Equality Analysis and Impact Assessment Tool

Transcription

1 Equality Analysis and Impact Assessment Tool Electro Convulsive Therapy (ECT) Policy& Procedures Equality Impact Assessment (EIA): 1

2 The following process should be used when revising, introducing or measuring new: - policies - strategies - procedures - services - project - function - Procurement Will be referred to as activity throughout the document Six Steps to carrying out Equality Analysis and Impact Assessment Step 1 Identify who is responsible for the analysis Step 2 - Establish the relevance to equality and protected groups Ensure you consult the right people, identify how you have consulted with them and document which protected groups you have consulted with. Identify the aims and objectives of the analysis and assessment Step 3 - Scope your equality analysis and impact assessment Identify what equality data is available to support you and if there are any gaps e.g. service user data, demographic data, public health prevalence, workforce profiles, health needs assessments, complaints and comments, other equality analysis and impact assessment, judicial review findings etc. Do your Human Rights Screening see guidance for the screening tool Step 4 - Analysing your equality information Ensure you include and reference all the evidence you have considered as part of the analysis. Ask what will happen, or not happen if we do things this way? Remember that equality analysis is not just about identifying and removing 2

3 any negative effects or discriminatory decisions or practice but is about demonstrating DUE REGARD to the general duties of the Equality Act. Ensure your decision regarding the extent of the impact includes: i. how you arrived at that decision and ii. how you have shown DUE REGARD to the equality duty aims The General Duties of the Equality Act are: to eliminate unlawful discrimination, harassment and victimisation to advance equality of opportunity between different groups to foster good relations between different groups Step 4 - Document the findings of the analysis No change the analysis shows the policy is robust and evidence shows no potential for discrimination Adjust the policy take steps to remove barriers or to better advance equality complete the action plan Continue the policy adopt your proposals despite any adverse effect or missed opportunities DOCUMENT the RISK ASSESSMENT and ensure it goes on the risk register where necessary. Complete the action plan setting out how you will mitigate the risk. Stop and remove the policy the adverse effects and risk are not justified and cannot be mitigated. Privacy Impact Assessment you need to carry one out contact your Information governance Team to support you. Step 5 - Monitoring and review identify How you will measure the effects of the policy once it is implemented When the policy will be reviewed and what might trigger and earlier review e.g. policy change Who will be responsible for monitoring and reviewing the policy and the equality analysis action plan if in place What type of information is needed to undertake the monitoring and review and how often will it be analysed How will you engage stakeholders in implementing, monitoring and reviewing the policy? Step 6 - Decision making and publication b. Send your completed Impact Assessments to the Diversity and Equality Lead for Scrutiny and sign off. c. Equality analysis is on-going and should be carried out as part of the ongoing policy review. d. All analysis decisions should be published on the Trust Website 3

4 Details Manager or Sponsoring Directors Name: Department/Directorate: Service/Team: Assessment Lead: Professor Max Marshall ECT Lead Consultants ECT Lead Nurses Mental Health (Adult & Older adults) ECT Suites Pam Tester, NICE Guidelines Lead Telephone: Who else will be involved in undertaking the equality analysis and impact assessment: Who are you involving and consulting with? ECT Lead Consultants ECT Lead Nurses Ideally service users who have received ECT would be consulted, this will be considered in a review of the policy. ECT Lead Consultants ECT Lead Nurses Pam Tester, NICE Guidelines Lead Phil Hesketh, Mental Capacity Act Project Manager Consultant Anaesthetists at Royal Preston Hospital, Royal Blackburn Hospital, Blackpool Victoria Hospital How are you consulting with people from different Protected Characteristics? We haven t but this will be considered in a review of the policy. Who does the policy or decision being made impact upon? Service Users Yes No Indirectly Carers or family Yes No Indirectly General Public Yes No Indirectly Staff Yes No Indirectly Partner organisations Yes No Indirectly Signature: Date: 4

