Provider collaboration reviews: equality impact assessment

Aims, objectives and methodologies

This EIA draws on aims, objectives and methodologies outlined in the following, to consider work to date and proposed next PCR U&EC module;

• PCR Information from CQC website
• PCR press release 08.07.20
• PCR letter to providers 16.07.20
• PCR methodology documents
• PCR next phase COVID-19 PCR paper
• CQC Covid-19 Regulatory Response Equality Impact Assessment v.2
• CQC Urgent and Emergency Care Statement 14.08.20
• NHSEI letter to the system - four actions to support BAME women June 2020
• Sir Simon Stevens Reset Letter to the system, 31 July 2020.

Recommended consultation on this EIA / PCR next modules methodology development.

Consider the following engagement options for co-production of Key Lines of Enquiry (KLOEs) as well as local intelligence gathering during PCRs:

• Existing CQC channels e.g. Citizen panel and voluntary sector organisations we have continuing relationships with, to hear from people who use the services which will be reviewed by the PCRs, prioritising those most vulnerable to poor care.
• CQC Closed cultures internal reference group
• CQC Equality networks
• CQC Urgent & Emergency Care or Ambulance working core service working group
• Other CQC colleagues with specialist knowledge as required e.g. closed cultures, mental health, learning disability / autism.
• Other external stakeholders who represent people who use services.

Cross-cutting equality issues

Impact:

Cross-cutting equality issues for PCR work:

People’s voice

The initial findings from the phase 1 reviews indicate that there have been limited capacity to gather the views of people who use services due to the work being undertaken remotely and within tight timescales (PCRs Next Phase paper).

Sir Simon Stevens Reset Letter to the System, 31 July 2020) highlights importance of better analysis and community engagement with people at highest risk of COVID.

There are acknowledged risks to the PCR programme from the speed of implementation – it is important to allocate sufficient resources to enable meaningful co-production/engagement and avoid epistemic injustice.

Focus on outcomes

Initial observations of phase 1 interviews indicate that there was not always a clear focus on older people and in different settings, beyond universal system responses to Covid-19. Though we recognise that the universal response to COVID 19 will have an impact on people over 65, the specific needs of older people and the system response to these could sometimes have been drawn out more.

Phase 1 PCRs have gathered information on system response, but this has not always been clearly linked to outcomes for the older adults (over 65) age group being considered. PCRs would be strengthened by a clearer focus on outcomes for people (as a result of the way systems are working) in the data, KLOEs and interviews.

Phase 1 PCRs have asked providers what went well, but limited data was collected on challenges encountered or on how providers across a system have tackled inequalities or potential barriers during the pandemic.

Phase 1 PCR intelligence packs include information on Covid-19 mortality and information on local demographics, but the data does not clearly highlight inequalities in terms of outcome. There also might need to be more support to enable interviewers to make better use of the data during PCR interviews.

Intersectionality and people living in different settings

For example, the proportion of older people in poverty, living with a disability or from Black and ethnic minority people. PCR wave one included some consideration of people digitally excluded. The consideration of equality issues in area data, will also highlight locally-relevant underserved groups for engagement in future modules e.g. disabled people’s access to urgent and emergency care, urgent maternity and neo-natal support for Black and ethnic minority women using urgent and emergency care or LGBT people seeking urgent health support connected with homophobic violence and abuse which has increased during lockdown.

Initial observations of phase 1 interviews indicate that there was not always a clear focus on older people living in different settings, for example people who live in their own homes or supported living settings as well as people living in care homes.

Plan for the future

PCR methodology provides an opportunity to test future methodology and therefore an opportunity to embed equality and human rights into methodology and potentially test methods relating to identifying and preventing closed cultures, if intended to shape next steps in our future direction.

Methodology

PCR first wave: (see separate table, below).

No specific equality or human rights questions in methodology, although possible positive impact if specific examples are captured.

Risk of negative impact if PCRS take a ‘service resilience’ focus without specifically considering issues of mental health, equality and human rights.

Opportunity to advance equality by building-in specific questions about EDHR into the PCR methodology.

Inspection teams

PCR first wave: as above, it is important for PCR teams to have the data, skills and relevant knowledge to identify and explore equality issues. Currently, PCR teams are drawn from inspection teams and do not include specialist staff and do not receive any specific briefing on equality and human rights issues for this work.

