Frontline Service EQIA

Equality Impact Assessment Tool for Frontline Patient Services

Equality Impact Assessment is a legal requirement and may be used as evidence for cases referred for further investigation for legislative compliance issues. Please refer to the EQIA Guidance Document while completing this form. Please note that prior to starting an EQIA all Lead Reviewers are required to attend a Lead Reviewer training session. Please contact CITAdminTeam@ggc.scot.nhs.uk for further details or call 0141 2014560.

1. Name of Current Service/Service Development/Service Redesign:

Esteem GG&C EARLY INTERVENTION SERVICE

2. Description of the service & rationale for selection for EQIA: (Please state if this is part of a Board-wide service or is locally determined).

A. What does the service do?

Esteem Glasgow and Clyde is an Early Intervention service that aims to provide a comprehensive mental health service for people experiencing a first episode of psychosis.

B. Why was this service selected for EQIA? Where does it link to Development Plan priorities? (if no link, please provide evidence of proportionality, relevance, potential legal risk etc.)

As part of GG &C health board objectives to tackle health inequalties,the need to review equal access opportunities in line with legislative changes and ongoing service improvement objectives.

3. Who is the lead reviewer and when did they attend Lead reviewer Training? (Please note the lead reviewer must be someone in a position to authorise any actions identified as a result of the EQIA)

Name:	Date of Lead Reviewer Training:
Ivano Mazzoncini	20/07/2015

4. Please list the staff involved in carrying out this EQIA (Where non-NHS staff are involved e.g. third sector reps or patients, please record their organisation or reason for inclusion):

