A collaboration between

1. A collaboration between NHS Sheffield, NHS Bradford & Airedale, NHS Leeds, Sheffield Hallam University & University of Leeds This project was funded by the National Institute for Health Research Service Delivery and Organisation (NIHR SDO) programme (project number 09/1002/14). Visit the SDO programme website http://www.sdo.nihr.ac.uk/projdetails.php?ref=09-1002-14 for more information. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the SDO programme, NIHR, NHS or the Department of Health.

2. Project Background & Purpose • Need to address ethnic inequalities in health outcomes, healthcare access and experiences highlighted in many NHS & government policies. • Increasing ethnic diversity, locally and nationally. • Areas of good practice; but persistent minority ethnic disadvantage. How can commissioning be a lever towards reduced ethnic inequalities? What role can (research) evidence play? How can this be supported? Aiming for: • Nationally relevant findings; transferable tools / interventions • Local-level influence; supporting key stakeholders to make progress

3. A complex arena • Ethnicity: a complex 'biosocial' concept; multiple influences on health. • Commissioning: a set of inter-related functions, processes and tasks, with both transactional and transformational elements; constrained and facilitated by broader relationships and structures. • Evidence: central to commissioning work, but many sources of data/information/insight/intelligence; many 'ways of knowing'; and varied uses for evidence.

4. Project Phases & Methods 1: Preparation, scoping, networking (Oct-Dec '10)  National, plus Sheffield, Leeds & Bradford 2: Scoping the terrain(Jan-Oct '11) Key informant interviews (local and national)  Mini case studies of good practice (local and national)  Feedback to stakeholders; respondent validation ← We are here 3: Commissioning in practice (Nov'11- Mar '12)← We are here Three detailed case studies (Sheffield; Leeds; Bradford) Strategic level plus operational level. 4: Tools/interventions development & refinement (Jan-Sep '12) 5: Piloting of tools via extension into CLAHRC (beyond 2 years)

5. Relevance to Sheffield and Sheffield's commissioners? • Increasing ethnic diversity; growing minority population; projected to be 26% by 2020 • Evidence of ethnic inequality in health and social care access and experiences and in health outcomes • Disadvantage among some BME groups in priority areas e.g. diabetes; CVD; smoking cessation; infant mortality • Not linked simply to economic deprivation - need to 'unpack' and understand • Not confined to new migrants or people who don't speak English (though additional need) • Taking ethnic diversity and inequality seriously is not a luxury 'add-on', it is central to the commissioning task

6. Relevance to Sheffield and Sheffield's commissioners? Aspirations - transformational • Higher quality and better patient/user/carer experience • Stronger preventative agenda • Reduced health inequalities • Sustainable; value-for-money • Working with local people to improve services & quality of life Duties - inclusion and fairness; equality of outcomes • Equality Act (2010); NHS Constitution • Equality Delivery System (EDS) - likely become mandatory Risks • Inefficiency (delayed diagnosis; non-adherence; ↓prevention) • Persistent or even widening inequality • Breach of duties • Challenge from local communities

7. What have we learned so far? Drawing on national and local data, we can identify: - enablers and common barriers to effective commissioning for multiethnic populations - local areas of weakness and strength existing at different stages of the commissioning cycle - some opportunities and challenges for future commissioning - key considerations for our emerging commissioning structures

8. Common 'core' obstacles(messages from national interviews) • Lack of senior leadership • Financial drivers detract from quality and equality focus • Health inequalities agenda not explicit about ethnicity • Not seen as 'core business'; lack of reward/sanction • Disconnect between elements of commissioning work • Fear, uncertainty and inexperience • Scepticism, complacency • Equalities staff remote from 'engine room' of commissioning • Unsophisticated understandings of ethnicity and health • Pockets of good practice not shared or mainstreamed

9. JSNA lacks detail on ethnicity • Ethnic monitoring data often poor • Equity Audits of services rare • Community consultation variable • Insight/evidence from VCF contested • Widespread recognition of need to improve • Pockets of expertise & good practice • Some dedicated needs assessments, insight work and research The Sheffield experience - local respondents' views

10. National guidance - little on ethnicity • Struggle to find 'how to' evidence • EqIAs 'tick box' exercise • Assumed extra cost • QIPP overlooks equality • 'Flat service'; 'one size fits all' • Stated willingness to innovate & pilot - essential in this area of work • Some co-production for BME needs e.g. trans-cultural mental health • Areas of good practice - some service specifications more explicit • Some learning from other locations • Local research expertise e.g. joint project on breast screening • CLAHRC(SY) investment

11. KPIs usually not specific with respect to ethnicity • Patient satisfaction / user feedback rarely stratified by ethnicity locally • Providers left unchallenged -'nervous commissioning' • No benchmarking for equalities • Some recent good practice - clearer KPIs e.g. smoking cessation • Some auditing work has highlighted ethnic inequalities e.g. revascularisation • Some models of provider-commissioner review of performance on equalities

12. Opportunities for future commissioning to do this better? (Local opinions) • Greater input from clinicians with first-hand experience of meeting the needs of minority ethnic patients • Chance to improve collection and analysis of ethnic monitoring data in primary care • Increased accountability of PH function once in SCC • SCC seen as stronger on ethnicity and equalities than NHSS - may strengthen PH work in this area • PH in SCC can mean wider impact and closer working with communities ►But, significant challenges also highlighted by all respondents.

13. Implications for future commissioning structures New structures (both CCG and HWBB) • Senior Champion for ethnic equality; an inclusive leader • Open to external challenge; learning organisations • Equality, as well as quality, explicit goals linked to work-plans • Commitment to bridge socio-cultural distance & engage all communities • JSNA explicit on ethnic inequality; must link population needs to integrated action across CCG and SCC commissioning plans; should appraise options and identify priorities

14. Implications for future commissioning structures Commissioning skills and experience (CCG support & SCC) • Sufficient data and evidence skills across whole commissioning cycle • Knowledge and experience in ethnicity & equalities to support Champions • Nurture and expect a proactive, integrated team of professionals across the city - share skills, insights and relationships Partnerships and relationships • Support and challenge all (inc. large) providers to improve; adopt EDS • Develop mature, respectful relationships with VCF(BME-inclusive) organisations • Work with universities and CLAHRC to mobilise best evidence, generate local solutions and increase competence

15. Thoughts? • Consistent / inconsistent with your experiences? • Gaps we need to fill? Issues we need to explore? • How can we make the research and outputs most useful? • Ideas for tools / interventions we should develop for (new) commissioners?s.salway@shu.ac.uk or john.skinner1@nhs.net www.eeic.org