Health Equity Resources
Focuses on creating a fairer society, where all individuals can take part in and access the same opportunities. It is underpinned by a legal framework.
Institutional discrimination: institutional racism was described in the Macpherson report as “the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture, or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantage minority ethnic people”.
These collective failures are also experienced by other groups and communities.
Achieving equity means that we need to do more than just prevent inequality. It recognises that inequalities arise not just from differences such as health status and disability, but from inequalities in power, money and resources. Only by giving people a voice, and ceding power to them, can we achieve true equity.
“The question we should ask is not, can we afford better health for the population of England, but what kind of society do we want… Every society will have some level of economic and social inequalities. What we envisage, and work towards, is a society that creates the conditions for everyone to be able to lead lives they have reason to value.
That we do not… is shown by the slowdown in life expectancy improvement, deteriorations in physical and mental health and widening health inequalities.”
(From: Health Equity in England: The Marmot Review 10 Years On
The range and variety of individuals and groups. It is often linked with differences in life chances and social inequalities. Factors that influence diversity include:
- those we are born with (e.g., ability/disability, race, gender, sexuality)
- those we are born into (e.g., culture, religion)
- those we develop as we grow and experience life (e.g., lifestyle, culture, identity, jobs/careers, relationships, trauma, joy)
Where everyone involved feels valued.
Staff have a more inclusive workplace when:
- it is a welcoming environment
- they know they will be treated fairly and have equal opportunities to progress and grow
- they have someone to go to if they experience discrimination.
People who use services experience more inclusive health and care services when:
- they are treated as individuals and their culture and values are respected
- they have choice and control over how their services are delivered
Public service budgets are more inclusive when:
- funding is targeted at those who need it most, based on evidence and understanding people’s lived experiences.
Procurement of services is more inclusive when:
- it incorporates social value as a key element of all contracts for services.
1. Lead with empathy. Get an understanding of individual experience.
Even individuals who have LOTS of privilege want to be acknowledged for their hardships. This makes sense - we all want empathy towards our life challenges. When I first enter into a conversation about privilege, I start by asking about the ways in which the person does not have privilege. This is helpful not only in understanding the person more, but also extending empathy. In a conversation as touchy as one on privilege, it’s important to try to disarm defensives and cultivate open dialogue. Then, after speaking with the person about the ways in which they don’t hold privilege, I ask in what ways they do. I find that structuring a conversation that includes the way people have and don’t have privileges makes it easier for others to understand the power of privilege in creating a system of oppression - and this process is transformative.
2. Understanding the relativity of privilege.
Our identities are nuanced and intersectional. Some of my close friends will get defensive when discussing privilege because they are afraid that the discussion will not talk about the powerful ways in which they do not have privilege, and as a defense, they deflect to speaking to only these things. It’s important to understand – just because we have don’t have certain kinds of privileges, it doesn’t mean that we don’t benefit from other kinds of privileges. If we realize this, it’s easier to work together with folks who share our privileges and those who don’t to create a better, more equal, world.
3. Systematic injustice is good for no one.
We all lose when people are treated unfairly and not on the merit of their person. Ultimately, in order to move from a space of marginalization, people need to confront their privileges and recognize that inequality helps no one. As global citizens, we have the revolutionary ability to transform the political, economic, and social environment by recognizing that injustice creates a societal imbalance that negatively impacts everyone.
4. You don’t need to feel guilty or defensive when discussing privilege.
Guilt is a feeling that ultimately does nothing in bringing about change. I try to use this concept when I talk to friends about privilege. A lot of time, people will respond with defensives, or guilt. Each of us is able to undermine the system of oppression by refusing to live with unchecked or unacknowledged privilege. Simply by reflecting and challenging our privileges, and working to change the system of discrimination through direct discussion, we can help to shift the status quo.
5. Consider ways in which to equalize power.
To create change, it’s important to frame discussion on privilege with actions. As such, the conversation shouldn’t be, “Check your privilege, stupid!” but rather, “How can we work to make sure that we are understanding and undermining the system of oppression and privilege that hurts all of us?”