	Lead Reviewer Questions	Example of Evidence Required	Service Evidence Provided	Additional Requirements
1.	What equalities information is routinely collected from people using the service? Are there any barriers to collecting this data?	Age, Sex, Race, Sexual Orientation, Disability, Gender Reassignment, Faith, Socio-economic status data collected on service users to. Can be used to analyse DNAs, access issues etc.	The service aims to provide a non discriminatory service to all patients referred. Our team data systems ( Psycis and PIMS) capture the data of all patients referred i.e. their age,gender ,socio economic status ,sexual orientation and disability . In addition, the service has been active in research funded by the Chief Scientist Office and this has provided a rich database of the actual services patients receive and the population we serve. We adopt a flexible ,home based care service which offers the patient and their family an active role in their treatment and journey to recovery. The service makes attempts to proactively engage each individual patient in their treatment and recovery so no patient would be discriminated against or not engaged with due to one of the protected characteristics	Re establishing our ICP and reasons for variance ( e.g if a review did not happen ) will ensure there are no 'accidental' access issues for patients or their families. It would also be good if the service could look at the routine data we collect and ensure that we are not' missing any groups' of people we may expect to access the service.
2.	Can you provide evidence of how the equalities information you collect is used and give details of any changes that have taken place as a result?	A Smoke Free service reviewed service user data and realised that there was limited participation of men. Further engagement was undertaken and a gender-focused promotion designed.	The service model was established based on values that are non discriminatory and patient/family focused. These values are underpinned by a theoretical and objective evidence base. We recognise that young people,across diagnostic groups and health difficulties do not engage well with services and in response to this we aim to be as flexible as is possible,we will assertively outreach our patients and we work in partnership with other service providers to make access to the service as accessible as possible. For example, we embrace diagnostic uncertainty and would offer treatment to people who had a range of complex needs such as psychosis and substance use. A recent research study was originally developed because we were aware there was a group of patients who did not make such a good recovery and who were less likely to engage in formal treatment approaches such as psychological therapy. By introducing research exploring the utility of an Integrated Care Pathway framework and a psychological formulation ( using a compassionate model) in particular, the service has been able to ensure all patients get access to psychologically informed care planning regardless of their ability to engage with formal therapy.	http://www.heraldscotland.com/news/14303715.Study_reveals_postcode_lottery_of_treatment_for_severe_mental_health_illness_in_Scotland/?ref=mr&lp=20 http://bjp.rcpsych.org/content/205/1/60 http://www.journalofpsychiatricresearch.com/article/S0022-3956(14)00091-0/abstract
3.	Have you applied any learning from research about the experience of equality groups with regard to removing potential barriers? This may be work previously carried out in the service.	Cancer services used information from patient experience research and a cancer literature review to improve access and remove potential barriers from the patient pathway.	We regularly explore the numbers of service users from ethnic minorities who access the service ( as traditionally this is a group who do not use mental health services. ) We established that our population percentages echoed that of the general population so we had successfully engaged patients and families from minority ethnic groups. Given high rates of mental health act detention processes in black and ethnic minority groups, it is important any psychosis specific service engages and tailors interventions appropriately. . Our leaflets all use plain language. Interpreters are employed where necessary	http://tinyurl.com/z6337vh We should annually review our caseload against up to date census information to ensure we are capturing the full range of the population we target.
4.	Can you give details of how you have engaged with equality groups to get a better understanding of needs?	Patient satisfaction surveys with equality and diversity monitoring forms have been used to make changes to service provision.	scottishrecovery.net	The service is currently working with the mental health network to lead focus groups to provide feedback from current service users. We are also auditing our family and friends potential attendees to explore any barriers to engagement, for example, a long journey
5.	Question 5 has been removed from the Frontline Service Form.
6.	Is your service physically accessible to everyone? Are there potential barriers that need to be addressed?	An outpatient clinic has installed loop systems and trained staff on their use. In addition, a review of signage has been undertaken with clearer directional information now provided.	As a home based care service, there are no barriers that would prevent us seeing someone. In one base the main office is on the first floor but in the circumstances that someone with mobility problems needs to attend the base for review etc then ground floor offices are used or we can arrange to see people in other facilities e.g their GP practice/ local CMHT. We also make arrangements to see people outwith 9 to 5 hours should the need arise, for example, if they cannot take time away from work or for family therapy sessions .
7.	How does the service ensure the way it communicates with service users removes any potential barriers?	A podiatry service has reviewed all written information and included prompts for receiving information in other languages or formats. The service has reviewed its process for booking interpreters and has briefed all staff on NHSGGC’s Interpreting Protocol.	Recent leaflet redesign has ensured the service complies with NHSGG&C Clear to all Policy. The operational policy was recently updated and approved at the appropriate groups. As communication is key, staff will demonstrate clear initiative to communicate with people for example, interpreters are booked and rebooked to ensure continuity of care. We also will seek advice from the COMPASS team to ensure we are communicating in the best possible way with patients from different cultures	Staff should be made aware of the phone no ro access ' emergency' interpreting services. The service should consider downloading an app for British Sign Language to be available
8.	Equality groups may experience barriers when trying to access services. The Equality Act 2010 places a legal duty on Public bodies to evidence how these barriers are removed. What specifically has happened to ensure the needs of equality groups have been taken into consideration in relation to:
(a)	Sex	A sexual health hub reviewed sex disaggregated data and realised very few young men were attending clinics. They have launched a local promotion targeting young men and will be analysing data to test if successful.	We have expected rates of male and female patients. Patients can request a male or female staff member, especially for sensitive interventions such as physical investigations or therapy for abuse. Staff have recently had training from the sexual abuse service on sensitive enquiry
(b)	Gender Reassignment	An inpatient receiving ward has held briefing sessions with staff using the NHSGGC Transgender Policy. Staff are now aware of legal protection and appropriate approaches to delivering inpatient care including use of language and technical aspects of recording patient information.	This characterististic would form part of our inital assessment and staff would explore a. the person's journey in the reassignment process/ how they wish to be addressed/ any distress or victimisation casued by their situation and this would be addressed during their treatment. Our recovery based approach would encompass all aspects of a persons' identity and well being. If necessary we can link with other specialist services such as the gender reassignment service at the Sandyford.	GG&C transgender policy to be circulated.
(c)	Age	A urology clinic analysed their sex specific data and realised that young men represented a significant number of DNAs. Text message reminders were used to prompt attendance and appointment letters highlighted potential clinical complications of non-attendance.	Esteem sees people between the ages of 16 and 35 years that have a first episode of psychosis. However we would also support any family member of any age who was distressed about their relatives illness.So, the criteria for older people being seen in the service is that they have to have a relative with a first episode of psychosis The rational for applying an age range is: 1. the incidence of first episode psychosis ( 80 % of cases occur between 16 and 35 years) 2.the evidence based model of care ( it has a developmental focus) 3.the economic factors 4. giving priority to a group identified as high risk of suicide ( because of their age and mental health problems)and who traditionally have poor engagement with mental health services. Our age range is in keeping with other Early Intervention services across the u.k. and internationally. The age range of Early Intervention services is objectively evidenced. Our aim is to target a group of patients otherwise disadvantaged due to poor uptake with services.i.e this age group traditionally do not engage with mainstream services. By targetting this group in this way we can improve outcome and reduce suicide rates. The effectiveness of EI services is summarised in the “ Guidance to support the introduction of access and waiting time standards for mental health services in 2015/2016” Dept of Health England. For older people who are referred with a first episode psychosis we would discuss the case and signpost on to more appropriate services. 1. 35% of people in EI services are in employment ( v 12% in other services) 2. rates of compulsory treatment drop from 44% to 23% during first 2 months 3. Suicide risk drops from 15 % to 1% https://www.gov.uk>uploads>file> "Achieving better access to mental health services by 2020"	We have recently identified the need to enquire, record and address parental mental health needs
