areas. Each organisation should assign the task of co-ordinating this initiative to a senior operational manager to ensure effective implementation. This manager should liase directly with the named executive lead. Each named executive lead should encourage senior colleagues to sign up to the Commission for Racial Equality Leadership Challenge. Action Plan Each organisation must prepare a detailed, dated and costed action plan outlining how it intends to continue its progress to cultural competence. This plan must include actions in each of the five elements of the Fair for All framework. The plan should draw upon the menu of further choices within this HDL. The plan must retain as its guiding principle the need to make clear the organisation s commitment to ethnic minority health. The plan must be developed jointly with the Organisation s community representatives and ethnic minority health forum and submitted to the Scottish Executive Health Department by 31 st March

8 Element 2 Demographic profile To what extent does the organisation have a clear understanding of minority ethnic make-up of the local population? Notes 1. NHSScotland Organisations are expected to ensure that they have achieved the following deliverables in Year One of their Fair for All programmes. 2. Organisations achieving these deliverables will be expected to move on to tackling deliverables from years two and three, within this strand, on their own initiative. 3. Achievement will be noted during the PAF round. 4. Advice and support on these issues will be available through the Ethnic Minority Resource Centre. Surveying the local population Each organisation must commission a targeted survey designed to ascertain the demographic make-up of their catchment area. Note: This deliverable will be assessed by Health Board area, but all organisations are expected to provide direction and resources for the project. This survey should pay particular attention to ascertaining the ethnic make-up of the area, as well as gathering data on age and gender profiles. Needs Assessment Each organisation should carry out and make available publicly a detailed Needs Assessment based on the ethnic minority profile analysis. This analysis must be consulted upon with local service users groups to more accurately ascertain where the blocks on service access are within the system. Commitment to research Upon completing the initial demographic survey and needs assessment, each organisation must begin further research on more detailed levels, regarding incidence of disease, service utilisation, and other topics as covered in further choices. The organisation must ensure that it is working towards more effective systems for gathering information on local ethnic minority communities on an ongoing basis. 6

9 These data should include data related to service use and utilisation, on facets such as religion, personal care needs, translation needs, etc, as set out in Section 3 Access and Service Delivery. 7

10 Element 3 Access and Service Delivery To what extent has the organisation taken account of access issues and concerns that may have arisen for ethnic minority communities? Notes 1. NHSScotland Organisations are expected to ensure that they have achieved the following deliverables in Year One of their Fair for All programmes. 2. Organisations achieving these deliverables will be expected to move on to tackling deliverables from years two and three, within this strand, on their own initiative. 3. Achievement will be noted during the PAF round. 4. Advice and support on these issues will be available through the Ethnic Minority Resource Centre. Access Audit Each organisation will be expected to utilise the results of its needs assessment (see Section 2 Demographics) to measure how effectively its service provision meets the needs of ethnic minority communities. In particular, each review will be expected to demonstrate: How the organisation s catering, interpretation, personal care, spiritual and religious, handling and mobility, and advocacy services respond to all elements of the community. What the organisation has in terms of these services What the organisation lacks in terms of these service NB It is assumed that each of the following deliverables will be the subject of appropriate training, for which, Section 4 Human Resources. Personal Care Each organisation will be expected to make provision for patients with particular spiritual or religious needs to perform appropriate ablutions (if the patient is in an inpatient facility). If this expectation is not practically achievable, organisations will be expected to make all reasonable efforts to provide appropriate facilities. Organisations will be expected to ensure that this provision is appropriately administered. 8