No specific equality impact on CQC staff identified; PCRs are carried out remotely using existing CQC technology, therefore no specific Covid risk from on-site visits. The approach may enable a greater range of staff to potentially become involved. There may be an opportunity for positive action to encourage BAME and disabled staff to join PCR teams and ensure secondment opportunities are fairly decided.

Mitigation:

Mitigations for all future PCR work:

(1) Strengthen people’s voice in the PCR process by engaging directly with people who use services and / or organisations who represent them.

Prioritise hearing from those people most vulnerable to poor care in each module of the PCRs and use this to support co-production and provide local intelligence e.g. to inform development of intelligence data packs and key lines of enquiry for interviews.

Consider involving CQC Citizenlab and experts by experience, include any recent engagement or relevant patient views survey / research in PCR intelligence packs.

(2) Ensure PCR inspection teams have the data, skills and relevant knowledge to identify and explore equality outcomes for people.

Ensure intersectional and locally-relevant data patterns on equality outcomes are used to inform PCRs.

Greater differentiation needed in future modules e.g. looking at outcomes for for Black and ethnic minority people who use mental health services and pathways for older and younger people / children.

Consider how to direct PCR teams to focus on the specific groups concerned, beyond universal covid-19 responses and to make better use of the data during PCR interviews.

Consider how to tailor KLOE questions to focus on the impact on outcomes for people, of system working.

Ensure PCR teams include people with the relevant skills e.g. MHAR or Learning Disability specialists may be relevant.

Ensure teams are briefed to effectively consider specific equality issues for each module.

Consider whether there are health inequalities in relation to other protected characteristics e.g. religion/belief or socio-economic factors which have not yet been considered, which would be relevant to include in the health inequalities PCR module.

Specific equality issues by protected characteristics

Age

Impact: Older people continue to be disproportionately affected by the pandemic (EIA Covid-19).

PCR first wave:

Likely positive impact due to: PCR focus on system response for older people (over-65s) during the pandemic and older people continue to be disproportionately affected (Covid-19 EIA).

Opportunity to promote equality as digital access/ exclusion considered within the Key Lines of Enquiry (KLOEs).

Opportunity to advance equality by highlighting specific issues & including good practice / case studies in report.

Limited engagement with organisations who represent people (Healthwatch only) means disabled people’s voices and experiences could be more strongly represented.

PCR discussions about system responses have not always been specifically focussed on work to support older people.

Little differentiation in PCR wave 1 within the over-65 group in terms of other protected characteristics or between older people living in different settings e.g. own home vs. in a care home; means specific needs may not be not highlighted.

PCR Urgent & Emergency Care module: Potential negative impact if experiences of children and young people not specifically considered.

Mitigation: PCR wave 1: Include specific issues and good practice example in report.

PCR next phase modules:

Review risk to disabled and older people’s human rights arising from changed pathways to access Urgent and Emergency Care (CQC Statement 14 Aug 20 and PCR wave 1).

Strengthen people’s voice in the PCR process by engaging directly with older people who use services and / or organisations who represent them e.g. consider involving CQC experts by experience, include any recent engagement or relevant patient views survey / research in PCR intelligence packs.

Ensure PCR inspection teams have the data, skills and relevant knowledge to identify and explore equality issues. Consider different experiences of older / younger people and children and people living in different settings.

Carers/people with caring responsibilities

Impact: Carers continue to be disproportionately affected by the pandemic (EIA Covid-19). Older people are more likely to be carers.

PCR wave 1:

Likely overall positive impact as PCRs focus on system response for older people (over-65s) who are more likely to be carers (Covid-19 EIA).

Opportunity to advance equality by highlighting specific issues & including good practice / case studies in report.

No specific questions, data or engagement in methodology.

See age, above and disability, below.

Mitigation: PCR wave 1: as above.

PCRs next phase modules: Ensure carers’ voices are heard and impact on this research, by engaging directly with people who use services and / or organisations who represent them.

Disability

Impact: Disabled people continue to be disproportionately affected by the pandemic (EIA Covid-19).

PCR wave 1:

Likely overall positive impact as PCRs focus on system response for older people (over-65s) during the pandemic and older people more likely to be disabled or have long-term health conditions (Covid-19 EIA).

