Equalities in Health

In the Equality Act 2010 ‘sex’ means a woman or a man or a group of women or men. Sometimes it is hard to understand exactly what is meant by the term ‘sex’ , and how it differs from the closely related term ‘gender’.

Our sex is determined by the sexual organs we are born with – men are born with a penis, women a vagina.

Gender relates to the types of behaviours society expects of men and women. We learn these behaviours as we grow through a range of images and messages given to us by parents, schools, friends and the media. For example, young girls might be given dolls to play with and princess outfits to play in, while boys may be given guns and soldier uniforms.

Society has a set of gender expectations of women and men that differ for each sex. Currently, masculine characteristics are more highly valued than feminine characteristics and world-wide, this ascribes more power and wealth to men than to women. This in turn reinforces sets of behaviour, which have significant implications for the pathways into poor health.

In terms of gender, some people describe themselves as gender fluid or non- binary The difference between gender fluidity and non-binary people is the fact that gender fluidity is one aspect of the non-binary spectrum. A range of people on the gender identity spectrum do not see themselves as male or female. They could be agendered, trans or simply identify as non-binary

Sex discrimination exists when a person (man or woman) or group of people (men or women) are treated unfairly solely on the basis of their sex. An understanding of gender is important to understanding inequality between women and men. Discrimination on the basis of gender is both subtle and persistent.

Women are expected to be ‘natural carers’ which has led to a huge imbalance in the types of jobs women do, how much they earn, how much housework/ caring they do and disapproval of society if they do not conform to this stereotype.

Men are expected to be ‘strong’ and unemotional, and they can often experience barriers when seeking jobs that require a degree of caring or empathy. Their masculinity can single them out for additional duties that rely on physical capacity rather than capacity to care.

There is a very serious side to this imposed difference. It means that women consistently earn less than men throughout their lives and often live in poverty when they are older. This lack of economic power has also meant that women have less power in society and less access to positions of power in politics.

In most cases we grow up feeling a sense of comfort or acceptance with our gender (as prescribed by biological sex at birth). However, a small number of us (around 1 in 11,500) find as we grow our prescribed gender is so different from our internal sense of where we exist in relation to being a boy/girl, man/women that we express a wish to live in the opposite, more appropriate gender. In Scotland, those of us experiencing this are referred to as ‘transgender people’ also covered by the Equality Act 2010.

Some people describe themselves as non-binary – not seeing themselves as male or female. In recognition that non-binary people experience extreme levels of discrimination in Scotland, the Scottish Government set up a working grouo in 2021

What is sex discrimination? – a short film by the Equality & Human Rights Commission

Sex differences cut across all the other protected characteristics such as age, race and social class.

For example:

• Male life expectancy is six years lower than for females across NHSGGC
• In NHSGGC, there is a nine-year gap in male life expectancy between East Dunbartonshire (77.7 years) and North Glasgow (68.6 years)
• Asian women aged between 15-35 are two to three times more vulnerable to suicide and self harm than their non-Asian counterparts
• Retired women and lone parents are most at risk of poverty and average incomes of women in work are lower

Other inequality issues can prevent people from receiving health services and treatment appropriate to their sex. For example, some disabled women have been told that they do not need cervical smear tests because of assumptions about their sexual behaviour.

NHS evidence has shown that treating women and men the same, without considering the differences between them, means that underlying sex-related links to health problems are ignored and patients’ health needs are not met. 

There is recognition by the Scottish Government that gender discrimination affects women and their health (Scotland’s Women’s Health Plan 2021-2024 – Health Inequalities) The health and societal differences for women and men are shown in the examples below-

• Women are more likely to live in poverty, be lone parents, experience abuse and  have less access to citizenship opportunities than men, due to historical gender stereotyping in society. This affect health differently during the life course.
• One in four women are likely to experience domestic abuse over their life course and that prevalence rates for child sexual abuse are estimated at around 21% of girls and 7% of boys.
• Men are more likely to participate in risk-taking behaviour which leads to premature mortality and to use their power to commit acts of violence and abuse which affect themselves and women and children of both sexes.
• Men are also less likely than women to participate in health improvement activity or to present to primary care in the early stages of illness.
• Where men have experienced abuse in childhood, this experience can manifest itself in a range of health and social problems in both childhood and adulthood but is often not identified as part of medical presentations.
• Women still tend to have multiple social roles as employees, as carers and as the primary managers of households. This imposes stresses that can have physical and psychological impacts on their health.
• Some diseases have been seen solely as ‘women’s’ or ‘men’s’ diseases due to gendered biases in medical research, leading to delays in diagnosis and treatment (e.g. heart disease – leading cause of mortality in UK women but still seen as a ‘male disease’)

