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Guidance and Tools (Equality Analysis)

Note: If you require this document in a different format or language, please contact equality@ldh.nhs.uk

1. What is an Equality Analysis (EA)?
Equality Analysis (EA) supersedes the need to carry out Equality Impact Assessments and is a requirement under the Equality Act 2010 for public sector organisations. An Equality Analysis is a way of thinking about the impact that a policy, strategy, project or service may have on different groups within the community including staff, service users and carers as a result of their Personal Protected Characteristics. These may be people from different ethnic groups, different age groups, different religions, different genders, disabled people and people with different sexual orientations.

Ultimately, EAs are about how we treat people and reflecting on whether we are being fair in all we do. An EA consists of two stages:

  • An EA Screening process and,
  • A full EA if the initial screening has identified a possible high negative impact.

We will use the word to ‘proposal’ to mean all policies, strategies, projects and services. This is to highlight that an assessment should form part of the process from inception and be given consideration throughout.

2. Why do we carry out EAs?
Because we want to: The aim of an EA is to ensure that all our activities as a Trust help to promote equality, challenge discrimination and are genuinely accessible to all. EAs offer a proactive approach to achieving fair and appropriate outcomes for staff, the local community and service users.

Because we have to: They also help us fulfil our legal obligations under equality legislation. Previous equality legislation, such as: the Race Relations Act 2000, the Disability Discrimination Act 2005 and the Gender Equality Act 2006, stated that public sector organisations need to undertake race, disability and gender impact assessments on new and existing policies.
These pieces of legislation have now been superseded by the Equality Act 2010, which provides a Public Sector Equality Duty on all public authorities. This includes a General Duty and a Specific Duty on public sector organisations to pay “Due Regard” to the 9 Personal Protected Characteristics when developing and reviewing a proposal. The personal protected are:

  • Age
  • Disability
  • Ethnicity
  • Gender or Sex
  • Gender Reassignment or Transgender
  • Marriage or Civil Partnerships
  • Pregnancy or Maternity
  • Religion or Belief
  • Sexual Orientation

The Act also requires public sector organisations to publish the results of EAs undertaken to demonstrate transparency and openness to eliminate discrimination and reduced health inequalities.

3. When should we do EAs?
An EA should be carried out when developing a new proposal, reviewing or amending an existing proposal (policy, strategy or service redesign) or when the Trust has identified an initiative specifically requiring an EA. An EA will be most effective when it is carried out as the proposal is being created or developed, as part of the whole process rather than an add on at the end of the process. It will also require open and honest assessment of the potential impact on people because of their personal protected characteristics.

4. Who should be involved with an EA?
The manager responsible for the proposal under consideration is the person responsible for ensuring that an EA is carried out. It is also very important to involve any other relevant staff in the process, and where necessary, community members from the 9 protected characteristics, to provide scrutiny and challenge of the established way of doing things. It is also important to make use of relevant qualitative and quantitative data in relation to the proposal to assist with the decision making process.

If a full EA is necessary, then there will a need for involvement from a wide range of stakeholders through appropriate consultation. Ultimate accountability for ensuring that EAs are completed and published lies with the Trust Board. The Chief Executive and Board should ensure that governance arrangements are in place to provide assurance that EAs are being undertaken on the development and review of all proposals.

5. Positive, Negative, Low, Medium and High Equality Impacts:
A negative impact is when a person or a group of people is left at a disadvantage as a result of their particular personal protected characteristic(s). This may result in an action or initiative that will minimise, reduce or eliminate the impact, or the justification of that negative impact.

Example: An event that was held in a building with no induction loop facilities would have a negative impact on some attendees with a hearing impairment.

A positive impact is when a proposal could have a positive effect on one or more groups or communities, or improve equal opportunities and/or relationships between communities. The Trust should always look to making a positive impact and share or celebrate with wider protected characteristics.

Example: A targeted training programme for black and minority ethnic women would have a positive impact on black and minority ethnic women. It would not, however, necessarily have a negative impact on white women and men.

Low – The proposal has limited or no relevance to the Public Sector Equality Duty and little impact on people as a result of their personal protected characteristics.

Medium – There is some concern or some evidence available that people from different personal protected characteristics may be affected, positively or negatively. The proposal may be relevant to parts or all of the Public Services Equality Duty.

High – There is strong evidence/concern to suggest that different groups will be affected as a result of them belonging to a particularly personal protected characteristic. The policy/function is relevant to the Public Sector Equality Duty.

The EA process requires either a good awareness level of the discrimination that could be faced by different groups, or some support from a wider group of people to carry out of the screening. The process may appear confusing to begin with and it is not the intention that one individual should complete the form in the first instance without the support and advice of others. Further support can be provided by the Equality and Diversity Officer who is accountable for the delivery and implementation of equality analysis within the Trust.

At the screening stage, you are trying to assess obvious negative or positive impact or important gaps in the Trust’s knowledge and information about likely impact. It is worth noting that what is being considered is the practice surrounding or resulting from the proposal as well as the proposal itself. The best way to find out if a proposal is likely to impact negatively or positively on sections of the community, is to analyse existing data or research already in existence, or to directly consult representatives of those groups or relevant organisations. If there is no data available, it is important to state how data will be collected in the future.