(d)	Race	An outpatient clinic reviewed its ethnicity data capture and realised that it was not providing information in other languages. It provided a prompt on all information for patients to request copies in other languages. The clinic also realised that it was dependant on friends and family interpreting and reviewed use of interpreting services to ensure this was provided for all appropriate appointments.	This characterististic would form part of our inital assessment and staff would explore a. the person's sense of self in relation to Race and how this impacts on his wellbeing,his/her access to services and the choices that are made as the patient embarks on their journey to recovery. In this process/ how they wish to be addressed/ any distress or victimisation casued by their Race and orientation would be addressed during their treatment. There can be a clear relationship between race and trauma and our service aims to address this . Our recovery based approach would encompass all aspects of a persons' identity and well being. If necessary we can link with other specialist services such as interpreting service,specialist teams and social networks which support a person to reintegrate into their network of choice. We have good links with the Compass Team and access their expertise cross culturally if necessary.
(e)	Sexual Orientation	A community service reviewed its information forms and realised that it asked whether someone was single or ‘married’. This was amended to take civil partnerships into account. Staff were briefed on appropriate language and the risk of making assumptions about sexual orientation in service provision. Training was also provided on dealing with homophobic incidents.	This characterististic would form part of our inital assessment and staff would explore a. the person's sense of self in relation to sexual orientation and how this impacts on his/her wellbeing. We have a depth of experience in working with patients whose sexual orientation is a factor which requires our support . Indeed sexual identity development is a key task of adolescence and therefor something we would consider routinely as part of a formulation and care plan. It is helpful to say that for many of our service users sexual orieination is not an area that requires our involvement.It is an area that is identified at our intial assessment and is revisited if approriate throughout the patients stay. We would also see it as an area were we can draw on the support of specialist servcices and community based resources .
(f)	Disability	A receptionist reported he wasn’t confident when dealing with deaf people coming into the service. A review was undertaken and a loop system put in place. At the same time a review of interpreting arrangements was made using NHSGGC’s Interpreting Protocol to ensure staff understood how to book BSL interpreters.	As a service that aims to maximise independence and recovery we would aim to establish if and to what extent physical barriers and social structures impact and how we can support the service user to address or negate the impact. As the service users advocate ,if this is needed we would aim to represent their views and needs. This can include supporting the application for physical adaptation to a home address, the application for the award of benefits, attending medical review appointments and liasing with employers. A key goal for the team is that we support the process of enabling employment and vocational rehabilitation.
(g)	Religion and Belief	An inpatient ward was briefed on NHSGGC's Spiritual Care Manual and was able to provide more sensitive care for patients with regard to storage of faith-based items (Qurans etc.) and provision for bathing. A quiet room was made available for prayer.	This characterististic would form part of our inital assessment and staff would explore a. the person's sense of self in relation to their faith . We have established links with the chaplain at the hospitals, the universities and have also accessed the muslim womens group.
(h)	Pregnancy and Maternity	A reception area had made a room available to breast feeding mothers and had directed any mothers to this facility. Breast feeding is now actively promoted in the waiting area, though mothers can opt to use the separate room if preferred.	yes, we have a fridge for storing breast milk. We do not have craiche facilities but appointments are planned around child care arrangements. We also liase with GP's, social workers and other child protection agencies	please see reference to parental mental health needs
(i)	Socio - Economic Status	A staff development day identified negative stereotyping of working class patients by some practitioners characterising them as taking up too much time. Training was organised for all staff on social class discrimination and understanding how the impact this can have on health.	Yes this would be a key part of our assessment. There is clear evidence of a link between social deprivation and increased risk of psychosis. We have support workers trained in benefit maximisation. All team members have links with specialist services such as citizens advice and welfare rights. We have in the past accessed emergency housing and emergency money for people who are destitute. If necessary we would support and accompany service users to employment based hearings to support return to work. We would pay out of pocket expenses for certain social activities or attendance at meetings. We arrange appointments closer to home or at home to avoid unnecessary travel costs.	Recent developments in technology have highlighted the benefit of mobile phone apps and text reminders as a cost effective way of providing service contact
(j)	Other marginalised groups - Homelessness, prisoners and ex-offenders, ex-service personnel, people with addictions, asylum seekers & refugees, travellers	A health visiting service adopted a hand-held patient record for travellers to allow continuation of services across various Health Board Areas.	We would routinely offer a service to all these groups, in fact some such as homeless people , those with addictions and asylum seekers or from the travelling community probably make up quite a significant proportion of our caseload. Engagement and assertive outreach, home or locally based care provision and individually developed package of care all help to address the difficulties faced by marginalised groups. We also collaborate frequently with addiction services, trauma services, homeless services and the GP	The Scottish CHI system which allows for a single patient record across health board area's is helpful to avoid duplication or communication problems. We have access to Care First and equivalents across the council area's we overlap with this and these systems are helpful in identifying any vulnerable characteristics, services involved and risk/ management plans
9.	Has the service had to make any cost savings or are any planned? What steps have you taken to ensure this doesn’t impact disproportionately on equalities groups?	Proposed budget savings were analysed using the Equality and Human Rights Budget Fairness Tool. The analysis was recorded and kept on file and potential risk areas raised with senior managers for action.	The Esteem service has expanded into Clyde area and West Dumbartonshire with little extra resource and this is to ensure equality of access for all GG&C. Suggestions to lower the age range were previously rejected as this is likely to lead to the exclusion of women who tend to present with first episode psychosis at a later age.
10.	What investment has been made for staff to help prevent discrimination and unfair treatment?	A review of staff KSFs and PDPs showed a small take up of E-learning modules. Staff were given dedicated time to complete on line learning.	The service keeps an active training log, all staff are encouraged to pursue cpd opportunities and link these to KSF profiles. Equality and diversity training would be part of this. For example, many East team staff recently completed the LearnPro module on FGM at the time a service user was affected by this. Senior staff have also completed adult support and protection training. We routinely have bespoke child protection training developed in line with specific case studies which included hypothetical cases with protected characteristics. We have also undertaken an exit interview with patients leaving the service to clarify any way their care and treatment could have been improved. We routinely ask service users and carers to contribute to teaching and have experts by experience volunteering in the service

