Mobilising evidence for action on ethnic inequalities

1. Mobilising evidence for action on ethnic inequalities Note to workshop participants: This resource is currently presented as a series of slides and will be facilitated as a group exercise. However, it may also be produced as an individual workbook in the future.

2. Background • Increasingly evidence-based culture of healthcare practice and policy. • Can inadvertently undermine attention to ethnic diversity and inequality, people struggle to find and present 'good evidence'. • Advocates need support to:- compile data/evidence around ethnic inequalities- present this information persuasively to different audiences.

3. Objectives To highlight the importance of: - Describing and understanding ethnic inequalities adequately, in order to identify appropriate responses, and - Packaging and presenting evidence effectively to get key stakeholders to support action To suggest some ways to : - Improve understanding of issues and how can be addressed- Overcome common data/evidence gaps - Prompt appropriate action even when knowledge incomplete

4. Types of evidence use: a view from the EEiC project Interviewer: So, tell me a bit about how you go about getting the evidence and information you need to improve services Respondent: Well, there's the information you need to work out what needs to be done; and then of course there's the information you need to convince people to let you get on and do it

5. Working out what needs to be done: beyond description ??? Health –related outcome Ethnicity

6. Describe►Explain ►Prescribe 'Culture' ‘Ways of being & doing’ Access to/exclusion from resources Genotypic/biological factors Health –related outcome Ethnicity

7. Describe ►Explain ►Prescribe 'Culture' ‘Ways of being & doing’ Access to/exclusion from resources Genotypic/biological factors Health –related outcome Ethnicity recognition, responses quantity & quality of healthcare risks, exposures, protective factors

8. Describe ►Explain ►Prescribe 'Culture' ‘Ways of being & doing’ Access to/exclusion from resources Genotypic/biological factors Health –related outcome Ethnicity recognition, responses quantity & quality of healthcare risks, exposures, protective factors Possible interventions

9. Varied sources of evidence needed Describing: What? Patterns/differentials across groups. local data analyses, JSNA [ ]; equity audits [ ]; expert opinion [ ]; other [ ] Explaining: Why? Underlying causes, pathways of effect. published research [ ]; user feedback [ ]; local insight [ ]; third sector reports [ ]; expert opinion [ ] Prescribing: How? Interventions that can tackle issues. NICE/other national guidance [ ]; published research [ ]; good practice examples [ ]; local innovations (pilot & evaluate) [ ]

10. Challenges to finding/generating evidence on minority ethnic health Describing Explaining Prescribing JSNAs lack detail on ethnicity Local data on health needs of minority ethnic populations lacking Ethnic monitoring in service settings remains poor Equity Audits rare No national/regional benchmarking on equalities outcomes Patient/carer satisfaction rarely stratified by ethnicity Community consultation variable Large distance between decision-makers and minority ethnic communities Insight/evidence from voluntary/community sector contested Front line staff distant from decision-makers Research studies not accessed by commissioners National guidance lacks detail on ethnicity; general statements only Few 'blue prints' 'How to' evidence limited Reluctance to transfer learning across settings Little cost effectiveness data

11. Enablers & Solutions Prescribing Describing Explaining Auditing work that takes an equity focus Service level Key Performance Indicators reported by ethnicity Creative use of national and local data to highlight likely inequities Special surveys to fill important gaps Models of joint provider-commissioner reviews of service from (in)equalities perspective Peer reviews Engagement of community members in service review work Special studies to understand issues behind inequalities (qualitative; insight work) Deliberative exercises with varied stakeholders to review and synthesise knowledge Willingness to take risks, pilot & learn Documentation/sharing good practice (networks) Co-production of solutions with communities Theory-driven systematic reviews focused on minority ethnic needs 'Reading across' service contexts to identify commonalities and areas of learning

12. Some principles for mobilising evidence to understand ethnic inequalities • Use varied and complementary sources. • Identify local assets and resources; useful partnerships. • Appraise all sources of evidence, data and insight. • Use process as an opportunity to engage stakeholders. • Aim for 'good enough'; avoid being blocked completely • BUT, identify gaps to be filled; clear improvement plan

13. Note to workshop participants • For the purpose of the workshop, we are providing you with a scenario and evidence sources to work with. • This scenario may be included in the final resource as a worked example. • In practice, users of the resource will need to access their own evidence sources, using the checklist below.

