Equal but not the same

Originally published in HSJ 12/10/2006 Volume 116 No. 6028

From next April, trusts will have a legal duty to demonstrate gender equity across all areas of service provision. But as the deadline approaches, the national picture is looking decidedly patchy. Gabriel Fleming looks at how it will work

To most, gender equality in service provision still means everyone getting the same services the same way.

But the gender equality duty, which comes into force in April as part of changes to the sex discrimination legislation contained in the Equality Act 2006, will alter that. Crucially, the duty will put the onus on trusts to actively demonstrate equality between men and women rather than waiting for individual complainants to highlight cases of discrimination. The duty will apply throughout NHS organisations, from human resources to every aspect of the delivery and commissioning of healthcare.

From a workforce perspective, initiatives like Agenda for Change have already forced the NHS to take a serious look at representation and equality of opportunity. But, in service terms, the Department of Health is keen to stress that compliance with the duty will be judged heavily on outcomes, which could come as a shock to trusts which discover they are not doing enough.

The rationale behind the duty is that women and men have different susceptibility to different diseases and conditions, and little in common in the way they perceive and access health services. So it follows that offering the same services delivered through the same channels regardless of gender is discrimination.

Some basic examples: men are half as likely as women to visit their GP, which often leads to late diagnosis and all the complications that come with it. Conversely, women tend be unaware of the risks of diabetes and lung cancer, both of which are more prevalent in the female population than breast cancer, although the latter is better understood and therefore better diagnosed.

Statutory code

The only way to address these and many other gender inequalities is to target services in gender specific ways through, for example, smoking cessation services tailored to male smokers or diabetes and lung cancer awareness campaigns targeted at women.

From April 2007, gender equity should be ingrained in healthcare strategies across the NHS. If not, trusts and others that fail to comply will find themselves on the wrong side of the law.

A key player in the assimilation of the duty is the Equal Opportunities Commission, whose statutory code of practice for public sector bodies was due to go before parliament this week, and which is due to issue guidance for the health sector early next month.

Andrea Murray, EOC director of public policy and lead on implementation of the duty, is far from confident that the NHS is ready. 'I don't expect trusts to be well prepared and they don't seem to have given it much priority, ' she says.

'Most people still think of equality as an employment issue, but have great difficulty in understanding equality issues in service delivery.'

Nationally, Ms Murray has no hesitation in pinpointing where the obstacles lie.

'It's the usual problem: when there is so much reform going on at the same time people are bound to see this as a legislative burden that has nothing to do with their core business, ' she says.

She cites the 2002 duty on race equality as a warning of what can happen when unprepared organisations are faced with new legislation, and stresses the need to avoid history repeating itself.

'The race duty required trusts to collect lots of data, but anecdotal evidence suggests they haven't actually changed outcomes or changed services in a radical way, ' says Ms Murray. 'We're trying to get organisations to take this more seriously, but technically it's very similar. A lot of people will think &Quot;pass it to that junior HR bod and let them fill out the forms so the rest of us can get on with our work&Quot;. It's not about that. It's about changing how you work and meeting the real needs of people who use health services.'

Initiatives to address women-specific problems such as breast cancer screening and the provision of mental health services in female-only settings, have demonstrated that the NHS is capable of redesigning services in response to gender-specific needs. But the duty will require trusts' entire service remit to be tailored to men or women, and in areas that are not as obviously gender sensitive.

Very low base

Men's Health Forum chief executive Peter Baker welcomes the duty as a statutory recognition of the importance of gender equity - a drum the MHF has been banging for years - does he think the NHS is ready to make it a central plank of service and strategy?

'Not at all. The health service is starting from a very low base, ' says Mr Baker.

That low base includes, for example, a national service framework on coronary heart disease that recognises but fails to address glaring differences between the sexes. Women are naturally more prone to heart failure but men are more likely to die from it, due largely to their failure to present to doctors when symptoms begin. Conversely, tests for coronary heart disease are designed around men although women are known to experience different symptoms, creating a gap in diagnosis and clinical understanding.

That a national strategy ignores such worrying and well-known trends is indicative of the problems the duty could bring to light. It does not auger well for April 2007, says Mr Baker. 'Why is data for the major disease areas not gender disaggregated?' he asks. 'People don't know what's going on, it's not a priority and there's no training.

The NHS is notorious for its one-size-fits-all policies and this is another example of that.'

But it's not all doom and gloom. While the national picture is admittedly patchy, there are pockets of good practice around the country that, if championed, funded and shared, could point the way to a more equitable future.

Earlier this year, Epping Forest primary care trust undertook three small-scale studies to assess whether its male-specific services had responded to previously identified areas of need, and to establish ways of targeting these areas. The results were mixed. Every GP practice in the area had a 'well woman' clinic, but none had an equivalent service for men.

A randomised trial and interview-based study found men were quite willing to attend MOTstyle check-ups (a progressive solution to the well-publicised issue of male patients not presenting early enough to receive the most effective treatment) if invited to do so with a specific time and date for an appointment. But when invited to make their own appointments, the results were less impressive. This is an example of why services need to recognise the different ways men and women access healthcare.

The conclusions of the study were that services had to be active rather than based on an assumption that men would come to them.

Resulting initiatives included a 'health bus', a vehicle borrowed from the local police service that goes out to areas with poor primary care provision armed with leaflets, posters and a multidisciplinary team of health professionals equipped to perform on-the-spot check-ups.

Caroline Gunnell, nurse practitioner and research governance co-ordinator at the PCT and vice-chair of the Federation of Primary Care Research Organisations, says the scheme was a resounding success that further underlined the need for gender-specific services. She cites the example of men with a family history of stroke who would stop by for a blood pressure check and tell health workers they 'had been meaning to do it for ages', but for the fact they were always at work when their local GP practice was open.