11 Food Each organisation will be expected to make appropriate provision for the appropriate provision of food which meets the religious and cultural needs of all services users. Each organisation to ensure that where cultural or religious needs dictate a diet pattern that is not standard, appropriate food is provided. Each organisation to ensure that food preparation in these cases is in line with appropriate religious or spiritual beliefs. Spiritual Care NB This section should be considered in conjunction with forthcoming NHS guidance on spiritual care within the NHS Each organisation to ensure that its services, where practicable, are sensitive to the religious and spiritual needs of users. Each organisation to ensure that the services it provides includes adequate provision of facilities for religious worship. Each organisation to ensure that access to religious counselling is appropriate to the needs of users. Translation and Interpretation Each organisation to ensure that it has examined the need for translation and interpretation services within itself. Each organisation to adopt policy on the provision of translation and interpreting services, stating that access to appropriate translation and interpretation services will be available. Further: Each organisation to ensure that, where need is considered insufficient to warrant internal provision of translation services, these services can be provided through agreements with local partner organisations. It is acknowledged that this provision is likely to be outwith the resource of individual organisations but will most likely be more practicable if considered in conjunction with local public sector organisations. In cases of geographic remoteness, it may be necessary for organisations to investigate other ways of providing this service. 9

12 Each organisation, in consultation with local communities, to make policy on provision of patient information in languages other than English. This policy to include: The types of information to be provided The languages in which these are to be provided To whom (carers, families, etc) the information is to be provided Each organisation, in conjunction with the above, to ensure that it investigates information sources, formats, providers, that may already be available nationally. Advocacy Each organisation to investigate, in conjunction with local communities, the possibility of providing and supporting advocacy services. Each organisation should take cognisance of forthcoming NHS guidance on this topic, which states that access to advocacy services must be provided in each and every organisation. Gender issues Each organisation must, where practical, make efforts to ensure that patients are given the choice of gender of the health professional, especially in relation to examination of the reproductive tract. 10

13 Element 4 Human Resources To what extent has the organisation integrated ethnic minority issues into its Human Resources strategies? Notes 1. NHSScotland Organisations are expected to ensure that they have achieved the following deliverables in Year One of their Fair for All programmes. 2. Organisations achieving these deliverables will be expected to move on to tackling deliverables from years two and three, within this strand, on their own initiative. 3. Achievement will be noted during the PAF round. 4. Advice and support on these issues will be available through the Ethnic Minority Resource Centre. Equal Opportunities Each organisation must ensure that it has adopted an equal opportunities policy in line with guidance issued by the Scottish Partnership Forum on the subject (January 2001). Each organisation must be able to demonstrate the effective implementation of the equal opportunities policy. Each organisation must have mechanisms for disseminating within the organisation the content of the equal opportunities policy. Each organisation should monitor the level of ethnic minority staffing within the organisation, and should be able to ascertain whether this is in line with the ethnic minority population within the catchment area. Each organisation must ensure that its training and development processes are open and available to all staff, and that all staff are appropriately accessing these services. Improvement Policies Each organisation should take steps to check that its recruitment processes reach ethnic minority communities. Each organisation must ensure that all staff receive equality training, and are aware of local issues regarding access to health services by local populations. 11

14 Element 5 Community Development The degree to which the organisation is outward facing and concerned with involving local ethnic minority communities and organisations in promoting their own health Notes 1. NHSScotland Organisations are expected to ensure that they have achieved the following deliverables in Year One of their Fair for All programmes. 2. Organisations achieving these deliverables will be expected to move on to tackling deliverables from years two and three, within this strand, on their own initiative. 3. Achievement will be noted during the PAF round. 4. Advice and support on these issues will be available through the Ethnic Minority Resource Centre. Consultative mechanisms Each organisation must establish a consultative forum, representative of its local ethnic minority community. This forum must be jointly chaired by the named member of the executive team and a senior member of the local ethnic minority community. This forum must be used to consult the local ethnic minority community on service delivery issues. This forum must draw sufficient membership from within the NHS Organisation it is attached to and local external agencies and groups to ensure that it can fairly be described as multidisciplinary. This forum should be consulted on all appropriate service development issues. This forum should be considered to be an authoritative voice on local service provision. Developing the community Each organisation should maintain a directory of key local agencies and individuals. Each organisation should explore the possibilities inherent in developing locallyprovided services involving advocacy for patients and relatives. Each organisation must ensure that it provides support for local carers. 12

