GENDER EQUALITY DUTY

The legal duty that must become a health service habit

Conference Report, March 2007

With the introduction of the gender duty requirement just weeks away, the Men's Health Forum's gender duty conference brought together men and women from across the voluntary and healthcare sectors to discuss a legal change that could have the biggest impact on men's health since the NHS was founded. MHF website editor Jim Pollard reports.

Men's Health Forum president Dr Ian Banks welcomed several dozen delegates to the King's Fund for the Forum's Gender Equality Duty Conference. It was a timely event — taking place less than three weeks before the duty was to become law.

Dr Banks stressed the 'huge breakthrough' that the gender duty represented. The health service had traditionally been plagued by process, he said, but this enshrined equality of outcome in the law. The problem was that health providers were overworked and likely to be cynical about a new duty. However, he said, the change of heart from the BMA proved that progress could be made once the duty was explained.

Morning Plenary Session:

'It's not just about the bits'

The first presentation of the morning was made by Professor Alan White from Leeds Metropolitan University who explained the relevance of gender to health.

He stressed that men and women's health was not just about 'the bits'. Neither group was a minority since all patients were either one or the other. He drew a distinction between the biological nature of sex and the sociological nature of gender. the latter affected both how the individual saw his or her health and how others, including health professionals, reacted to it.

The contribution of the chair of the MHF's trustees has been simple yet profound — by disaggregating health data by gender he has demonstrated graphically the men's health deficit. A population-wide approach was bland and lacked sophistication. He gave a number of examples from coronary heart disease to osteoporosis to autoimmune diseases. It was not a competition, Professor White stressed. It was about focused services. He underlined this by pointing out that the gendered nature of CHD was such that women's heart attacks were less likely to be recognised and more likely to be fatal.

Professor White called for the mainstreaming of gender. 'Policy or practice that doesn't include gender, serves neither men nor women well,' he concluded.

To demonstrate the mutual benefits that the duty could bring, Jenny Watson, the chair of the Equal Opportunities Commission followed Professor White onto the podium. She explained the duty in more detail.

Jenny Watson, pictured between Ian Banks and Alan White, welcomed both the duty and the opportunity it afforded to work with the MHF. She said that the duty switched the emphasis in discrimination by placing the onus on organisations to take action to prevent it. Previous legislation had relied on individual cases.

The duty applied to any body including private and voluntary organisations with functions of a 'public nature'. This was not a 'cut and dried' definition, she said. There were already cases concerning this definition in connection with the Human Rights Act. "If you're unsure, follow the duty,' Jenny Watson advised.

She stressed that the gender duty did not prevent single-sex services being offered. Anything requiring special care or where service-users were likely to be embarrassed, undressed or in receipt of physical contact could be provided as single-sex services.

The duty also applied to procurement. Public money could not go to 'discriminatory suppliers'.

Compliance orders could be served by the EOC or other enforcers though the county court.

Jenny Watson concluded by calling for awareness-raising at all levels and urged delegates to respond to any consultations on the duty.

During the questions session which followed both Professor White and Jenny Watson were able to develop their ideas. The duty should encourage 'broader thinking' not sexism, said Professor White. Pharmacists should be included said JW.

Professor White did not expect massive changes within five years and wouldn't necessarily want it as he'd like the evidence to be properly evaluated. Jenny Watson hoped for earlier intervention and less traditional guidance.

There was no financial limit, Jenny Watson stressed. All services that met the 'public nature' test were obliged to comply. There was concern from the floor that funders might misunderstand the duty — deliberately or otherwise — and use it to deny or withdraw funding. Professor White said it was important to make sure funders understood sooner rather than later.

Andrea Murray, also from the EOC, said that of the inspectors, the Healthcare Commission were enthusiastic although others were less so. The concern in all cases was capacity.

The issue of measuring outcomes was mentioned a number of times. The final question was key to this: is there money to collate the data? 'Ask the Department of Health,' Jenny Watson replied.

Breakout Sessions

• Sexual Health - An issue since 3000BC
• Obesity - Not rocket science 
• Bowel Cancer - report to come
• Mental Health - let's lay off labelling

Afternoon Plenary Session:

'NHS has not traditionally been gender-centric'

Surinder Sharma, right, the national director of the Equality and Human Rights directorate at the Department of Health began discussion on the progress the NHS has made in meeting the duty.

He put the duty in the context of the government's manifesto commitment to outlaw discrimination which had led it introduce the Equalities Act of which both the duty and the new Commission for Equality and Human Rights were a part. There was also the Equalities Review chaired by Trevor Phillips which had reported in March and the Discrimination Law Review which was expected to lead to legislation in the autumn.

He said that the Department of Health had set up a gender duty advisory group, developed an equality impact tool and published its own gender duty guidance.

It was all part of the modernisation of public services, he said. The NHS needed to use its contractual muscle to improve equality. It was an opportunity to provided leadership at the highest level and engage with voluntary organisations and local authorities to provide joined-up government.

