Information

Redesign of urgent care: equality impact assessment

Impact assessment (EQIA) for the redesign of urgent care to ensure patient safety during the winter period while the NHS continued to respond to the pandemic.


Stage 2: Table setting out data gaps, actions taken and possible mitigation, by each characteristic

Characteristic

Evidence Gathered and Strength/Quality of Evidence

Source

Actions Taken / Mitigation

Age

Urgent Care Use

The NHS NSS 'Who Attends Emergency Departments' report highlights that very young (0 to 4) and older people (65+) are more likely to attend an emergency department and more likely to be admitted to hospital following their attendance.

Digital

Age is the leading characteristic of low digital engagement, with digital engagement decreasing as age rises. Those over 70 are particularly less likely to engage digitally.

Older people are less likely to have internet access, and even if they do they are less likely to use it. Over a third (36%) of households where all adults are over 65 do not have home internet access. This rises to three fifths (60%) of households where all adults are over 80. Two-thirds (65%) of adults aged 60+ used the internet in 2018 – compared to under one-third (29%) in 2007.

Moreover, older Asian people are significantly less likely to have used the internet than white people belonging to the same age groups, suggesting that there may be particular digital barriers to the engagement of some older minority ethnic groups.

While almost all young people use the internet, there are still many who lack good digital skills or access to resources such as home computing and broadband.

Evidence relating to care-experienced young people has highlighted the inequalities they can experience when accessing health services. They are also a group of people more likely to experience socio-economic disadvantage. Ensuring that efforts are made to engage with this group of people to convey information around the changes is essential.

NHS NSS (2015) Understanding Emergency Care in Scotland. Who Attends Emergency Departments.

Working with Public Health Scotland we will undertake a population needs assessment to further identify the needs of the population and the ongoing improvement data required for monitoring purposes.

Working with third sector organisations and Healthcare Improvement Scotland (HIS) Community Engagement we will co-produce the change needed to deliver urgent care which meets the needs of the Scottish population using local HIS engagement offices within Boards to undertake gathering views exercises, HIS citizen panel and jury.

Potential mitigation strategies identified include:

  • Improving access to basic mobile telephones with specific instructions on how to access NHS 24.
  • Exceptions to current visiting guidelines when appropriate.

By partnership working with local libraries to provide private space for remote consultations, this may increase access to video enabled care for those without access to video devices. Noted that further mitigation will need agreed to ensure 24 /7 access.

Further mitigation strategies will be developed after the feedbackfrom public and professional engagement has been fully explored, particularly for those digitally excluded.

Monitoring Impacts

Data on the age of those using urgent care (attending A&E, contacting NHS 24 and contacting out of hours) are published by Public Health Scotland. Additional data or research may be needed over time to understand impacts.

Lloyds Bank 2020

ONS 2019

Scottish household survey 2019: key findings - gov.scot (www.gov.scot)

Disability

Urgent Care Use

Some people with a disability have conditions which make them more prone to needing urgent care and more likely to present to A&E.

Moreover, some disabled people may be experiencing gaps in social care provision as a result of Covid-19 and responses to the pandemic (e.g. this could mean they are in less regular contact with social care staff/a PA and may be more inclined to contact emergency services.

Reduced availability of some therapies and treatment may mean people feel they can cope less well with existing conditions. They may then be more likely to request emergency care.

Digital

Disabled people are also more likely to live with socio-economic deprivation.

Disabled people are more likely to be digitally excluded. For example, in 2018, 27% of adults in Scotland with a long-term physical or mental health condition reported not using the internet, compared with 8% of adults who do not have any such condition.

Clear communication and access options at every stage will be important for people who rely on information in, for example, Easy Read, BSL, Braille, audio/visual formats. A range of access points for information will also be important for people who are more likely to be digitally excluded and/or without regular access to media. Separate accessible info/communication and language barriers.

Disabled people whose conditions impact their verbal communication could be deterred from accessing urgent care further to the introduction of the requirement to call NHS 24. For example, a person with a stammer may be deterred from calling because of their anxiety around having telephone conversations.

When promoting changes to the urgent care model and the new NHS 24 pathway, consideration should always be given to the provision of information in accessible formats, such as Easy Read, large print, colour contrasted backgrounds or audio. The need to make information accessible to British Sign Language Users and others with language barriers should also be met.

Interactive voice recorded menus could be a barrier to some disabled people. People with hearing impairments may struggle to hear the options or people with cognitive impairments may find long questions, or multiple response options, difficult to remember.

