‘Inequalities Sensitive Practice’ is central to Goal 5. This kind of practice involves taking into account underlying issues of social inequality, such as money worries or gender-based violence, in order to improve the health of individual people. Evidence shows that if these issues are not taken into account by the health service, opportunities are missed to improve health and to reduce health inequalities.
An Inequalities Sensitive health practitioner:
- understands the impact that inequality has on a patient’s experience of life and health
- doesn’t judge and understands power within the practitioner/patient relationship
- is sympathetic and has good listening skills which enables the patient to tell their story, thus making it ‘real’
- challenges in a sensitive way, providing alternative options
- takes a person centred approach
From 2006 to 2009, NHS Greater Glasgow and Clyde delivered an Inequalities Sensitive Practice Initiative which produced evidence and resources for staff.
The organisation now has a number of programmes of work aimed at ensuring our services know and understand their responsibilities in identifying and responding to experiences of social inequalities.
Evidence of good practice across NHSGGC
Healthier Wealthier Children
Working in partnership to tackle child poverty and inequality can produce meaningful and far-reaching results. The Scottish Government-funded Healthier, Wealthier Children project has been operating in the NHS Greater Glasgow and Clyde area since October 2010 and has succeeded in embedding financial inclusion referrals into care for pregnant women and families that are experiencing or are at risk of poverty.
Key to the project is the ethos that tackling child poverty is everyone’s business, and that money and debt worries need to be routinely discussed as part of assessments. It brings together maternal and early years health and social care professionals with voluntary sector providers of money advice, debt advice, and income maximisation services which explore benefit and tax credit entitlement. Onward referrals from advice services are also made to address related issues such as fuel poverty, homelessness, addiction, mental health and immigration advice.
At the end of March 2012, 3853 referrals had been made to advice services which resulted in 54% uptake among pregnant women and families. Six out of 10 people accessing the advice services received some type of intervention with a total annual recorded gain of just over £2.7 million (for 644 referrals) and £328,000 in one-off lump sums (for 370 referrals). The majority of referrals – 80% – were made by midwives and health visitors.
The project achieved its aims of increasing access to money advice services for equality groups. Women are more at risk of poverty due to the gender pay gap, occupational segregation, part time working and caring roles. Evidence also shows that women are more likely than men to go without food and clothes in families experiencing poverty with a female and male composition. 94% of referrals in this project were women This is particularly encouraging as pregnancy & childbirth can be risk times for increased financial hardship.
The majority of referrals were single parents. 17% of referrals were from BME communities (83% White Scottish / British / Irish; 6% Pakistani; 3% Polish; with a range of other ethnic groups referred also).
A NHSGGC wide Equality Impact Assessment (EQIA) was carried out early on in the project with some areas carrying out local EQIAs, which supported marketing to equalities groups.
Within the health board area 10 community health (and care) partnerships and 6 local authorities are involved in the delivery of the project, which is being evaluated by the Glasgow Centre for Population Health. A learning network has been established to share information and support emerging good practice across the partnership.
For more information and detailed case studies visit the HWC web site.
Gender based violence
Gender Based Violence (GBV) is recognised as being a major public health issue causing pain, injury and suffering, particularly to women and children and as such is an important contributing factor to poor health outcomes for individuals attending NHSGGC services. It is known that all health staff have a unique and crucial role in identifying and supporting all those affected by it.
GBV and Maternity Services
In NHSGGC, routine enquiry about domestic abuse was introduced at the maternal history taking visit prior to the issuing of CEL_41 (2008). However, it wasn’t a uniform roll-out as it occurred prior to the amalgamation of NHS Argyll & Clyde and Greater Glasgow NHS.
Early on in maternity services, the work to embed routine enquiry about domestic abuse was supported by 3 midwives, who received intensive training around gender based violence (GBV). These staff now co-ordinate a strategic response to GBV in all of the Women’s and Children’s Directorate.
The approaches have been different for Greater Glasgow and Argyll & Clyde areas with a wide range of work carried out over the years including:
- Assessing midwives training needs and what they perceived were the barriers to routine enquiry
- Ensuring that service issues were addressed for all areas (e.g. ensuring that all staff were introducing private time)
- Development of a rolling programme of basic awareness and skills based training (the latter provided by the Women’s Support Project)
- Standards of care were written (based on the All Wales Pathway but following the incremental stages of establishing a pathway for routine enquiry) and a set of competencies
- Mentoring for staff who lacked confidence after initial training in how to ask the question sensitively and responding to disclosures. (e.g. the mentor sits in through two booking visits feeding back after each one so that the midwife is aware of the improvements (if any needed) in her approach, & developed a range of practical case studies to work with mentees on how to deal with disclosures)
- Evaluation and monitoring of routine enquiry and mentoring
GBV and Sexual Health Services
The Sandyford Initiative provides all specialist sexual health services within NHS Greater Glasgow and Clyde. A GBV Policy was developed in January 2011. It sets out procedures for supporting staff to identify and respond appropriately to clients who have experienced gender-based violence, or who are perpetrators of gender-based violence. It also provides up to date information about all forms of GBV and appropriate support services available for referral.
Given the significant levels of gender-based violence within the population and its consequences for health and well-being it is important for staff working in sexual health services to have the competence and confidence to ask about GBV including domestic abuse. Sandyford staff already regularly deal with people who have experienced abuse, whether or not the abuse is a direct or indirect cause of their presenting condition, including self harm or suicide attempts.
In house education sessions have been provided and clinical supervision sessions and appropriate support from line managers provide additional opportunities for staff to discuss their experiences of sensitive routine enquiry and other GBV related issues.
GBV work in Renfrewshire HSCP
Renfrewshire HSCP has led work across NHSGGC to ensure Sensitive Enquiry on GBV becomes part of routine practice.
A GBV lead was identified by the CHP Director to drive delivery of NHSGGC GBV Plan. The GBV lead was able to garner support for this programme at an early stage by having an extended management team session. This resulted in a whole systems approach being taken across primary care services.
Renfrewshire CHP is in the process of extending the national programme to include Health and Community Care Settings and have provided short training sessions for admin staff. They have also utilised local Multi-Agency Partnership relationships and resources to ensure that all key staff access Basic Awareness Domestic Abuse Training.
A programme of support for staff has been agreed, covering Peer Support, Clinical Supervision, Line Manager Support and Complex case discussion/review. The involvement of a specialist local women’s organisation (Women & Children First) has been secured to support complex case discussion. Extensive internal communication and promotion of the GBV plan has included NHSGGC’s team brief system as well as team meetings.