From: Kathleen Ebbitt (2015) Why It's Important to Think About Privilege — and Why It's Hard - https://www.globalcitizen.org/en/content/why-its-important-to-think-about-privilege-and-why/?template=next
Intersectionality is “basically a lens, a prism, for seeing the way in which various forms of inequality often operate together and exacerbate each other. We tend to talk about race inequality as separate from inequality based on gender, class, sexuality or immigrant status. What’s often missing is how some people are subject to all of these, and the experience is not just the sum of its parts.” (Kimberlé Crenshaw, Time Magazine, 2020)
- Work with complexity and do not treat people’s and communities’ issues in isolation.
- Take an approach that recognises how the different characteristics, health inequalities and socio-economic issues interlink for individuals, families and communities, and can lead to further marginalisation and isolation.
- Use personalised care approaches that tackle the challenges and risks that people and families face in a holistic way, where all those involved in their care understand the complexity of their lived experiences and collaborate to deliver sensitive, responsive, flexible and inclusive services.
- Take community-based approaches that value diversity, recognise how intersectionality impacts on different groups and communities, and bring people with different and multiple characteristics together to promote inclusive communities that build on their multiple assets.
- Listening to a wide range of people. We must learn how the multiple inequalities they live with impact on them, and use this to inform everything we do, through co-production, and joint monitoring and oversight.
- Focusing on outcomes for people, not for us. We need to become allies to those we serve, delivering what they need rather than solely what we have made available.
- Changing how we commission and deliver services, ensuring that culturally competent practices enable health and care services to work flexibly with intersectionality. We must not continue to create barriers through rigid structures and pathways.
- Finding new ways to record and reflect intersectionality in performance measurement. This will help us to be assured that we are reaching the most marginalised people and communities, and providing the right support for their needs.
Many people have more than one protected characteristic, and this means that will they experience multiple types of discrimination and disadvantage. This does not simply mean that they experience more inequalities. Their experience, and therefore the solutions, are more complex. We need to:
This will mean:
- Appetite - This is the first and probably the most important A. Asking yourself whether you have the appetite to immerse yourself in the world of race equality, which is complex, convoluted and extremely emotive. Spend some time thinking about whether you will be in it for the long haul or whether this is just a fad. Allyship is forever, not just during crises.
- Ask - This is where you have to be brave and actually ask questions about race, your race included. Be curious, look things up, read. Question all your received wisdom about race and other people. Be prepared to be surprised and even shocked at what you hear. Accept - Having done your homework on the issue and spent time reflecting, it’s now time to accept, really accept that there is an issue for people of colour in our society. This acceptance is an internal process.
- Acknowledge - Acknowledgement is external. People will now know where you stand on race inequality because you will openly acknowledge that there is an issue that needs to be dealt with.
- Apologise - The apology is not about saying you are sorry for any individual wrong doings, but saying you are sorry about what is happening globally to people of certain races. That apology needs to come from the heart and be authentic.
- Assumptions - Don’t make assumptions. Too many plans and ambitions – personal or corporate – are driven by assumptions that are wrong. Plans like these are doomed to fail. Full and informed views are critical prior to making any plans. Always seek the views of others and understand the implications of your actions across all interested parties. By doing so you will be better informed, and you will have gathered the intelligence and ownership of individuals or groups for whom your endeavours have implications and you will significantly enhance your chances of success.
- Action - The final A is taking some sort of demonstrable action on the agenda. It can be sponsoring someone, it can be making a difference via policy changes, it can be any action that shows that you are indeed a true committed and authentic ally.
(Source: London Workforce Race Strategy 2020)
- Eliminate unlawful discrimination, harassment, victimisation and any other conduct prohibited by the Act;
- Advance equality of opportunity between people who share a protected characteristic and people who do not share it; and
- Foster good relations between people who share a protected characteristic and people who do not share it.
- Have enough relevant information about equality issues, and consider it when and after making decisions.
- Assess the impact on equality of decision-making, policies and practices.
- Consider equalities within procurement of contracts.