11. In addition to understanding and responding to our legal responsibilities under the Equality Act (2010), services have a duty to ensure a person's human rights are protected in all aspects of health and social care provision. This may be more obvious in some areas than others. For instance, mental health inpatient care (including dementia care) may be considered higher risk in terms of potential human rights breach due to removal of liberty, seclusion or application of restraint. However risk may also involve fundamental gaps like not providing access to communication support, not involving patients/service users in decisions relating to their care, making decisions that infringe the rights of carers to participate in society or not respecting someone's right to dignity or privacy.

Please give evidence of how you support each article, explaining relevance and any mitigating evidence if there's a perceived risk of breach. If articles are not relevant please return as not applicable and give a brief explanation why this is the case.

Right to Life

A key aim of the service is to reduce suicide rates in an at risk group and our research studies combined with our review of critical incidents have highlighted that we are effective at reducing suicide rates and therfore contribute to article 1

Everyone has the right to be free from torture, inhumane or degrading treatment or punishment

child protection procedures outlined above familiar with procedures to respond to domestic violence Additional training delivered by the police on child trafficking If necessary, clinicians will write reports to contrbute to immigration decisions about asylum status when we have received reports of patients receiving inhuman treatment in their country of origin

Prohibition of slavery and forced labour

Everyone has the right to liberty and security

At all times efforts are made to minimise the use of compulsory care including regular crisis contact of necessary. However, if compulsory detention procedures are required this would be done as compassionately and respectfully as possible and in all circumstances, the patients family would be kept aware of proceedings. People are actively encouraged to access legal representation and develop an advance statement. We continue to work with goals that would enable people to leave hospital more quickly such as arranging housing

Right to a fair trial

During the process of detaining a patient under the mental health act, the psychiatrists would also be advising the patient to their right to a lawyer and in some cases the team will facilitate this for people such as provide phone numbers/ accompany to appointments if requested

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

Our focus on the family by providing support/ information and if necessary therapy when their relative is ill, highlights our focus on the respect for family life

Right to respect for freedom of thought, conscience and religion

As unusual beliefs may be common in the population or may be a hallmark of psychosis, lengthy sensitive assessment of these usually clarify if the person's beliefs are culturally appropriate and they would be supported to practise in this regard A recent case example of a women who changed her religion daily from muslim to christian and her diet accordingly was accommodated during her inpatient stay

Non-discrimination

Staff would be encouraged to join their union

12. If you believe your service is doing something that ‘stands out’ as an example of good practice - for instance you are routinely collecting patient data on sexual orientation, faith etc. - please use the box below to describe the activity and the benefits this has brought to the service. This information will help others consider opportunities for developments in their own services.

Following a recent research study ( Glasgow Edinbrugh study) we identified a cohort of patients who were not making as good a recovery as we hoped. By assessing the quality of their relationship with their keyworker we were able to capture the people who were at risk of poorer recovery and by adapting our Integrated Care pathway to provide a compassionate based formulation of the person's difficulties, we were able to increase the access this group had to psychological therapy and decrease use of compulsory measures.