Other examples of where gender expectations affect health are:

• In NHSGGC, like the whole of Scotland, women are between two and two and a half times more likely to report experiencing depression and anxiety than men.
• Suicide rates are almost three times higher in men than in women.
• Men are more likely than women to die of injuries outside the home.
• The gap between women’s and men’s smoking rates is changing, with more young girls taking up the habit than boys.
• Young men aged 16-24 are most at risk of becoming a victim of violent crime

‘A Fairer NHSGGC 2016-20 – Meeting the requirements of Equality Legislation’ sets out what the organisation is doing to ensure it meets its responsibilities to promote gender equality and remove sex discrimination across all its services and functions. Most actions in this document involve addressing issues around sex. In addition, actions on closing the health gap between affluent and deprived communities in NHSGGC take into account the different needs of women and men.

Some examples of actions include:

• Equality Impact Assessments undertaken throughout NHSGGC has a strong gender element
• An NHSGGC Gender-based Violence Action Plan has been in place for a number of years
• Women and child poverty work has gained increasing prominence in NHSGGC, endorsed by the Scottish Government funded Healthier Wealthier Children Project
• Sex issues are key within Human Resources Equality Scheme actions (e.g. Equal Pay Audit,Audit of family friendly policies)
• A gender analysis of our equality scheme, ‘A Fairer NHSGGC’, which sets out how we will meet the needs of equality legislation

John’s Story

John is a survivor of childhood sexual abuse. Now in his 40s, he has struggled to cope throughout adulthood with the experience and knowledge of being abused and has felt that many areas of his life have been negatively affected.

“I’d lost family, friends and jobs – that one major incident was affecting my whole life. I knew I needed help to stop the slide, so I spoke to my GP.

“I was referred to nine different counsellors. None of them specialised in childhood sexual abuse issues. After listening to me talking about my abuse experience, they would pass me on to another counsellor.”

The whole experience left John extremely depressed and contributed to a major breakdown.

John finally contacted Thrive, a counselling service for adult male survivors of childhood sexual abuse which is part of the Sandyford Initiative – NHSGGC’s sexual, reproductive and emotional health service.

“The initial telephone contact was really helpful – the person I spoke to was very supportive and put me at my ease. At my appointment, they explained how the counselling service would be run. They told me that counselling could take a long time and I appreciated that, I didn’t want to be kidded on.

“Hearing those words (‘we can help you’) made such a difference.   When I left I cried all the way to the Underground, I was just so full of relief and happiness.”

Dr Rosie Ilett, Head of Planning and Partnerships at Sandyford, developed the original funding application for Thrive and appreciates the importance of gender sensitivity in services. “Thrive has been developed because we know that many men have real difficulties seeking professional help about sensitive issues – it’s just not considered ‘manly’.   Experience of abuse can test men to breaking point.   Understanding what makes men tick and the barriers that living up to a stereotype of masculinity can impose on them helps our counsellors work effectively with the most challenging cases and start the healing process”.

Thrive is based at the Sandyford Initiative in Glasgow. Men can access the service by calling the direct line on 0141 211 8133 or visit the Sandyford Initiative website at: www.sandyford.scot

Add info here…

Publications

• A Guide to Support Services for Children and Young People Experiencing Domestic Abuse in West Dunbartonshire
• Ethnic Survivors Forum
• Everyday Terrorism: How Fear Works in Domestic Abuse
• Facts for Fathers-to-be
• Human Trafficking – Making the links
• Older Women and Work: Looking to the Future
• Women – Where to go for advice, support and information in the Glasgow area
• Women Living with Domestic Abuse in West Dunbartonshire

Websites

• Scottish Women’s Health Plan 2021-24
• Engender
• Non-Binary Scotland
• Equally Safe
• Women’s Support Project
• Men’s Health Forum
• Rape Crisis
• The Sandyford Initiative
• Violence Against Women Prevention Scotland

Ethnicity refers to a common group identity based on language, culture, religion or other social characteristics. This means that people define their own ethnicity, that everyone (and not just those in minorities) has ethnicity and that a person’s ethnic identity may change over time. For example some people might describe themselves as Scottish Chinese.

Race is the group you belong to, or are perceived to belong to, in the light of a limited range of physical factors. The term ‘race’ should be used in relation to legislation only and not to describe people who belong to an ethnic group.

The term BME is often used within the public sector. It’s an abbreviated term for Black and Minority Ethnic and is often used to describe people from minority ethnic groups, particular those who have suffered racism or are in the minority because of their skin colour and/or ethnicity.