In 2019, NHS 24 staff undertook a number of engagement activities (Art of the Possible) with disabled people who can experience barriers to communication. This engagement highlighted a number of things for NHS 24 to consider when delivering telephone-based services. They include:

  • Complex language and jargon can make it difficult for people who can experience barriers to communication to interact with services. It was noted that not everyone has the confidence to ask questions when they are given information they don't understand.
  • Staff should have an awareness and understanding of communication and language differences, and how this negatively impacts the accessibility of phone-based services. For example, background noise in a contact centre environment can make it difficult for someone with a hearing loss impairment to communicate effectively, and they may need more time. It can also be a distraction for those with attention difficulties too.
  • There was a general lack of awareness of healthcare services and knowledge of how to access them.
  • Involving range of users in the development of services, and planning access and for reasonable adjustments at the start of a project.

BSL (Scotland) Act 2015: promote and support the language, culture & identity of British Sign Language users.

Augmentative and Alternative Communication (AAC) Duty

In 2016, the Scottish Parliament passed legislation which entitles people with severe communication difficulties to be provided with communication equipment and support. Referred to as Augmentative and Alternative Communication (AAC), this equipment includes communication aids and accessories, as well as other non-electronic aids such as symbol communication books.

The duty to fulfil the legislation lies with NHS Boards and Integration Joint Boards throughout Scotland.

People who require AAC equipment may contact healthcare services, but it is more likely that a carer, a relative or a friend will call on their behalf, which means for those without a 24-hour care presence, it can be difficult to make the call when they might need it. It could be difficult for healthcare providers to meet the needs of people who use AAC equipment. However, an approach proposed to address this is to create a national communication hub similar to the service provided by Contact-Scotland-BSL.

One UK study recorded that BSL/English interpreters were present at just 17% of GP and 7% of A&E consultations. Another study found that over three-quarters of Deaf patients had difficulty communicating with hospital staff.

Scottish Government (2019) Scottish Household Survey 2018

Poverty and Inequality Commission

THE HEALTH OF DEAF PEOPLE IN THE UK .pages (bridgewater.nhs.uk)

Actions: as above

Potential mitigation strategies identified include:

  • Providing call handlers, clinicians, and reception staff with any information related to the practical and emotional needs of the user, may reduce the user's anxiety and fatigue by repeatedly reassuring them at every step that they have been listened to and their needs are being addressed.
  • Improving NHS 24 automated messaging menu to meet the needs of those for whom English is not a first language, while improving awareness of these improvements among affected communities, may minimise difficulty and frustration people have when accessing interpretation support when in need of urgent care.
  • Improving access to basic mobile telephones with specific instructions on how to access NHS 24 for issues most commonly experienced by people who experiencing homelessness.
  • Exploring how NHS practitioners and third sector organisations might collaboratively provide clinical, practical and emotional support in community spaces trusted by vulnerable people, may enable greater access to preventative treatments and avoid later trips to A&E.
  • Providing a simple, clear, and dignified exemption process to allow supporters to attend A&E appointments similar to that for mask exemptions, may reduce user anxiety, enable better clinical outcomes, and reduce health inequalities through access.
  • Increasing awareness among clinicians and patients of functionality to enable multi-person conversations via Near Me, may improve access to additional emotional and practical support for those who need it most.
  • Introducing a feature whereby communication and language support needs are highlighted on the call handling system, so that NHS 24 staff are immediately aware of a caller's specific needs.

Mitigation already in place includes:

  • The communication plan for the policy has been drafted to now ensure that public messaging is delivered in a variety of languages including BSL and Easy Read format.

Monitoring Impacts

There are no specific plans to routinely monitor the disability status of those using urgent care. Additional data or research may be needed over time to understand impacts.

Sex

Urgent Care Use

Children and parents/care-givers are noted as more frequent attenders at A&E.

Around 60% of unpaid carers are women.

People who provide unpaid care for someone because of a long-term physical condition, mental ill-health or disability, or problems related to old age.

Women do more unpaid caring than men in most age groups.

90% of single parents are women, with 45% of single parents living in poverty.

Just over half (51%) of Scotland's population are women.

There are a higher ratio of women to men in older age groups, reflecting women's longer life expectancy. Therefore it is possible that women may need to access unscheduled care more frequently.

Women are disproportionately more likely to experience domestic abuse. In 82% of all incidents of domestic abuse recorded by the Police in 2018-19 the victim was a woman and the accused was a man (where gender information was recorded).

Digital

This could make a preliminary conversation/digital engagement with services more risky if it takes place in the home. However, further research would be beneficial here.

Women are more likely to be the victim of controlling behaviours/ coercive control and this could impact on their access to healthcare or access to healthcare for their families.