5 What is being analysed and assessed? Name of activity : ECT treatment Implementation Date: ECT has been delivered by the Trust since pre-2003, this policy will be ratified from November 2012 How was the need for the activity identified? As part of work completed to implement NICE TA59 ECT How is the activity meeting that need? It is bringing together the 3 previous protocols and ensuring a Trustwide policy and procedure is available for this What is the activity looking to achieve? To have a policy that outlines how ECT treatment will be delivered within a safe, evidence based and ethical framework What are the aims and objectives? To ensure a policy is approved that identifies clear roles and responsibilities for ECT Leads, and that legal and ethical obligations are made explicit. Services currently provided: There are currently 3 ECT suites in the Trust Recommendations following change in service: Convene an ECT working group and review consent forms and written information to make it more accessible. Review the proportionality of those services who received ECT treatment What Evidence have you considered as part of the Equality Analysis and Impact Assessment? National Institute for Clinical Excellence. Final assessment report: Electroconvulsive therapy (ECT) for Depressive Illness, Schizophrenia, Catatonia and Mania. Guidance No nd May Efficacy and Safety of Electroconvulsive therapy in Depressive Disorders: a systematic review and meta-analysis. The UK ECT Review Group. The Lancet. Vol th March The ECT Handbook. Second Edition. Council Report CR128 Royal College of Psychiatrists The practice of Electrode Convulsive Therapy. Task Force Report of the American Psychiatric Association. 2nd Edition MCA Code of Practice 2005 Code of Practice Mental Health Act NICE (2009) Depression. CG90. NICE October

6 Does the activity have the potential to: Have a positive impact (benefit) on any of the groups? Explain how Have a negative impact / exclude / discriminate against any person or group? Explain how this was identified? Evidence/ Consultation? Equality Analysis and Impact Assessment Group Age Disability Marriage & Civil Partnership Pregnancy and maternity Race Religion or belief Positive (Y/N) Y Y Negative (Y/N) Y Y Don t know DK Reasons for positive / negative impact (Please include all evidence you have considered as part of your analysis e.g. population statistics, service user data broken down by equality group (e.g. those undergoing liposuction in the last 12 months including ethnicity, gender, age, disability/long term conditions). Older people are more likely to fall into the categories where NICE recommends ECT treatment (i.e. severe Depression) and therefore be treated with ECT. NB The ECT leads have developed procedures for ECT in older people, and for people under the age of 18 There is a procedure for co-morbidities, and ECT suites are accessible to people with disabilities. NB We do not have written information in braille or large font action point None identified The ECT Leads have considered this and have developed a procedure for delivering ECT to service users who are pregnant. The medical (pre-ect) assessment considers pregnancy. The medical (pre-ect) assessment considers sickle cell. NB We do not have written information in other languages action point None identified, but the group acknowledges it needs to be assured of this action point Guidance Please refer to the guidance notes NB: Requires (existing or new) consultation with relevant people who are from these groups or who have knowledge insight into these groups. N.B. Marriage & CP is only protected in terms of work-related activities NOT service provision (please refer to guidance notes) 6

7 Sex Sexual orientation DK Prescription / dose of ECT is individualised dependent upon factor such as weight. None identified, but the group acknowledges it needs to be assured of this (query re ECT being used in previous decades to cure people of homosexuality) action point If no negative impacts have been identified please explain why Does the activity raise any issues in Gender reassignment Vulnerable Groups Deprived Communities Carers Other (please state) Y DK DK The pre-ect medical assessment would ensure any surgery was highlighted and that the service user is fully fit for anaesthetic / ECT treatment, but does not specifically ask this question action point Capacity and consent procedures are fully followed. Not applicable, although advice is given to any carer looking after a service user post ECT Yes, article 5. The MHA, MCA would be strictly adhered to if a service user was detained and prescribed ECT. A lack of negative impacts must be justified with evidence and clear reasons. Highlight how the policy negates any possible negative impacts. See the Guidance Notes It is important to 7

8 relation to Human Rights as set out in the Human Rights Act 1998 Have you carried out the Privacy Impact Assessment Yes No What is the overall cost of implementing the activity? What were the findings of the privacy impact assessment when carried out: Not applicable, this isn t a new service and the information is going to be collected and recorded as all clinical information is. A PIA would only be required if we were sharing this information outside the Trust in a new way. (Confirmed by Sue Stone, ) Cost & Source(s) of funding ECT is already funded within existing network budgets. This policy will not impact upon this, but we may need to identify a budget for providing accessible written information. note that if the decision removes or engages a person s absolute right the policy/decision will need to be changed. Where it is a Limited or Qualified Right the decision needs to be proportional and legal. Representatives from IM&T will make this decision as part of the scrutiny process Input cost e.g. Financial investment, HR, to realise and achieve benefits of the activity Source e.g. specific funding stream, pooled budget or mainstream budget 8

9 What are the benefits? What targets/indicators will be used to measure these? Benefit Indicator For example EDS Equality Tool for NHS Care Quality Commission (CQC) Outcomes Impact Assessment Risk Score See Appendix 1 Score: Actions to minimise risk: Action following analysis: No major change in policy Adjust policy Continue policy We do not to change the policy, as we have developed protocols for those client groups identified as impacted; but we may need to adjust some of the documents that are referred to in the policy, i.e. written information. (Agreed with Clive Taylor ) See page 7 above. It is important that the correct option is chosen depending on the findings of the analysis. The action plan and risk assessment must be completed as required. Stop and reconsider policy 9