- Publish information on equality issues, steps being taken and equality objectives for your organisation.
- Embed equalities into business planning, policy, budgets, operations, governance, staffing and training.
- ensure that your decisions impact in a fair way
- make your decisions based on evidence
- make decision-making more transparent
- provide a platform for partnership working
The Equality Act 2010 Public Sector Equality Duty requires public bodies to have due regard to the need to:
Public authorities should:
Equality and Health Inequalities Impact assessments
Equality Impact Assessments enable us to consider how our plans or our programmes impact on people with protected characteristics. Equality and Health Inequalities Impact Assessments recognise that there are also wider issues that cause inequalities, in four overlapping dimensions:
Benefits of a high quality impact assessment:
1. EIAs are not relevant to us.
- Not necessarily! The reality is that, in times of financial constraint, public authorities will have to make difficult and often unpopular decisions regarding funding and service provision. The Public Sector Equality Duties do not prevent authorities making these decisions, provided that decisions are taken in accordance with the duties. Potential for adverse impact or missed opportunities may be identified but despite that you will still need to proceed. In this instance the Commission will be looking for steps you have taken or considered to mitigate any adverse impacts.
2. EIAs will stop us doing what we need to do.
- The consultation process should be part of the evidence set. Gaps in evidence should be identified and filled where possible. Lack of data is never a reason for not assessing impact and does not provide an excuse for not completing an assessment. Different types of evidence, for example, can be used. Decisions will need to take into account information deficiencies and reach the best judgement possible using what is available.
3. We don’t have all the information to carry out an EIA.
- A key point of an impact assessment is that you take account of equality as you develop your policy and plans. Just “doing it at the end” will not enable you to properly consult and involve and opportunities for picking up issues and making adjustments as part of the policy development will be missed. It won’t save time and may in fact lead to delay or even fundamental repositioning – see 9 below. Public authorities have a statutory duty to consult groups on the likely impact of a policy/proposal on race and we recommend that you also involve disabled people and consult men and women. Consultation and involvement can also address information issues mentioned in 5 below.
4. We can carry out an EIA at the end of the decision making process.
- The duties actually encourage and expect public bodies to take a proportionate approach. Once you have established if a policy is relevant to equality, and so needs to be impact-assessed, this should be done on a basis proportionate to the relevance of the policy. Possible questions to help determine relevance are provided in the Equality and Human Rights Commission’s guidance on EIAs which is available on the Commission’s website.
5. It is a disproportionate approach.
- If set up to be an integral part of the policy development and review, rather than a one-off exercise, there is no reason that an EIA cannot be completed quickly. The quality of an EIA is not measured by page count but by quality of the analysis and action taken etc. Much of the process can be systemised, and benefits can be had from up-front thinking, e.g. on use of templates, information collection, which will support all EIAs.
6. The EIA process is labour intensive.
- EIAs are not an end in themselves - they are a way of showing that due regard has been paid to the general duties. EIAs must demonstrably be used to inform the final decision on a policy. Internal dissemination can help consistency and also build knowledge. Arrangements for publication are required by the race equality duty, and gender and disability duties recommend publication.
7. We can ignore the outcome of an EIA.
- There is a legal obligation to undertake Equality Impact Assessments (EIAs) to assess the impact of your actions on people of different racial groups, disabled people, and men and women, including transsexual men and women. A best practice approach, which will be law under the Equality Act 2010, is to consider impact on religion or belief, sexual orientation and age.
8. It is just bureaucracy and red tape and we don’t have to carry out an Equality Impact Assessment.
- Untrue! There are many examples of service users who have successfully challenged decisions that have been taken by public authorities and the Commission is working with its partners to secure compliance of public authorities meeting their duties.