Poverty and Inequality Commission

Scottish Health Survey 2017 Scottish Health Survey 2018

Mid-Year Population Estimates Scotland, Mid-2019

Domestic Abuse: statistics 2018-19

Actions: as above

Understanding the impact on women, particularly those who are the primary care-givers for children or who are experiencing domestic abuse.

Gaps in data relate to why people access urgent care and how the genders may be disadvantaged or advantaged by the change.

Potential mitigation strategies may include:

  • Providing access to text based communication methods for initial urgent inquiries via 111, may improve access to urgent care for people who are vulnerable to the surveillance or judgement of people they live with, improving safety and the ability to provide essential, confidential information.
  • By working with community based charities to provide access to space for private conversation, may reduce user anxiety, enable better clinical outcomes, and reduce health inequalities through access.

Monitoring Impacts

Data on the sex of those using urgent care are published by Public Health Scotland. Additional data or research may be needed over time to understand impacts.

Pregnancy and Maternity

Urgent Care Use

Complications or health conditions associated in pregnancy may create a need for urgent care.

People who are pregnant or who have recently had a baby are often offered a direct contact number for their labour unit ward so that they can speak directly to a midwife. Ensure clear messaging on the best route for urgent care is provided for people who are pregnant/recently had a baby.

 

Actions: as above

Gender Reassignment

Urgent Care Use

Past experience of discrimination or poor treatment can mean that LGBT people are less likely to access some key health services, like GP services and screening programmes, but are more likely to use A&E and minor injuries clinics.

Digital

Some trans people may experience mis-gendering over the phone depending on a number of factors. It may be that their CHI details do not recognise the gender they identify as or call handlers could mistakenly assume someone's gender based on the sound of their voice.

LGBT populations and mental health inequality – 2018 report

Stonewall's LGBT in Britain Health Report - 2018

Actions: as above

To understand fully what would make a new urgent care system accessible to LGBT people.

Gaps in data in relation to why people access urgent care and how the gender reassignment may be disadvantaged or advantaged by the change.

Monitoring Impacts

There are no specific plans to routinely monitor the gender reassignment status of those using urgent care.

Sexual Orientation

Urgent Care Use

Past experience of discrimination or poor treatment can mean that LGBT community are less likely to access some key health services, like GP services and screening programmes, but are more likely to use A&E and minor injuries clinics.

Though there is evidence to suggest that LGBT people can experience poorer health outcomes than non-LGBT people, it is unclear if the redesign of urgent care would present any new issues/barriers.

LGBT populations and mental health inequality – 2018 report

Stonewall's LGBT in Britain Health Report - 2018

Actions: as above

To understand fully what would make a new urgent care system accessible to LGBT community.

Gaps in data relate to why people access urgent care and how people's sexual orientation may be disadvantaged or advantaged by the change.

Potential mitigation strategies include:

  • Augmenting the national campaign with specific messaging for communities vulnerable to health inequalities with people from those communities, delivered by people trusted by the communities, may reach people who may not engage with national communication campaigns and increase the numbers of people from these communities seeking urgent care support and mitigate the spread of inaccurate information about the service.

Monitoring Impacts

There are no specific plans to routinely monitor the sexual orientation of those using urgent care. Data or research may be needed in future to understand impacts.

Race

Urgent Care Use

35% of Minority Ethnic people are in poverty compared to 18% of White British people.

A significant number of people speak English as a second language and this is more common among minority ethnic communities. Access issues such as the availability of interpreters, literacy issues and perception around short appointment times can impact early engagement with health services.

For Gypsy Traveller communities, issues to consider include difficulties with GP registration, anticipated discrimination or poor treatment, digital exclusion, lower levels of literacy and the need for a tailored approach to communicating within communities, who may not be engaged with mainstream messaging or who may have concerns about a digital first approach.

It is known that Gypsy travellers have poorer health than the general population.

In 2017, it was reported by NHS Health Scotland that Gypsy/Travellers had low rates of outpatient appointments, hospital admissions, A&E attendances, cancer registrations and maternity hospital admissions. It was suggested that this may be due to the under-recording of Gypsy/Travellers compared with the proportions reported in the census, and issues with accessing services. Engagement with Gypsy/Travellers, undertaken in 2015 and 2016 by NHS 24, highlighted that Gypsy/Travellers can often use urgent care services as their primary healthcare access point due to barriers relating to registering with GP services.

The EHRC's 'Is Scotland Fairer? 2018' report noted migrants were generally found to be low-level users of health services, possibly due to a lack of knowledge around how the healthcare system works in Scotland. Changes to the urgent care model may increase confusion for this group of people who are already reported to have a lack of understanding of the Scottish health system.

Minority ethnic people whose first language is not English, may be unable to understand information about the changes to the urgent care model unless this information is communicated in their preferred languages.