Despite the project's success, Ms Gunnell says more needs to done in making gender equity a permanent fixture. 'It was a one-off project, an add-on made possible by the enthusiasm of myself and other staff. But it needs to be an ongoing priority for the PCT. We hope the gender equality duty will help with that.'

The danger is that, as the duty approaches, places like Epping Forest are the exception rather than the rule. For trusts looking to follow suit, Ms Gunnell says collecting gender-specific disease data is the crucial first step, and by most accounts this is not happening anywhere near enough.

And with the ongoing structural and financial upheaval in the NHS, the new legislation is by no means a guarantee of action.

'I hope we won't lose momentum with the reconfiguration, but we're lucky because we'll be merging with PCTs who are also doing good work on this, so whatever happens we'll have a merry band of brothers that keep banging on about it and hoping people take notice, ' says Ms Gunnell.

In Bradford, the Health of Men project is a fiveyear, Lottery-funded initiative that aims to improve men's health and tackle inequalities affecting them. Involving the former three Bradford PCTs and Airedale PCT (now Bradford Airedale teaching PCT) as well as various partner organisations, the project specialises in offering services in non-traditional settings such as pubs, barbershops, shops and betting shops. It also goes out to council employees' places of work - for example, working with men from the parks department (see pictures).

Health of Men business director David Newman is confident that the project will stand out as a pillar of good practice as the gender duty approaches. 'The good thing about the Bradford project is that it is something where others can look at what we've done and decide they need to be doing it, ' he says. 'We are on a learning curve for the rest of the NHS.' But even Mr Newman's enthusiasm is tempered by the uncertainty of restructuring: 'A lot rests on the newly reconfigured PCT in Bradford and whether new staff will see it as a priority. We don't know whether men's health will be kept as a dedicated service or absorbed into other areas. We simply don't know what the effects will be.' Again, the emerging picture is one of isolated pockets of good practice, with questionable permanence and a no clear sense of readiness on a national scale. By the time the gender equality duty kicks in, trusts will need to understand how services will have to be changed. But they must also be armed with the information to execute those changes ? trends such as those flagged up for male smokers and diabetes prevalence in women can only be identified if data is gathered with gender in mind. Like Men's Health Forum's Peter Baker, Ms Murray points out that vast reams of data on major disease areas are not separated by sex, something which evidence suggests the DoH should address.

'We did a small gender equity project last year with a lot of health bodies in it and, without fail, they all went to the DoH website for guidance and found nothing, ' says Ms Murray.

'NSFs for coronary heart disease and others will mention sex as a determinant at the beginning then won't say anything more about it.

It was impossible for health organisations to get a steer on the big issues. Rather than have however many hundred health bodies reinventing the wheel, we want something that says: &Quot;These are the 10 biggest issues in gender equality nationally ? you may have specific local problems to deal with, but this is where you should start.&Quot;' But if trusts are planning to use lack of data as an excuse for falling foul of the duty, they are unlikely to find a sympathetic ear at the DoH.

Director of equality and diversity Surinder Sharma says the duty is part of an overarching equality strategy in the NHS for which trusts have had more than enough time to prepare.

'The duty should not be seen as new. There's been a whole landscape of legislative changes in this area since 2004. If you look at National Standards, Local Action, it clearly states that targets and principles should be set to deliver equity. So they need to take into account differing needs of the local population in terms of socioeconomics, disability, age, faith, sexual orientation and gender, ' she says.

Asked whether trusts are ready, Mr Sharma shows little sympathy for delays: 'Trusts have to be ready. There should be no excuses. People have known about this for a long time and should have been building up to it.' It is an uncompromising stance, and Mr Sharma pulls no punches about where responsibility lies, although he reassures trusts and managers that they will have robust central support in the run-up to the duty.

The DoH is running a pilot programme on gender equality with nine trusts ? each with a 'buddy' trust to spread learning. This work will inform guidance that should be out by the end of 2006, followed by regional visits in January.

Where trusts require specific problem-solving help and support around gender equality and disability, they will be able to make use of secondees to the DoH, says Mr Sharma.

'We're producing the guidance, supporting staff and running workshops, ' he stresses. 'If people don't feel they've got the knowledge or expertise, we are willing to help but in the end boards, chief executives and non-executive directors will be liable.

'Let's not mince words, this is a legal duty. The help and support will be there, but the onus is on trusts.' .

Registered users of the HSJ website can find out more information on this topic at www. goodmanagement-hsj.co. uk/equality

HIT FOR SIX: THE EOC'S TOP TIPS

The Equal Opportunities Commission, which will be producing a statutory code of practice for the gender quality duty, makes six key recommendations:

• Collect data on the differences in how women and men access and use services and their satisfaction rates.
• Consult employees, service users, trade unions and other stakeholders. The key is to ensure that women and men provide input on gender-relevant issues.
• Assess the different impact of policies and practices on both sexes. For example, tests on coronary heart disease are designed to be performed on men, yet the symptoms in men and women are different.
• The national service framework for CHD recognises that CHD rates vary by gender, and this information can be used to assess the impact of trusts' policies.
• Identify priorities and set gender equality objectives. Priorities must be selected in consultation with stakeholders and by analysing all relevant information.
• Plan and take action.

In reaching your gender equality goals, it is important to focus on outcomes and specific identifiable improvements in policies. It may help to designate a lead for each objective with an achievable timescale and interim actions.

Publish a gender equality scheme by 30 April 2007 and supply an annual progress report.

Key points

In April 2007, the gender equality duty will make it obligatory for all health providers to actively demonstrate equity in service provision.

Good practice tends to exist in small projects with little evidence of national progress towards gender equity.

The DoH says trusts should already be working towards the duty and will have 'no excuses'.