Opportunity to advance equality by highlighting specific issues & including good practice / case studies in report.

Limited engagement with organisations who represent people (Healthwatch only) to date, means disabled people’s voices and experiences could be more strongly represented.

PCR discussions about Covid-19 response have not always been sufficiently focussed e.g. to explore issues relating to mental health or sensory impairment.

Little differentiation in PCR wave 1 within the over-65 group in terms of other protected characteristics, means specific needs of disabled people not highlighted.

Demographic data included in briefing packs for inspection teams does not include disability / long term conditions.

PCR Urgent & Emergency Care Module:

Likely positive impact from inclusion of mental health acute pathways within the specific module on urgent and emergency care module.

People experiencing mental health problems continue to be disproportionately affected by, and to present via urgent and emergency care routes, during the pandemic (Covid-19 EIA). Mental health is likely to be a key concern in coming months with possible local lockdowns and second wave of infection, coupled with end of furlough and increased redundancies.

There is a risk of a negative impact if the experiences of people experiencing poor mental health are not considered. There is an opportunity to advance equality if these issues are specifically considered.

There is an opportunity to advance equality if the experiences of people with other disabilities who also experience poor outcomes from urgent and emergency care, are also considered e.g. people with a learning disability/autism, d/Deaf people and people with physical/sensory impairments.

Mitigation: PCR wave 1: as above.

PCR Urgent & Emergency Care Module:

Ensure disabled people’s voices are heard and impact on this research, especially in this urgent and emergency care module, by engaging directly with people who use services and / or organisations who represent them to support co-production and provide local intelligence. For example, consider involving CQC experts by experience and include any recent engagement or relevant patient views survey / research in PCR intelligence packs.

Review risk to disabled and older people’s human rights arising from changed pathways to access Urgent and Emergency Care (CQC Statement 14 Aug 20 and PCR wave 1). This includes issues around changes to urgent and emergency pathways that have a high impact on older and disabled people, for example additional triage for people living in care homes before admission.

Include data in relation to people with disabilities e.g. people who are d/Deaf or who have a sensory impairment, in the urgent and emergency care module, to highlight people most vulnerable to poor care.

Consider intersectional data and experiences e.g. Black and ethnic minority disabled people.

Consider issues around changes to urgent & emergency pathways that have a high impact on disabled people, for example additional triage for people living in care homes before admission.

Involve colleagues with specialist knowledge of closed cultures, in development of KLOEs / data packs for local systems.

Greater differentiation needed in future modules e.g. looking at older and younger people and children, in future PCR module which will focus on learning disability / autism.

Race/ethnicity

Impact: Black and ethnic minority people including older people, continue to be disproportionately affected by the pandemic (Covid-19 EIA).

PCR first wave: No specific race equality questions in methodology, although possible positive impact if specific examples are captured e.g. work to develop women-only testing centres to meet needs of older Black and ethnic minority women.

PCR next wave modules:

Likely no positive impact unless the experiences of Black and ethnic minority people are specifically sought and highlighted, where different.

Black and ethnic minority people are more likely to experience poor mental health and to access mental health care via U&EC in crisis. Consider that some BAME people are more likely to access healthcare via U&EC routes e.g. refugees and asylum seekers, migrant workers

Mitigation: PCR wave 1: as above.

PCR Urgent & Emergency Care Module:

Ensure Black and ethnic minority people’s voices are heard and impact on this research, especially in the learning disability and autism module and in the urgent and emergency care module, by engaging directly with people who use services and / or organisations who represent them. For example, consider involving CQC experts by experience and include any recent engagement or relevant patient views survey / research in PCR intelligence packs.

Review system responses to Black and ethnic minority maternity and neonatal mortality in the pandemic e.g. NHSEI letter to the system (four actions to support Black and ethnic minority women June 2020) (as in Race/Ethnicity, above) – see also pregnancy and maternity, below).

Identify good practice where providers reach out to equality groups to encourage people to use appropriate urgent and emergency care pathways.

Gender

Impact: Women continue to be disproportionately affected by the pandemic (Covid-19 EIA).

Men continue to have higher mortality rates than women from Covid-19 (Covid-19 EIA).

PCR first wave: No specific gender equality questions in methodology, although possible positive impact if specific examples are captured e.g. work to develop women-only testing centres to meet needs of older Black and ethnic minority women.