In 2018, NHS 24 undertook engagement with minority ethnic people and organisations that represent their interests to help understand what could be done to improve NHS 24 services for minority ethnic communities, refugees and asylum seekers. Findings from this engagement were as follows.

  • Many people identified that they would seek medical help and advice from trusted sources within their communities e.g. local networks, instead of seeking help from a health professional.
  • More needs to be done to raise awareness of healthcare service amongst minority ethnic communities, refugees and asylum seekers. It was fed back that there is disparity between particular communities, in regards to the amount of knowledge and awareness they have of available health services.
  • Many will not seek help at all, until an emergency arises. This results in their first experience of using a health service being at A&E.
  • There was a reported lack of awareness of Language Line and it was noted that there were difficulties in understanding and using Language Line when it was accessed.
  • Language Line interpreters should be provided to suit the caller, for example if a woman states that she would prefer to have a woman interpret the conversation then this should be provided.
  • Staff should be aware of the cultural sensitivities related to sharing some health issues, for example, mental health issues or sexual health issues.

Poverty and Inequality Commission

Population level data

See Scottish surveys Core Questions for detailed results by ethnicity for a number of questions: "White: Other British", "White: Other" and "All other ethnic groups" reported higher good/very good general health than the "White: Scottish" reference group. Since 2012, levels of good/very good general health have increased by 3.0 percentage points for the "White: Other British" group.

The Scottish Government (2015) 'Which ethnic groups have the poorest health?' report, based on analysis of 2011 Census data. Key findings:

  • Most ethnic groups in Scotland reported better health than the "White: Scottish" ethnic group;
  • Across most ethnic groups, older men reported better health than older women. Older Indian, Pakistani and Bangladeshi women reported poor health, and considerably worse health than older men in these ethnic groups;
  • Gypsy/Travellers in Scotland had by far the worst health, reporting twice the "White: Scottish" rate of 'health problem or disability' and over three and a half times the "White: Scottish" rate of 'poor general health';
  • "White: Polish" people aged under 65 reported relatively good health, whereas those aged 65 or over reported relatively poor health;
  • The age-standardised rates of "health problem or disability" by ethnic group in Scotland followed a similar pattern to the results for England and Wales.

Is Scotland Fairer 2018 report'

Actions: as above

To understand fully what would make a new urgent care system accessible to people who are black, Asian or from a minority ethnic community.

Gaps in data relate to why people access urgent care and how race may be disadvantaged or advantaged by the change.

Potential mitigation strategies may include:

  • Improving NHS 24 automated messaging menu to meet the needs of those for whom English is not a first language, while improving awareness of these improvements among affected communities may minimise difficulty and frustration people have when accessing interpretation support when in need of urgent care.
  • Providing call handlers, clinicians, and reception staff with any information related to the practical and emotional needs of the user, may reduce the user's anxiety and fatigue by repeatedly reassuring them at every step that they have been listened to and their needs are being addressed.
  • Augmenting the national campaign with specific messaging for communities vulnerable to health inequalities with people from those communities, delivered by people trusted by the communities, may reach people who may not engage with national communication campaigns and increase the numbers of people from these communities seeking urgent care support and mitigate the spread of inaccurate information about the service.

Mitigation strategies already in place include:

  • The communication plan for the policy has been drafted to now ensure that public messaging is delivered in different languages, Easy Read and BSL language format. Messages will be delivered in a range of mediums including radio, film and written and will include delivering messages in ways which meet key characteristic group's needs, for example by word of mouth to the Gypsy Traveller Community.
  • Providing call handlers, clinicians, and reception staff with any information related to the practical and emotional needs of the user, may reduce the user's anxiety and fatigue by repeatedly reassuring them at every step that they have been listened to and their needs are being addressed.

Mitigation strategies will be developed after the feedbackfrom public and professional engagement has been fully explored

Monitoring Impacts

There are no specific plans to routinely monitor race of using urgent care. However, work is underway across health and social care to improve ethnicity data in health care and administrative records and Health Boards have been asked to address this as a priority. Covid has highlighted gaps in Scottish data on ethnicity. Additional data or research may be needed over time to understand impacts.

Different BME groups are not evenly distributed across Scotland, so ensuring equality of treatment, and good quality monitoring will vary across boards.

Religion or Belief

We are not aware of any relevant existing evidence currently on religion or belief in relation to the Redesign of Urgent Care Programme.

   

Marriage and Civil Partnership

Scottish Government does not require assessment against this protected characteristic unless the policy or practice relates to work, for example, HR policies and practices. Refer to Definitions of Protected Characteristics document for details

   

Contact

Email: UnscheduledCareTeam@gov.scot

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