Racism refers to the combined use of power with racial prejudice (the belief that some races are inferior to others) which leads to the oppression or discrimination of specific racial or ethnic groups.

Racism can be detected through attitudes, processes, behaviours and actions which impact on any ethnic group/s and can lead to differences in education and employment opportunities, living conditions and health. We all have an ethnicity.

The Equality Act is designed to ensure that large public organisations like NHSGGC promote race equality and challenge discrimination on the grounds of race, colour, nationality (including citizenship), ethnic or national origins. We are required to;

1. eliminate unlawful racial discrimination;
2. promote equality of opportunity; and
3. promote good relations between people of different racial groups.

Following is a short film by the Equality & Human Rights Commission titled ‘What is race discrimination?’.

Racism can be intensified by other forms of discrimination, for example on the basis of sex, disability, age and social class.

1. Black African women are six times more likely to die from pregnancy-related causes than white women.
2. Women from the South Asian community are less likely to attend breast cancer screening and only half as likely to accept an invitation to be screened for bowel cancer than members of the non-Asian community.
3. Evidence suggests the health gap between white and black/minority ethnic communities is greater in older people.
4. Over a third of people from minority groups are in poverty after housing costs are taken into account, compared with 17% of the ‘white British’ group

Race and ethnicity affect people’s health in a number of ways. Our ethnic background can affect our susceptibility to certain diseases and conditions. There is also a clear link between discrimination and health and implications for the way in which health services should be provided.

For example:

1. Black and Minority Ethnic Scots are much more likely to live in poverty, with a poverty rate of 38% for  Mixed, Black or Black British people and 34% for the Asian or Asian British community, compared to 18% for White British people. Poverty is a key factor in poor physical and mental health and creates barriers to accessing health & social care services
2. One third of black and minority ethnic people in Scotland report experiencing racial discrimination. Racially motivated hate crimes are the most reported type of hate crime.
3. Gypsy/Travellers are more likely to report long-term health conditions than the general population. They are also twice as likely to report three or more categories of health conditions. 

How we are addressing race issues

‘A Fairer NHSGGC 2020-24’ explains how the organisation is meeting the requirements of equality legislation. This includes demonstrating how we will assess the impact of the measures we have put in place to ensure race equality for service users and staff.

Areas of work include:

Access to Services

National evidence shows the BME community experience additional barriers in accessing health and social care services.

We are currently working intensively with two services – diabetes and pain management/physiotherapy – to improve access for BME patients. The learning from this has helped develop a Equality Sensitive Patient Pathway for NHSGGC as a whole.

Following consultation with staff and patients current actions include –

Review all patient information for readability and accessibility
Develop information routes for those with lower health literacy around pain
Explore how the opt-in service accommodates the needs of those from BME communities specifically
Develop a route for non-English speakers to ask for advice outwith appointment times via direct patient access to telephone interpreting
Understand how therapeutic group work can work best whilst utilising spoken language interpreters.

Perinatal Care

National evidence indicated marginalised groups, in particular, BME pregnant women; women living in poverty and those experiencing gender based violence, fair worse in accessing and using maternity services.

A local baseline research was conducted with patients, maternity and third sector staff to assess current issues for marginalised groups using NHSGGC maternity services. A review of best practice interventions was also carried out. The focus of the work has been to look at the patient journey through maternity and identify any barriers for BME women.

Actions identified so far to address these issues include –

Develop a leaflet in multiple languages to describe each stage of the maternity pathway, how to access support and highlight emergency routes
Explore how to maximise the value of ante natal classes for non-English speakers
Develop training for Maternity Staff on meeting the needs of BME women thnrughout our pathway
Develop a route for non-English speakers to ask for advice outwith appointment times through direct patient access to telephone interpreting.

Interpreting service

Interpreting services address a number of risks for both service users and staff. For example, patients who have a limited understanding of English:

• may not be able to give informed consent
• may not be able to ask questions or seek assistance
• may not be aware of what services are available to them
• may not be able to use medication properly or follow care plans
• may come from cultures with different understandings of health and illness
• may not understand how to use NHS services
• may not understand their rights and responsibilities within the healthcare system

Ensuring that everyone has an equal opportunity to engage in the health care process benefits all concerned.In addition, equalities legislation stipulates that the organisation must be pro-active in ensuring that this is the case.

NHSGGC’s in-house interpreting service provides interpreters to NHS patients on request. The service is available to a wide range of service areas and departments, including hospital wards, outpatient clinics, medical practices, dental surgeries,pharmacies and opticians located throughout the NHSGGC area.