9. No one will notice if we don’t carry out an EIA.
Source: Equality and Human Rights Commission
Human Rights Act 1998:
- being pregnant or on maternity leave
- gender reassignment
- being married or in a civil partnership
- religion or belief
- sexual orientation
- race including colour, nationality, ethnic or national origin
- at work
- in education
- as a consumer
- when using public services
- when buying or renting property
- as a member or guest of a private club or association
- you’re associated with someone who has a protected characteristic, for example a family member or friend
- you’ve complained about discrimination or supported someone else’s claim
- are at a disadvantage
- have particular needs
- are under-represented in an activity or type of work
- direct discrimination - treating someone with a protected characteristic less favourably than others
- indirect discrimination - putting rules or arrangements in place that apply to everyone, but that put someone with a protected characteristic at an unfair disadvantage
- harassment - unwanted behaviour linked to a protected characteristic that violates someone’s dignity or creates an offensive environment for them
- victimisation - treating someone unfairly because they’ve complained about discrimination or harassment
- It can be lawful to have specific rules or arrangements in place, as long as they can be justified.
“The [Act’s] rights and freedoms… shall be secured without discrimination on any ground such as sex, race, colour, language, religion, political or other opinion, national or social origin, association with a national minority, property, birth or other status.”
Fairness, Respect, Equality, Dignity and Autonomy are a way in which to understand human rights and is a core element of the NHS Constitution.
Equality Act 2010
The Act protects individuals from unfair treatment and promotes a fair and more equal society. It is against the law to discriminate against anyone because of their protected characteristic(s):
You are protected from discrimination:
You are also protected from discrimination if:
You can do something voluntarily to help people with a protected characteristic. This is called ‘positive action’. Taking positive action is legal if people with a protected characteristic:
Discrimination can come in one of the following forms:
“Compliance with the general equality duty involves a conscious approach and state of mind.”
(Equality and Human Rights Commission)
“The Act promotes better access to opportunities, but it does NOT guarantee different or better outcomes.”
(Professor Paul Miller, Leadership Development & EDI Consultant, Educational Equity Services)
We have a duty as members of society to care about each other and want the best for each other. It is not just legally wrong, it is morally wrong to reinforce or exacerbate inequalities.
- Doctors: “You must not unfairly discriminate against patients or colleagues by allowing your personal views to affect your professional relationships or the treatment you provide or arrange. You should challenge colleagues if their behaviour does not comply with this guidance.” GMC Good Medical Practice
- Nurses and midwives: “You make sure that those receiving care are treated with respect, that their rights are upheld and that any discriminatory attitudes and behaviours towards those receiving care are challenged.” NMC Code
- Social workers: “I will… Recognise differences across diverse communities and challenge the impact of disadvantage and discrimination on people and their families and communities… Promote social justice, helping to confront and resolve issues of inequality and inclusion.” SWE Professional Standards
We see moral duties reflected in codes of professional ethics. Examples include:
There are many reasons to incorporate health equity into our work, but essentially …… it is the RIGHT THING TO DO
1.Listening to people’s experience
Some people and communities can feel invisible, so different ways must be found to hear their voices:
- Listen to lived experience – of those on the frontline, both staff and people using services.
- Plan and deliver care together – ‘with us not to us’, and enabling self-advocacy
- Co-produce services – full involvement at all stages from design to monitoring and review
- Ensure representation of people with a broad range of lived experience at all levels in the system – including representation in delivering training programmes, and enabling more diverse leadership.
2. Removing barriers to treatment, care and support
- People, families and communities can experience barriers to services, for example because of a lack of cultural competence.
- Knowledge and understanding of the issues – where commissioners and providers do not have detailed data on needs among different groups, or a good understanding of lived experience e.g. pressures on children to translate for adults in their family, impact of multi-generational households, isolation among young and older people, not having access to transport or the right foods.
- Attitudes of professionals and services – some people and communities find health and care staff lacking sensitivity, not inclusive, intimidating, leading to fear and mistrust e.g. LGBTQ+ people or those living with obesity.
- Accessibility of services – some people and communities do not all have the right information in the right format/language, knowledge about services and how to access them, or knowledge about their rights e.g. those with learning disability, sensory impairment, asylum seekers or refugees.
3. Changing our approach
To make real change, we need to change our own personal, professional and organisational cultures:
- Recognise our shortcomings – recognise privilege, develop allyship, solidarity, empathy, compassion and acceptance.