10 Action Plan What is the negative/adverse impact? Written information in braille or large font is not currently available Written information / consent forms in other languages is not currently available Risk Score current target Actions required to reduce/eliminate the negative impact Reconvene ECT Leads working group and establish demand / develop as appropriate Reconvene ECT Leads working group and establish demand / develop as appropriate Resources required* (see guidance note below) Unsure yet, potentially small Potentially yes, to be determined Who will lead on action? ECT Leads collectively ECT Leads collectively Target completion date November 2012 November 2012 The pre-ect medical assessment does not include a specific question about gender reassignment 1 1 Reconvene ECT Leads working group and establish if the assessment form needs amending No ECT Leads collectively November 2012 The ECT Leads are unaware if the amount of ECT prescribed is in proportion to the communities they serve 2 1 Reconvene ECT Leads working group and identify proportionality of ECT Time to identify and analyse data ECT Leads (with support from corporate staff) January 2013 * resources required is asking for a summary of the costs that are needed to implement the changes to mitigate the negative impacts identified. 10

11 Monitoring and Review Monitoring The responsibility for establishing and maintaining the monitoring arrangements of the EIA action plan lies with the service completing the EIA. These arrangements should be built into the performance management framework. The Impact Assessment action plan will also be visible at a corporate level through the scrutiny and sign off of the EIA summary by the Equality and Diversity Lead. Monitoring arrangements for Impact Assessments and there subsequent action plans will be achieved at a strategic level, through the Strategic Equality and Diversity Group. Please describe briefly, how the action plan will be monitored? E.g. Monitored by departmental E&D group Strategic D&E Group - NHS ECT Leads working group will reconvene in November 2012 and work through the actions identified with a deadline of January 2013 Review The responsibility for establishing and maintaining the review arrangements of the Impact Assessment and the action plan lies with the service completing the Impact Assessment. Date of the next review of the Impact Assessment? It should be reviewed at least every three years to meet legislative requirements How often will the EIA action plan be reviewed? When policy and procedure is next reviewed ie 3 years. During progress, every month until completion, then in 3 years. 11

12 Who will carry out this review? References (websites, journals, reports etc) ECT Leads Anecdotal, experiential mainly but also based on the underlying data in the NICE guidance. One of the actions of the group is to review proportionality and establish more information about the communities the ECT suites serve. Please identify additional sources of information you have accessed to complete the EIA. Signature of person completing the impact assessment: Signature of Equality and Diversity Lead or Scrutiny group representative: Date Completed: Date received: Signature of Network / Service Lead: Date Completed: Date Scrutinised: Date Signed Off:

13 Appendix I - Impact Assessment Risk Grading Severity score Descriptor Objectives / Projects Injury Client/Patient Experience Service / Business Interruption Staffing and Competence Insignificant Minor Moderate Major Catastrophic <5% over budget / 5-10% over budget / 10-25% over budget / >25% over budget / schedule slippage. Minor schedule slippage. schedule slippage. Does schedule slippage. Does reduction in scope or Reduction in scope or not meet secondary not meet primary quality quality objectives objectives Insignificant cost increase / schedule slippage. Barely noticeable reduction in scope or quality Minor injury not requiring first aid Unsatisfactory client/patient experience not directly related to patient care Locally resolved complaint Minor injury or illness. First aid treatment needed Unsatisfactory client/patient experience readily resolvable Justified complaint peripheral to clinical care Loss / interruption up to 1 hour Loss / interruption up to 8 hours Short term low staffing level temporarily (<1 day) reduces service quality Ongoing low staffing level reduces service quality RIDDOR / Agency reportable Mismanagement of client/patient care Below excess claim. Justified complaint involving lack of appropriate care Loss / interruption up to 1 day Late delivery of key objective / service due to lack of staff. Minor error due to poor training. Ongoing unsafe staffing level Loss 0.25 to 0.49% of budget Major injuries or long term incapacity / disability (loss of limb) Serious mismanagement of client/patient care Claim above excess level. Multiple justified complaints Loss / interruption up to 1 week Uncertain delivery of key objective / service due to lack of staff. Serious error due to poor training Death or major permanent incapacity Totally unsatisfactory client/patient outcome or experience Multiple claims or single major claim Permanent loss of service or facility Non-delivery of key objective / service due to lack of staff. Loss of key staff. Critical error due to insufficient training Financial Loss <1% of budget Loss 0.1 to 0.24% of budget Loss 0.5 to 0.99% of budget Loss >1% of budget Potential cost Up to 50k Up to 100k Up to 500k Up to 5million Over 5 million Inspection / Audit Minor recommendations. Minor Prosecution. Zero rating. non-compliance with standards Severely critical report Recommendations made. Non-compliance with standards Reduced rating. Challenging recommendations. Noncompliance with core standards Enforcement action. Low rating. Critical report. Major non-compliance with core standards 13