‘Clear to All’ Accessible Information Policy

Effective information and communication are vital for the provision of high-quality services and care. Many of those who access services have difficulty understanding the information provided. An Accessible Information Policy has been produced to ensure that all information can be made available in various languages and formats to meet the needs of our diverse community.

A toolkit for staff has been developed which helps to provide information and support in the development of accessible information for NHS patients, their carers and the public. The toolkit aims to ensure that the material we develop is clear, consistent with NHSGGC guidance, accurate and in everyday language.

Details are available on the ‘Clear to All’ Accessible Information Policy web page.

Briony’s Story

Briony is part of the travelling people’s community and has lived in Scotland all her life.

Briony and her family have lived on the caravan site for 8 of the last 10 years. They were there for three years, moved into a flat for two years, and then have been back at the site for the last five years. When they moved into the flat it was mostly due to her health problems, but they also felt like maybe they would want a change and settle in for a little while. But after a couple of years, they wanted to move back to the caravan site because that is who they are and it was where they wanted to be.

She tells about how it was for her and her family to register with the local surgery when they first moved to the caravan site. There was not just one doctor’s surgery for everyone on the site, so all of the people living there were allocated to different surgeries. Briony herself went around to all of the local surgeries to see if she could register with one, but none would take them on. “They kept telling me ‘you aren’t from this area, so we can’t take you. She had to wait to get a letter from NHS telling her which surgery they had been allocated to and where to go before she could register.

When they moved into the flat, they didn’t have any problem registering with a surgery, and everyone was really nice to her. When asked why she thought there were no problems with getting registered and why they were nice, she says, “Oh, I couldn’t speak for them. But it could because I was in a flat at the time and not from the caravan site. This surgery was one of the ones I went around to when we were first at the caravan site and they said they wouldn’t take us on. But when we were in the flat, they would.

“I‘m still with that surgery now, even though we’ve moved back to the site. And they are still nice”.

Publications

• Amina
• Awaz FM
• Black and Ethnic Minority Infrastructure in Scotland (BEMIS) 
• CEMVO Scotland
• Glasgow Helps
• Govanhill HA
• Scottish Refugee Council

Ageism can be very subtle but is common throughout society; it can affect wellbeing, damage confidence and create exclusion. Individuals can be subject to assumptions and different treatment based on their age or perceived age, no matter how old or young they are.

Older people in particular, are subject to stigma, prejudice and social isolation. Older people are often also the poorest in society, and some are vulnerable to abuse. 

Children and young people can also be discriminated against and are viewed with suspicion by society. Their lack of power means that their views are often ignored and they are also vulnerable to abuse.

Discrimination arises either because difference is ignored and therefore people’s needs are not met or difference is recognised but forms the basis of unfavourable treatment or stereotyping.

Age equality means that age should not be used to define or presume anything about the role, value or potential of an individual.

The following video is a short film by the Equality & Human Rights Commission titled ‘What is Age Discrimination’.

Age and Other Protected Characteristics

Age discrimination links to other forms of discrimination- 

• Older people, especially older women are often on low incomes. This is caused by a combination of factors including the state pension not being linked to earnings and women being less likely to have occupational pensions of sufficient level.
• Disability increases with age, especially visual impairment and blindness. 74.25% of those registered blind or partially sighted in Scotland are aged 65 or over.
• Young people may be discriminated from exploring their sexuality and their gender identity by their family, at school or in hospital. LGBTQ+ young people may be less likely to express their sexuality or their gender identity due to fear of discrimination from family, friends and other young people. This can lead to low self-esteem and serious long-term negative health effects e.g. anxiety, depression and feeling suicidal.
• Peer pressure can pressure young people into concealing their religious beliefs or practices, while overt symbols of faith make young people more likely to be victims of religious provocation.
• Ageing may further reduce the ability to communicate for those for whom English is not their first language.
• Teenage women living in areas of highest deprivation are four times more likely to become pregnant than those in the least deprived areas. ; Teenage women from the most deprived areas are more likely to deliver than to terminate their pregnancy. In contrast, those from the least deprived areas are more likely to terminate than to deliver their pregnancy.
• The health of older people in Scotland varies according to social circumstances. The gap in life expectancy between the most affluent and deprived communities has widened significantly in the last 40 years, particularly among males. Life expectancy has either stopped increasing or has decreased in almost all council areas since 2012-2014.
• Emergency hospital admissions as a result of unintentional injury are over 40% higher for children living in the most deprived areas.

Older People

Long life is a sign of good health, and the ageing of the world’s population is an indicator of improving health worldwide. Although there are no specific conditions or illnesses associated with ‘being old’, the older people get the more likely they may be to experience a range of different conditions such as chronic disease, cancer and disability and to experience more than one of these together.