6. Partnership Working
The statutory duty to assess the impact of policies and functions on equality apply to partnerships and contractual relationships. The EA procedures apply to all proposals where the Trust is the lead agency in a multi-agency partnership. On joint projects and initiatives where the Trust is not the lead organisation, the Trust should raise the issue of the need to carry out an EA in order to comply with the requirements of the Equality Act 2010 and the public sector equality duty.

7. Guidance and notes for completing the EA Screening Form
The screening form is used to identify impacts on people as a result of their personal protected characteristics and highlight any changes that could be made as a result of the assessment. It is also used to determine whether a Full EA is required. The form also gives an opportunity to record and celebrate positive impacts that the proposal might have on different groups.
The initial section asks for basic details on who is completing the form, purpose and aims of the proposal, and who will benefit from it. The second section takes the form of a table listing the different groups or issues which may be impacted on as a result of the proposal. There is a column to add comments on how you think a particular group may be impacted upon either positively or negatively. The final section of the form is for recording the overall level of impact and details of the decision of whether to proceed to a Full EA as well as a record of any changes that need to be made to minimise negative impact.

8. Guidance and notes for completing the Full EA Form:
If the screening form has highlighted a possible high negative impact it will be necessary to carry out the Full Equality Analysis process. The first section of the form asks for details of the particular areas of concern and a summary of the high negative impact areas highlighted in the screening form.

The next section asks for details of any planned consultation, or any consultation that has already taken place, around the issues of concern. This might be with relevant community groups, reference groups or with staff groups.

There is also an opportunity to look at any national, local data or research about the potentially disadvantaged groups. For example, if you were considering the impact of a new patient assessment process which did not take account of people’s religious needs, this would be regarded as a high negative impact for people of different religious groups. In carrying out a Full EA Assessment, you may want to look at research around culturally sensitive assessment tools, the benefits of meeting people’s spiritual needs, human rights issues around this area of care etc. It is also beneficial to give consideration to existing work streams, such as Respect and Dignity, Essence of Care and Patient-Led Assessments of the Care Environment.

You may want to talk with local religious groups about what needs to be included in the tool and you may want to look at local demographics around religion and belief. There is then a chance to identify any gaps which you are aware still remains in terms of information to support necessary changes.

The final section on the form is the creation of an action plan for changes that need to be made, with details of how this will be monitored and reviewed. Further support can be provided by the member of staff responsible for the delivery and implementation of Equality and Diversity for the Trust.

9. Prompts to consider as you’re developing your proposal

  • Does the proposal affect our general duties to?
  • Promote equality of opportunity?
  • Eliminate discrimination?
  • Eliminate harassment and victimisation?
  • Promote good community relations?
  • Promote positive attitudes towards disabled people?
  • Advance equality of opportunity between different groups?
  • Consider more favourable treatment of disabled people?
  • Consult and Involve?
  • Protect and promote human rights?

10. Training
It is vital that the members of staff responsible for the implementation of EAs have the relevant competencies to carry out their roles. The Trust will provide the necessary training to support staff in the following areas:

  • Chairs and Vice-Chairs of committees and groups where proposals are presented
  • Relevant managers who develop and review proposals
  • Members of staff who develop, review or implement care pathways
  • Members of staff involved in organisational restructuring and redesign
  • Members of staff who carry out commissioning and procurement for the Trust

The above list is not exhaustive and should be seen as a guide. If there is a need for you or someone you manage requires EA training, then it is vital that they attend the training and reduce the risk for the organisation.

11. Standard Proposal Statement:
The very nature of EA is that the demographics and needs of the communities we serve are in constant change and having conducted an EA may not identify all of the positive or negative impacts on the people as a result of their personal protected characteristics. Therefore, to provide assurance to the Trust, the following statement should be used on all proposals:

“An EA has been conducted on this policy and where possible all negative impacts identified at the time of development have been considered, reduced, removed or justified. If however at the time of implementation a negative impact is identified, please inform the responsible manager or the Trust Secretary so that the relevant action can be taken”

12. Governance and Monitoring of EAs
As previously mentioned, the completion of an EA is the responsibility of the manager who is developing or reviewing the proposal. A completed form (screening or full assessment) with the Action Plan is to be attached to the proposal when being presented to the relevant policy approval group.

Proposals that are being presented to the Trust Board must provide assurance to the Board that an EA has been conducted by completing the relevant section of the front page of the proposal.

It is vital that the Chairs of committees within the Trust are fully aware of their responsibilities to challenge proposals where an EA has not been conducted.

For the purposes of transparency and openness, a list of completed EAs is required to be published on the Trust’s Internet site.

The Equality and Diversity Officer will carry out regular audits or checks to ensure that EAs are being conducted correctly and support implementation, wherever necessary, and to ensure that any themes which arise that should be addressed more widely than at Divisional level, are discussed at the Equality and Diversity Committee or taken to the Executive Board.

It is the responsibility of the Division in which the EA has been undertaken, to ensure that any resulting actions are incorporated into the planning, review and reporting processes of that area.

When you have completed the EA Screening Form, or the Full EA Assessment Form, please send a copy to EqualityAnalysis@ldh.nhs.uk along with a copy of the proposal.

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