This research looks at how regulators can tackle inequalities experienced by those using services.
We commissioned SQW, supported by the King’s Fund Library Service and Dr Tammy Boyce, to carry out this research, write the summary below, and the full report.
Purpose of this research
One of the Care Quality Commission (CQC)’s strategic aims is to tackle inequalities in health and care. CQC have invested in an ambitious research programme to support its strategy.
CQC commissioned SQW to deliver a rapid evidence review, supported by the King’s Fund Library Service and Dr Tammy Boyce. The review explored how regulators can tackle inequalities experienced by those using services. It identified lessons from other sectors and countries.
The study reviewed 46 documents. These documents were identified through a literature search and a call for evidence. A total of 12 interviews took place to add to the findings from the review.
Findings
Understanding inequalities
Legislation sets out the role of regulators in tackling inequalities experienced by service users. In the UK, this includes the Equality Act 2010. Legislation acts as a driver to regulators’ actions. Other drivers include:
- The scope of regulators (e.g. the sectors they operate in)
- How regulators respond to the legislation
- Wider expectations of what the role of a regulator should be.
The legislation means that regulators largely understand inequalities in a similar way. Some regulators extend their definition of inequalities to encompass socio-economic disadvantage.
Health inequalities are more broadly described. Definitions identify a wider range of factors which lead to inequality.
But, there is some variation in how regulators understand inequalities. Some regulators make explicit links to equalities in their strategies. Some set out specific equality objectives.
Approaches to tackling inequalities
Progress in embedding approaches to tackling inequalities experienced by service users is variable. Some regulators are further ahead than others. Multiple approaches are often delivered at once. They are rarely delivered as a stand-alone activity.
Common approaches fall into nine core themes:
- Working with partners. Regulators collaborate with government departments, third sector organisations and providers. They also work with other regulators to develop standards or guidance.
- Working with service users. Regulators work with service users to co-produce guidelines. They also seek advice from service users by involving them in governance. Regulators deliver formal consultation and other engagement activities.
- Supporting accessibility. Regulators develop and issue guidance to providers. This supports them to make accessibility improvements. Regulators implement approaches in their own organisations to improve access and communications.
- Effective use of data and evidence. Regulators use the wider evidence base to inform their activities and develop guidance. They set expectations and offer support to providers. This helps providers undertake effective monitoring.
- Contributing to the evidence base. Regulators conduct research into key equality issues and share learning. They analyse and share meaningful data with others in their sector.
- Allocating responsibility for equality within regulators. Regulators assign accountability and responsibility to their staff.
- Using regulatory mechanisms. Regulators build mechanisms focused on tackling inequality into their regulatory frameworks. They also provide frameworks, standards and guidelines for providers.
- Assessing the impact of activity on equalities. When undertaking their own equality impact assessments, regulators make sure they use the right skills. They make sure those undertaking assessments have the capacity to do so. They set expectations for providers to complete equality impact assessments.
- Assessing specific inequalities. Regulators target key groups to make sure they use their resources most effectively. It also means learning can be identified, transferred and shared.
Enablers and challenges to tackling inequalities
Regulators face enablers and challenges in tackling inequalities experienced by service users. These are set out below, categorised into four themes.
It is important to note that regulators are one step removed from service users. This is a challenge that cuts across all four themes. They have less direct influence on inequalities than providers.
Regulator leadership, culture and workforce knowledge
Strong leadership is a key enabler. Leaders need to prioritise inequalities in organisational strategies. Priorities should be well communicated to staff. This fosters an organisational culture focused on tackling inequalities.
A key challenge is a lack of consistent understanding amongst staff about inequalities. Staff need to understand their responsibilities in relation to tackling inequalities.
Learning and development activity is a key enabler. It ensures staff have the knowledge and awareness to monitor practice on inequalities. It also means they understand their role in tackling inequalities.
Collaboration and engagement
Engaging service users is an enabler as it fosters trust and legitimacy. Renumerating service users enables engagement, but any impact on statutory benefits should be made clear.
Collaboration between regulators and providers is important. Transparency is a key factor in fostering collaborative relationships. Open communication and clear expectations build trust, foster mutual understanding and promote shared goals.
A shared and consistent vision across the system is an enabler. This was identified as particularly important where regulators were spread across a large number of providers.
Capacity and resourcing
Regulators and providers face challenges due to limited capacity and resources. Regulator progress can be hampered by resource constraints or priority changes. This means attention can be diverted to other areas.
Providers with COVID-19 backlog and staffing issues face challenges in tackling inequalities. The extra workload and stress associated with inspections can further strain resources. Regulators mitigate this by reducing administrative burden and focusing on reflective learning.
Quality and availability of data
Gaps in data make it challenging to identify differences in service provision. This includes data on protected characteristics.
Inequalities are complex. This makes it difficult to measure and attribute progress made by providers. Addressing inequalities can take time. Improved awareness can appear to worsen performance. This is because awareness can surface previously hidden or unknown inequalities.
Considerations for regulators
The findings from the review are likely to be useful for regulators seeking to tackle inequalities experienced by service users. This includes CQC. The considerations are set out below. They are not specifically aimed at CQC.
Implementation
- Approaches used to tackle inequalities are holistic. Regulators could consider how multiple interventions and approaches can be combined and embedded.
- Regulators could consider how to embed sustainable approaches to tackling inequalities. This includes amongst different service areas or user groups.
- Regulators could consider focusing on equality in their existing regulatory frameworks.
- It is important that regulators assign accountability for tackling inequalities within their workforce.
- It is important for regulators to communicate their vision for tackling inequalities. This includes to their own staff and the organisations they regulate.
- Regulators need to remain realistic about how far they can affect inequalities. They are one (or more) steps removed from service users.
Engagement
- It is important for regulators to continue to share learning with other regulators.
- It is important that regulators work collaboratively to address inequalities. This includes with partners within the systems in which they work.
- Regulators need to demonstrate the characteristics they seek from providers in tackling inequalities.
- Dual ‘encouragement and enforcement’ functions can support engagement with providers. Regulators could consider how this can be most effective.
- It is important that regulators continue to assess the transparency of their communications. This will ensure clear expectations are set with a view to building trust and confidence.
- Regulators may wish to assess the extent to which providers use service user voices. This includes to inform continuous service improvement.
- Regulators need to reflect service user voices in their approaches to addressing inequalities.
- It is important that regulators ensure processes and communications are accessible. This includes within their own organisations and their providers.
Data, evidence and impact
- Regulators may wish to test and implement approaches to measure their impact on equalities.
- It is important that regulators contribute to the evidence base around inequalities. This will likely support the providers they work with.
- It is important that regulators identify the trajectory that a provider is on in tackling inequalities. The reasons for any changing performance need to be fully understood.
- Tackling inequalities experienced by service users takes time. Regulators could identify expected interim outcomes to ensure realistic expectations.