- Build bridges – create connections and meaningful partnerships with community leaders and groups that build trust.
- Be accountable – to each other and to all of our people, families and communities.
4. Taking action
We need to work together to adapt services to be inclusive:
- Gather and use the right data – to understand the differences in experiences of different groups and communities and the impact of levels of deprivation, as well as gaps in local community
- Change services in response to what we have learned – develop programmes that recognise diverse needs and the importance of affordability, and ensure people know about them and how to access them.
- Invest more, and target investment – for example ethnic minorities, young people, women, elders, those at higher risk of long-term conditions and mental ill-health
- Tackle factors affecting wellbeing and wider social determinants of health and care – for example families in deprivation, those with No Recourse to Public Funds, those who cannot access faith settings due to frailty or disability, experiences of bullying and discrimination, people in debt, social isolation.
- Joint strategic needs assessment – Essex https://data.essex.gov.uk/dataset/exwyd/essex-jsna-and-district-profile-reports-2019
- Joint strategic needs assessments – Suffolk https://www.healthysuffolk.org.uk/JSNA
- NHS Race and Health Observatory https://www.nhsconfed.org/networks-countries/nhs-race-and-health-observatory
- Inequalities in Gypsy, Roma and Traveller communities https://publications.parliament.uk/pa/cm201719/cmselect/cmwomeq/360/report-files/36005.htm
- Office for National Statistics https://www.ons.gov.uk
- Scope – disability statistics https://www.scope.org.uk/media/disability-facts-figures/
- Macmillan – cancer statistics https://www.cancerresearchuk.org/health-professional/data-and-statistics
- Equality Act 2010 guidance https://www.equalityhumanrights.com/en/equality-act/equality-act-2010
- Human Rights (including HRA 1998) guidance https://www.equalityhumanrights.com/en/human-rights
Voices of local people
- Healthwatch Essex https://healthwatchessex.org.uk
- Healthwatch Suffolk https://healthwatchsuffolk.co.uk
- Norfolk and Suffolk NHS Foundation Trust LISTEN project https://www.nsft.nhs.uk/listen/
- Kings Fund Podcast on tackling LGBTQ+ health inequalities >https://podcasts.apple.com/us/podcast/if-youre-not-counted-you-dont-count-what-can-be-done/id1363947403?i=1000529065140
- London Workforce Race Strategy https://www.england.nhs.uk/london/our-work/equality-and-diversity/london-workforce-race-strategy/
- NHS allyship resources https://www.england.nhs.uk/about/equality/allyship/
Equalities and Health Inequalities Impact Assessment
- Public Health England Health Equity Assessment Tool https://www.gov.uk/government/publications/health-equity-assessment-tool-heat/health-equity-assessment-tool-heat-executive-summary
Theory and practice
- Kimberlé Williams Crenshaw (1994) ‘Mapping the Margins: Intersectionality, Identity Politics, and Violence Against Women of Color’ available at https://drive.google.com/file/d/1ifzT7WVGj-C7k_f0qiQDSTDxqp7bssK3/view
- Kings Fund podcasts on inequalities available at https://podcasts.apple.com/us/podcast/the-kings-fund-podcast/id1363947403
- Suffolk Public Health Commitment to Change resources- https://www.healthysuffolk.org.uk/jsna/annual-public-health-report/aphr-2020-commitment-to-change
- NCVO and partners (2021) ‘Respond, recover, reset: the voluntary sector and COVID-19’ available at
- The Richmond Group (2021) Taskforce on Multiple Conditions available at https://richmondgroupofcharities.org.uk/taskforce-multiple-conditions.
Summary document is available at https://richmondgroupofcharities.org.uk/sites/default/files/richmond_group_response_to_the_taskforce_on_multiple_conditions_report_you_only_had_to_ask.pdf
100 Day Challenge guidance
- Nesta (2019) ‘Sparking change in public systems: The 100 Day Challenge available at https://media.nesta.org.uk/documents/100_days_to_change_a_system_v8.pdf