PCR Urgent & Emergency Care module: Likely no positive impact unless the experiences of women are specifically sought and highlighted, where different and inter-sectionality considered.

Opportunity to advance equality if system responses to meeting needs of people at risk of domestic violence who present at A&E.

Mitigation: PCR wave 1: as above.

PCR Urgent & Emergency Care Module:

Review system responses to increased safeguarding risks to women and men at risk of domestic violence.

Disaggregate inequalities data by gender and ethnicity where relevant, to highlight key inequalities and inform engagement and KLOEs.

Gender reassignment

Impact: Trans women and men, continue to be disproportionately affected by the pandemic (Covid-19 EIA).

PCR first wave: No specific gender equality questions in methodology, although possible positive impact if specific examples are captured e.g. work with trans community.

PCR Urgent & Emergency Care module: Likely no positive impact unless the experiences of trans women and men are specifically sought and actively considered.

Mitigation: PCR wave 1: as above.

Marriage and civil partnership

Impact: No differential impact (Covid-19 EIA).

PCR first wave & PCR Urgent & Emergency Care module: No differential impact (Covid-19 EIA).

Mitigation: See general comments above.

Pregnancy and maternity

Impact: Pregnant women, particularly Black and ethnic minority women, continue to be disproportionately affected by the pandemic (Covid-19 EIA and NHSEI letter).

PCR first wave: No specific questions in methodology, although possible positive impact if specific examples are captured.

PCR Urgent and Emergency Care module: Opportunity to advance equality if system responses to Black and ethnic minority maternity and neonatal mortality are considered e.g. NHSEI letter to the system (four actions to support Black and ethnic minority women June 2020).

Mitigation: PCR wave 1: N/A.

PCR Urgent & emergency care module: Review system responses to Black and ethnic minority maternity and neonatal mortality in the pandemic e.g. NHSEI letter to the system (four actions to support Black and ethnic minority women June 2020) (as in Race/Ethnicity, above).

Religion and belief

Impact: Some people in faith groups continue to be disproportionately affected by the pandemic (Covid-19 EIA) e.g. by changes to hospital visiting and arrangements for end of life care.

PCR first wave: No specific questions in methodology, although possible positive impact if specific examples are captured.

PCR Urgent & Emergency Care Module: Opportunity to advance equality if system responses to meeting needs of faith groups are considered e.g. where visiting and end of life care arrangements have changed.

Mitigation: PCR wave 1: as above.

PCR Urgent & Emergency Care Module: Review impact of changes to hospital visiting and arrangements for end of life care, on people in different faith groups and how this affects people’s access to Urgent and Emergency Care.

Sexual orientation

Impact: Some LGB people continue to be disproportionately affected by the pandemic (Covid-19 EIA).

PCR Urgent & Emergency Care Module: Opportunity to advance equality if system responses to meeting needs of LGBT people are considered e.g. acknowledging partners appropriately in ED and end of life situations; responding to people in mental distress or people at risk of homophobic abuse who present at A&E (e.g. some LGB people, especially young people, may be confined in family situations where they are at risk of homophobia, homophobic abuse and violence and GB people experience poorer mental health).

Mitigation: PCR wave 1: as above.

PCR Urgent & Emergency Care Module: Review system responses to increased safeguarding risks to people at risk of homophobic abuse and people experiencing mental distress.

Right to Life

Human rights duties compliance:

Many of the equality issues in the section above relate to right to life, if they could lead to deaths that were avoidable by public bodies taking a different course of action. This relates to CQC’s duty to protect people’s human rights through use of our regulatory powers.

Some examples (which have also been noted in wave 1 PCRs):

• Decisions on DNACPR notices that are unrelated to clinical factors and do not involve the person and their representatives, such as blanket decisions
• Other clinical decisions about access to healthcare that are not based on clinical factors that may result in avoidable death, such as blanket decisions not to transfer people from care homes to hospitals. Also, decisions not to provide critical care to individuals where there is not clinical basis for the decision and there is critical care capacity to treat the person
• Decisions about use of health and social care facilities which do not enable others to be protected from COVID-19 infection, when an alternative option was available which would not have led to this outcome.

(CQC Covid-19 Response EIA v.2)

The initial findings from the phase 1 reviews indicate that there have been examples of these issues identified and these have been escalated to operational teams.