14 Adverse Publicity / Reputation Contained within the organisation. Rumours Local media short term. Minor effect on staff morale Local media long term. Significant effect on staff morale National media up to 3 days National media >3 days. MP concerns (Questions in the House) 14

15 2 Likelihood score Descriptor Rare Unlikely Possible Likely Almost Certain Frequency Not expected to occur for years Expected to occur at least annually Expected to occur at least monthly Expected to occur at least weekly Expected to occur at least daily Probability <1% 1-5% 6-20% 21-50% >50% Will only occur in exceptional circumstances Unlikely to occur Reasonable chance of occurring Likely to occur More likely to occur than not 1 (severity) x 2 (likelihood) = total risk score and rating Severity Likelihood Low 2 Low 3 Low 4 Moderate 5 Moderate 2 2 Low 4 Moderate 6 Moderate 8 Significant 10 Significant 3 3 Low 6 Moderate 9 Significant 12 Significant 15 High 4 4 Moderate 8 Significant 12 Significant 16 High 20 High 5 5 Moderate 10 Significant 15 High 20 High 25 High 15

16 Equality Analysis and Impact Assessment Checklist An Equality Impact Assessment (EIA) is a tool for identifying the potential impact of the organisation policies, services and functions on its residents and staff. EIAs should be actively looking for negative or adverse impacts of policies, services and functions on any of the nine protected characteristics This document contains a number of questions/prompts to assist team leaders and managers to ensure they have met the necessary requirement to complete Equality Impact Assessments. NB: Policy/strategy/procedures/services/projects/functions commissioning or decommissioning decision will be referred to as activity throughout the document. Checklist Area/Question Yes/No /Unsure Identify who is responsible for the analysis Has all the data been included and signature of sponsoring Director/Manager? Have you included information on the consultation process and who you have consulted with including: Service users from a range of protected characteristic groups where applicable Staff side/unions where applicable Employees where applicable Who are the stake holders - have you identified who is impacted upon and whether there is any positive or negative impact Establish the relevance to equality and protected groups Have you clearly identified the activity you are analysing? Have you identified what the aims and objectives of the activity you are analysing are? Have you highlighted what services are currently provided and any recommendations that have arose following this assessment? 16

17 Scope your equality analysis and impact assessment Have you considered how your activity will impact on all relevant protected groups including minority and vulnerable groups? (Useful prompts and supporting material available in guidance notes). Does the activity promote equal opportunities? Have you included evidence to support your reasons for the decision for each relevant protected group? Where there is evidence of indirect discrimination in relation to any protected groups or direct discrimination arising from Disability have you provided sufficient evidence to justify continuance to a court of law, Judicial review or Employment Tribunal? Where no negative impacts have been identified for each characteristic, have you justified the decision? Have you undertaken the Human Rights Screening and where applicable considered alternative approaches to minimize detrimental engagement of peoples human rights? Have you identified the overall costs of implementing any activity needed and included this in the impact assessment? (including time, role, workload and costs) Have you identified what the benefits are and how these will be measured e.g. equality of outcomes for different protected groups? Have you undertaken the risk assessment and included the score and rationale? Have you identified what action will be taken with the policy and why following the analysis? Does the activity include specific measures to compensate for any reduction in the level of public sector service provision? Have all potential opportunities arising from the proposed changes been fully identified and realised? Analysing your equality information & Document the findings of the analysis Have you moved all identified negative impacts to the Action Plan template and identified the current and target risk score? Have you identified actions to reduce or remove any negative impact? Have you identified all resources required including: Financial Training And Human resources 17

18 Monitoring and Review identity & Step 6 - Decision making and publication Have you identified how the action plan will be monitored? Have you identified when it will be reviewed and who will be responsible for this review? Has the Impact Assessment been signed by the person completing the impact assessment? Has the Impact Assessment been signed by the head of service / directorate lead? NB: Supporting literature and useful questions are supplied within the EIA Guidance to assist managers and team leaders to complete all EIAs. 18

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