Taking questions, Surinder Sharma admitted that much of the NHS was yet to comply with the race duty so these things could take time to filter down. He stressed that the Department could issue guidance but not diktats.

He said that equality assessment training was being provided stressing the importance of outcomes rather than the NHS's traditional obsession with process. He hoped that in five years time male life expectancy would be improved. He said that society should not be institutionalising as many young black men as it did. he said the NHS had a very Eurocentric view of psychiatry which needed to change but pointed out that altering psychiatric training required the Royal College.

Sarah Payne, reader in social policy at Bristol University, put the debate in its social context. health services needed to react to differences in biology and gender, she said. Were services appropriate and accessible?

The NHS had not traditionally been gender—sensitive but the duty could change that.

Public Service Agreements (PSAs) were three year agreements between government departments and the treasury she said. The next set, to run from 2008-2011, were now being discussed. The DoH's PSAs were not gendered. Sarah Payne, pictured right chatting to delegates, gave examples of this drawing on the PSAs for suicide, smoking and obesity, concluding with the big question: could the gender duty lead to gendered PSAs?

The session concluded with Peter Baker, the chief executive of the MHF, offering the Forum's perspective. He said that if implemented, the duty could make the biggest difference to men's health since the foundation of the NHS. But it was a big 'if'.

Just 1% of NHS Trusts had fully met their requirements under the race equality duty, he said. Add this to the deep-rooted financial problems and the fact that the NHS generally saw its equal opportunities responsibilities as concerning its staff rather than its patients and the outlook was not good.

However, there was good news. The legislation was clear. It was everything the MHF could have asked for. The problem was the absence of teeth.

Peter Baker gave the example of Chlamydia. Two years ago just 12% of those screened were men. Now that the NHS had followed the MHF's advice for targeting men, the rate was up to 40% in some places. The BMA's change of heart was another example.

To make the duty effective, we need data disaggregated by gender, he said. We need gender leads at every organisational level, training, a database of good practice and proper stakeholder consultation. He said that for these reasons, the MHF was setting-up the Gender Duty Network to bring organisations together and perhaps, in the future, take up test cases.

• Peter Baker's speech in full

During questions afterwards, it was stressed that women's health was not a gold standard. There were also doubts expressed about whether PSAs could be gendered because there was not, yet, the disaggregated data. However, their importance was recognised since the PSAs had money attached to them.

Sarah Payne said that lack of monitoring, lack of teeth and difficulties in measuring compliance were behind the failure of Trusts to comply with the race duty.

Question Time Panel:

'How do we capture the public imagination?'

A panel of Peter Baker, Barbara Limon from the EOC, Mike Birtwhistle from lobbyists AS Biss, David Brindle of The Guardian and Simon Blake of Brook took questions. Chair Ian Banks asked how delegates could ensure that the duty did not sink without trace or lead to the diversion of resources from women's health services to men's.

Brindle (pictured with Mike Birtwhistle): the media's increasing interest in personal health rather than public policy could help keep it up the agenda.

Limon: the EOC will not let it disappear. The CRE are taking action over non-compliance with the race directive and this will help us.

How do we capture public imagination?

Birtwhistle: the man on the street is never likely to talk about the duty but they are likely to complain about the NHS. We need to campaign on the basis of better public services.

Baker: it's an opportunity to increase the involvement of men in equality issues. we work closely with women's organisations now compared to 20 years ago.

Is it lack of willingness or lack of capacity?

Blake: There's a con going on. People think that there is gender equality. There is for a lot of middle class people but the discriminatory system is still there. PCTs need to change the way they work not just tag the duty onto it.

Birtwhistle: what would have been different if we'd had this law in the past? Well, the NHS probably wouldn't have got away with its after-hours access provision. We need to find those pressure points and demand change. Why? Because the law says so.

Baker: It's about working together. they have a problem — compliance — that we can help them with.

With funding limited how can the gender duty in health not lead to fewer women's organisations?

Limon: it should increase opportunity. We have sample letters asking PCTs to follow the duty.

Brindle: the Guardian would run features on this. these sorts of issues are attractive to local papers too.

Blake: don't forget non-health organisations like schools and the home office. We need cultural change.

How will things be different in five years time?

Baker: I think we see change in health promotion fairly quickly. Then improved policy and finally, more slowly, change at PCT level.

Limon: I hope we'll have a better evidence base and better data. I hope it will encourage other EU countries to follow suit.

Blake: we'll see increased discussion about the allocation of resources.

Brindle: I think we might see a bigger impact than you expect. Public service reform is about the personalisation of services and this fits that well.

Concluding the event, Dr Ian Banks stressed that there was no guarantee of the duty being implemented 'unless we do it ourselves'. He called on all present to join the MHF's Network.

• More on the Gender Duty from the MHF
• Pictures by Neeki Okafor