Mitigation:

All PCRs and especially Urgent & Emergency Care module:

Review risk to disabled people’s human rights arising from changed pathways to access (CQC Statement 14 Aug 20 and PCR wave 1).

If we find that the practices of individual providers are creating barriers for access, address this through our regulatory work, escalating as necessary; make sure our methodology enables inspectors to identify where this is happening and to support providers to improve or take other action (CQC Covid-19 Response EIA v.2). Provide training to support PCR teams as required.

Use provider engagement methods and work with system partners to flag good practice and expectations around equality issues in clinical decision-making (CQC Covid-19 Response EIA v.2).

Right to freedom from inhumane or degrading treatment

Human Rights duties compliance: Could be potential negative impact if human rights is not adequately considered in:

• development of methodology during COVID-19
• engagement with people who use services and their families and advocates during COVID 19.

(CQC Covid-19 Response EIA v.2)

The initial findings from the phase 1 reviews indicate that there have been issues in gathering the views of people who use services due to the work being undertaken remotely and within tight timescales.

Mitigation: All PCRs including Urgent & Emergency Care module:

Ensure methodology enables people’s voices to inform all PCR work for each module.

Right to Liberty

Human Rights duties compliance: As above. Article 5 rights relevant to the application of MCA DoLS may be more complex to monitor. (CQC Covid-19 Response EIA v.2)

As above, the initial findings from the phase 1 reviews indicate that there have been examples of these issues identified.

Mitigation: As below.

Right to respect for family and private life, home and correspondence

(includes autonomy issues in care and treatment)

Human Rights duties compliance: As above, plus attention to how providers consider whether “social distancing” approaches to COVID-19 might have an avoidable impact on human rights, through taking a less restrictive approach as described above.

Article 8 is a qualified right, which means it can be ‘interfered with’ by a Public Authority in certain circumstances including public safety, protection of health or morals, or for the protection of rights and freedoms of others. Any interference must be proportionate.

Health and social care services may need to restrict access to family and friends in order to protect right to life. However, providers need to consider how they can limit visitors whilst fulfilling Article 8 rights, for example by considering alternative ways that each person can maintain contact with their family and friends if possible.

(CQC Covid-19 Response EIA v.2)

As above, the initial findings from the phase 1 reviews indicate that there have been examples of these issues identified.

Mitigation: All PCRs including Urgent & Emergency Care module:

If we find that the practices of individual providers are creating barriers for access, address this through our regulatory work, escalating as necessary; make sure our methodology enables inspectors to identify where this is happening and to support providers to improve or take other action (CQC Covid-19 Response EIA v.2). Provide training to support PCR teams as required.

Action 1: Strengthen people's voice in PCR work

Strengthen people’s voice in the PCR process by engaging directly with people who use services and / or organisations who represent them. Prioritise hearing from those people most vulnerable to poor care in each module and disaggregate data where relevant.

(a) Prioritise hearing from people vulnerable to poor care e.g. for urgent and emergency care module - disabled people and black and minority ethnic people, including where possible;

• people who use mental health services,
• people with a learning disability /autism,
• people living with long-term health conditions,
• people who are d/Deaf or who have a sensory impairment,
• organisations who represent these people, and

(b) Consider how people’s voice and disaggregated local / national data can inform the methodology of the PCRs given timeline e.g. development of intelligence data packs, key lines of enquiry, corroboration, feedback and report-writing.

(c) Consider involving CQC experts by experience and citizen panel, public insight data or other methods, include any recent engagement or relevant patient views survey / research in PCR intelligence packs or national report.

(d) Consider the membership of any expert reference group for future modules to include representation of people who experience poorest outcomes i.e. Black and minority ethnic groups.

Action owner:

• Operational lead - Carolyn Jenkinson
• (a & b) Policy lead with Engagement, Experts by experience team
• (c) Public engagement lead –and Intelligence lead
• (d) Public Voice & Partnerships with Policy lead (as above) and Equality, Diversity and Human Rights (EDHR) team.