Increased protection for adults at risk of harm or neglect is in place through the Adult Support and Protection (Scotland) Act 2007. While the Act defines adults at risk as those aged 16 years and over, it provides protection to many older people with cognitive impairments such as dementia.

Young People

Healthcare, lifestyle and experience in childhood and adolescence have a significant impact on physical and mental health in later life. Certain conditions particularly affect young people, such as some inherited problems, accidents and injury and sexual and mental health issues, or they may have different experiences of conditions which affect all ages.

The United Nations Convention on the Rights of the Child (UNCRC) is the base standard for children’s rights and sets out the fundamental rights of all children. On 16 March 2021, the Scottish Parliament unanimously passed the United Nations Convention on the Rights of the Child (Incorporation) (Scotland) Bill (‘the UNCRC Bill’). The UNCRC Bill is a landmark piece of legislation that aims to incorporate the UNCRC into Scots law to the maximum extent of the Scottish Parliament’s powers. We already use the UNCRC as a framework to ensure that we consider children’s rights whenever we take decisions, and to help provide every child with a good start in life and a safe, healthy and happy childhood. It forms the basis of our national approach for supporting children, called Getting it right for every child (GIRFEC). Fulfilling children’s rights is also critical to our commitment to #KeepThePromise that all care experienced children and young people will grow up loved, safe and respected.

All Ages

Traditional assumptions about age related conditions are increasingly being challenged. People with conditions previously associated with childhood, e.g. cystic fibrosis, severe physical disability, are increasingly surviving into adulthood. Similarly, younger people may suffer from conditions previously associated with ‘old age’ such as dementia or the need for social care and support.

Age Discrimination and Health

Age discrimination in health can lead to inappropriate treatment, misdiagnosis or reluctance from patients to get involved with health services. It may take some of the following forms:

• Stereotyping of old age as being automatically linked to ill-health
• Low expectations of older people’s mental capacity, leading to inappropriate behaviour or symptoms not being believed.
• Health or social care support or treatments having upper or lower age limits.
• Lack of support or time for meals, resulting in undernourishment
• Young people being placed in adult wards
• Information not produced with age group in mind
• Judgemental attitudes
• Confidentiality and anonymity not respected
• Abuse or neglect or older or young people, in hospitals, care settings or at home
• Denial of the right to make choices about health and personal affairs

How we are addressing age issues

NHSGGC is working to ensure no-one using our services is discriminated against on grounds of age or any other protected characteristic.

We are also working to raise awareness of the nature of direct and indirect age discrimination and our responsibilities under equalities legislation. We will do this by improving education and training of healthcare professionals on the effects of ageism in clinical care and care settings and by improving patient and carer experience of discharge planning.

Patients aged 81 and older are less likely than younger patients to feel they have been given adequate information about their discharge and what to do about their health if they are worried after leaving hospital. A Fairer NHSGGC 2024-25 highlights our plans to ensure that older people and their carers are routinely involved in discharge planning and decisions as part of person centred care.

This will be supported by the application of the Frontline Equality Assessment Tool (FEAT) which has been designed to assess inequalities sensitive practice within frontline services. This involves checking the patient information collected, how communication support is assessed and knowledge of protected characteristic related issues as well as the impact on discharge planning. Within NHSGGC’s frontline services the use of FEAT will contribute to the recognition and sharing of good practice as well as highlighting where improvements in services can be made.

Overall service planning is increasingly taking account of the changing age profile of the population and the impact this will have on demand for services. Awareness of the need to ensure age equality within our services informs this planning process. However, there are circumstances where a targeted approach to specific age groups is appropriate both when providing services and when consulting and involving individuals. For example, Sandyford sexual health services have been designed to ensure that they are accessible to young people and have the confidence of young people.

Publications

• Age discrimination: key points for the workplace
• Fairer Scotland Older People Framework
• Ethnic Health Inequalities in Later Life
• Later Life UK Factsheet
• That Age Old Question
• UN Convention on Rights of the Child

Websites

• Age Scotland
• Public Health Scotland 
• NHSGGC Public Protection Team
• UNICEF –  Convention on the Rights of the Child
• Research Institute for the Care of Older People (RICE)
• Scottish Public Health Observatory

• Workforce Equality Documents including Equal Pay Statement

A Fairer NHSGGC 2024-25 is available in other formats such as easy read, large print, British Sign Language DVD and alternative languages. Please contact us with your request.  

EQIA is a vital part of NHSGGC’s overall approach to dealing with inequalities and discrimination. It means that services, policies and projects are thought about carefully in terms of their likely impact on different groups of people and on the various aspects of inequality.