15 Section 6 Menu of further choices for years 2 and 3 It is intended that during this period of consultation NHS Organisations, the Commission for Racial Equality, Community Groups and other stakeholders be invited to comment on deliverables that would be suitable for inclusion in further years of the Fair for All programme. It should also be clearly remembered that the job of pursuing further action and developing and enabling good practice within organisations is for a partnership between individual organisations, their local communities and the Ethnic Minority Resource Centre. Broadly, however, SEHD would expect to see organisations monitoring their efforts and making adjustments to their programmes in line with community wishes. It may be, also, that specific issues such as ensuring that each NHS Organisation monitors the commitment to race equality of its partners and suppliers, will be added to the package carried by each Organisation. 13

16 Section 7 - The Health Policy background Introduction This section is intended to provide a short overview of: i) The policy context within NHSScotland ii) Efforts regarding ethnic minority health in other parts of the UK. In doing so, it is hoped that NHSScotland Organisations will have a better understanding of the policy rationale behind this HDL. The NHSScotland policy context The then-minister s Introduction to Our National Health: a plan for action, a plan for change opens with: We must build an NHS which listens better to patients and responds more effectively to their needs. Elsewhere in this document, it has been noted that Our National Health also promised that NHSScotland staff would be committed to becoming Professionally and culturally equipped to meet the distinctive needs of people and family groups from ethnic minority communities. These commitments, taken together, signify NHSScotland s acknowledgement that it has failed not only to provide a culturally competent service in the past, but that it has been unable, despite its best efforts, to fully tackle the challenge of treating each individual according to their need. NHSScotland, however, has redoubled its effort to provide a patient-centred service. A patient-centred service is defined as a service that ensures that the service exists for the patient, not vice versa. Each individual is indeed treated according to their needs and wishes, as far as is practically possible. In terms of all patients, this means ensuring that access to appropriate services is available, that appropriate information is available, that dietary and other personal requirements are serviced, and that the service responds to the patient. The deliverables noted in this document are thus in line with NHSScotland s aim of producing a patient-centred service. These deliverables also include Human Resource issues. Good HR practice leads to an effective organisation, which in turn will be better placed to deliver a patientcentred service. 14

17 Conclusions The Fair for All programme must be seen as an integral part of a new patient-centred approach to the provision of Scotland s healthcare services. Organisations may choose to see the Fair for All approach as a first step to providing more responsive care to all users. The approach taken by SEHD in preparing the Fair for All programme has been to ascertain readiness through the stocktake process, and then use this information to prescribe actions that are felt to be reasonable requests to make of organisations pursuing highly standards of healthcare. Yet it should also be remembered that SEHD wishes to enable organisations to take forward their own work in this important area. Hence, the Ethnic Minority Resource Centre, which will provide the enabling support and aid organisations in mainstreaming ethnic minority health, is an important resource and should be used as such. 15

18 Section 8 - Ethnic Minorities and Health the Legal Framework This section will provide an overview of the legal framework that all NHS Organisations must conform to. This framework is likely to be altered considerably by the Race Relations (Amendment) Act 2001, the implementation orders for which are currently being drafted by the Development Department. These orders will be supplemented by Commission for Racial Equality Codes of Practice, which all NHS Organisations will be expected to adhere to. With this situation in mind, it was therefore considered imprudent to essay a section on the Legal Framework, other than a few key points. NHS Organisations should remember that they are subject to all civil and criminal legislation as regards race relations and ethnic minorities. This not applies to the Race Relations Act 1976, the keystone of race legislation, but also to the 1998 Scotland Act. Put simply, it is illegal, and wrong, to discriminate against any individual on the basis of their skin colour, belief, or ethnic origin. The Race Relations (Amendment) Act 2001 places a general duty upon all bodies to ensure that they promote equality within themselves. A full description of the legal position will be drawn up in collaboration with the Commission for Racial Equality and published with the final HDL. 16