Action 2: Explore inequalities in each module

Include specific content in KLOEs to explore identified inequalities for each module

(a) Identify specific equality issues to consider in each module e.g. for the Urgent and Emergency Care module this should consider the specific mitigations identified in sections 6&7 above;

• Review risk to disabled and older people’s human rights arising from changed pathways to access Urgent and Emergency care (CQC Statement 14 Aug 20 and PCR wave 1).
• Evaluate mental health access / barriers and system response to priority expectations on prioritising, monitoring and data and digital pathways – (Sir Simon Stevens Reset Letter to the System, 31 July 2020).
• Review system responses to BAME maternity and neonatal mortality are considered e.g. NHSEI letter to the system (four actions to support BAME women June 2020).
• Consider the impact on different faith groups from any changes to visiting and end of life care arrangements (Covid-19 EIA).
• Ensure equality issues are sufficiently visible e.g. if a ‘service resilience’ approach is taken.
• Ensure mental health providers are included in PCR work.
• Consider specific safeguarding issues including – domestic violence, people experiencing homophobic violence or abuse, children.
• Consider the different experiences of older/younger people and children and people living in different settings.

(b) For each module; identify good practice and innovation that reaches out to equality groups (e.g. to encourage people to use appropriate urgent and emergency care pathways) to include in interim and final reports and in feedback to systems.

Action owner: Policy lead and Intelligence lead as above, with support from EDHR team.

UPDATE OCT 2020: Each PCR next phase module will now include specific system-level questions on health inequalities, with a particular focus on how providers meet the needs of Black, Asian and minority ethnic people.

Action 3: Data, skills and knowledge

Ensure PCR inspection teams have the data, skills and relevant knowledge to identify and explore equality outcomes for people.

• Consider how to tailor KLOE questions to focus on the impact on outcomes for people, of system working and identify and reflect equality issues identified for each module.
• Consider what and how intersectional and locally-relevant data patterns on equality outcomes are used to inform PCRs. Include disaggregated data on disability and ethnicity where relevant, to highlight people most vulnerable to poor care in each module.
• Consider whether to involve colleagues with specialist knowledge of closed cultures (including internal reference group) and other equality issues e.g. mental health / learning disability, in development of KLOEs and intelligence, for each module.
• Consider involving relevant external stakeholder groups, to support identification of key equality issues to consider in each module e.g. groups representing people who are vulnerable to poorest outcomes, discrimination or human rights breaches.
• Ensure PCR operational teams include people with the relevant skills e.g. children’s inspectors, mental health or learning disability specialists may be relevant. Consider positive action to encourage Black and ethnic minority colleagues to join.
• Consider how to direct PCR teams to focus on the specific groups concerned, beyond universal covid-19 responses and to make better use of the data during PCR interviews.

Action owner:

• (a) PCR Policy lead as above, with Engagement lead support
• (b) PCR Intelligence lead (as above)
• (c) PCR Policy lead (as above)
• (d) PCR Policy lead as above, with Engagement leads, EDHR team support
• (e) PCR Operational lead with internal engagement lead support
• (f) PCR Operational lead, with Policy lead, Intelligence lead as above.

Action 4: Development for PCR teams

Provide training to support the PCR team as required; to explore the specific identified equality content and patterns of inequality for each PCR module, and; to escalate and address concerns regarding potential human rights breaches or discrimination.

For example, if we find that the practices of individual providers are creating barriers for access, address this through our regulatory work, escalating as necessary; make sure our methodology enables inspectors to identify where this is happening and to support providers to improve or take other action (CQC Covid-19 Response EIA v.2).

Owner:

• (a) PCR policy lead & EDHR team
• (b) PCR operational lead

Action 5: Sharing and learning

Maximise positive impact both by learning from and highlighting specific equality and human rights challenges and by including examples of good practice / case studies in PCR report;

• Use engagement channels to work with system partners flagging good practice and wider system expectations around equality issues e.g. for urgent and emergency care, in clinical decision-making (CQC Covid-19 Response EIA v.2) and in future modules – expectations of NHS Phase 3 reset letter action on inequality
• Use PCR report to flag good practice in delivering equal access, experience and outcomes in each module.
• Record any equality themes / concerns arising from each module in learning log to carry forward to relevant future modules or other parts of CCQs work – from KLOEs, people’s voice, intelligence and decisions.

Owner:

• PCR Engagement leads as above, Operational lead, EDHR team.
• PCR Operational lead, with report-writing lead, inspection teams.
• PCR Operational lead as above.