14. Exercise in pairs - Introduction Scenario: You are • A mid-level public health practitioner and • A manager from a third sector organisation working to improve minority ethnic health. You are aware that smoking rates are higher among sections of the minority ethnic population than in the White British population in your area, and that the representation of BME people in smoking cessation services is low. The Director of Public Health has agreed that this is an important issue to address, and has tasked you with getting the CCG committed to this issue. He has asked that you compile the relevant evidence to 'make the case'.

15. Information sources for the exercise • Local data on access to cessation services by ethnicity. • National level data on smoking patterns by ethnicity. • NICE guidance statements. • Brief descriptions of good practice interventions. • Qualitative study illustrating BME smokers' barriers, and practitioner perspectives.

16. Exercise in pairs - part 1 • Look at the sources that you have been given and identify the key pieces of information/evidence relating to: - describing ethnic inequality- understanding ethnic inequality- prescribing action on inequality • Identify gaps. What else would you like to know? • How/where might you get this extra information?

17. From knowledge to action Simple direct application of evidence use (instrumental use) is rare in commissioning! Most likely to happen where: • Evidence is non-controversial; problem/issue uncontested • Certainty in the best course of action • Requires limited change or upset to current status quo • Clear responsibility for action • Wider environment is supportive These are not often the characteristics of evidence on ethnic inequalities!

18. From knowledge to action Using evidence in other ways: Conceptual: changes understanding; redefines the problems/issues; relocates the causes; suggests alternative places to look for solutions; challenges taken-for-granted assumptions etc. Influential: reframes issues to increase their perceived importance, urgency, relevance; empowers actors to take action; gives legitimacy; persuades etc. Identify ways to mobilising evidence/information/insight to increase understanding and prompt action

19. Challenges to mobilising evidence for action on ethnic inequalities As well as gaps in the data/evidence base, mobilising evidence around ethnic inequalities can be difficult because: • Ethnicity is complex; people struggle to understand its varied links to health. • Stereotypes and misunderstandings: people pre-judge the issues (e.g. assuming the causes of observed inequalities lie in cultural practices or ignorance). • Decision-makers lack confidence: demand a higher standard of evidence before committing resource. • Assumption that addressing ethnic inequality will add complexity and cost • Lack of local good practice: assume inequality is inevitable and progress is impossible. • Prevailing values and norms: decision-makers question whether it is right to focus attention on minority ethnic groups

20. Mobilising evidence for action on inequalities Describing: What? Highlight the unacceptable; urgent. Explaining: Why? Locate cause within influence/responsibility Prescribing: How? Identify what should be done. Benchmark. Aim to align issues with core priorities, engender commitment, empower and leverage resource. Influential and conceptual uses are key to success.

21. Some principles for effective presentation of evidence for action • Empower (challenge, but also offer support/hope) • Focus on key themes • Remember most people have little time to read • Draw on national/international data and policy • Illustrate with local examples that resonate • Use varied data/evidence types - statistics + local patient stories can be a powerful combination • Articulate an attractive vision; align with audience's key priorities • Articulate a clear expectation - what do you want of the audience?

22. Return to exercise - part 2 Look again at the evidence/information you have. Think about how you would use this evidence to make the case to the CCG. Think carefully about this audience. • What are you trying to achieve? What do you want/need them to do (at this stage; later on)? • What are their key concerns likely to be? • What sort of information/evidence will they respond well to? • How do you think it should be packaged? • How, where, when and by whom should it be delivered? Work in pairs for 25 minutes

23. Return to exercise - part 2 Jot down your ideas here: Outcome wanted: Key message: Facts/information to be included: Format and packaging considerations: Delivery considerations:

24. 'For change effort to be successful, it has to succeed in attracting new people to 'the cause' ' 'Your goals need to be described in language that others will hear. This is not about making false statements or hiding the truth but recognising what is important to others and what will help align them with your goal.' (NHS Institute for Improvement and Innovation) Evidence gaps should not block all action; be creative; draw on diverse sources; work to improve data; pilot and evaluate.