Patient Safety Commissioner for Scotland Bill: combined equality, Fairer Scotland and health inequalities impact assessment

Equality, Fairer Scotland Duty and Health Inequalities Impact Assessment Record

Title of legislation: Patient Safety Commissioner for Scotland

Minister: Maree Todd MSP, Minister for Public Health, Women's Health and Sport

Lead official: Will Wood

Officials involved in the impact assessment: Jenny Hunt and Will Wood

Directorate: Division: Team: Healthcare Quality & Improvement: Healthcare Planning & Quality: Patient Safety Commissioner Bill Team

Is this new policy or revision to an existing policy?: New policy

Screening

Policy Aim

The policy originates in the Independent Medicines and Medical Devices Safety Review, which was commissioned by the UK Government and carried out by Baroness Cumberlege. The review examined how the healthcare system in England responds to reports received from patients of adverse outcomes and side effects caused by medicines and medical devices.

The report of the review contained the following recommendation:

Recommendation 2: The appointment of a Patient Safety Commissioner who would be an independent public leader with a statutory responsibility. The Commissioner would champion the value of listening to patients and promoting users' perspectives in seeking improvements to patient safety around the use of medicines and medical devices.

Although the review focused on the healthcare system in England, Baroness Cumberlege also took evidence from users of the healthcare system in Scotland, and the review's findings were recognised to be applicable to all four UK nations. The Scottish Government therefore committed to implementing all recommendations of the review as far as it had devolved competence to do this.

The aim of the policy is to establish a Patient Safety Commissioner for Scotland who will:

• promote and improve patient safety by amplifying the patient voice within the patient safety system;
• develop a system-wide view of the health care system in Scotland and use it to identify wider safety issues; and
• promote better coordination across the patient safety landscape in Scotland in responding to concerns about safety issues.

This is a Programme for Government commitment.

The Patient Safety Commissioner will be a statutory Parliamentary Commissioner, independent of the Scottish Government and the NHS. Their core purpose will be to bring together patient feedback and other information relating to patient safety concerns, so as to be well-placed to identify trends and wider safety issues of the kind which may be missed at a local level. They will also have a role in encouraging co-ordination across different parts of the patient safety systems in Scotland, promoting the importance of the patient voice and helping healthcare services to listen to and better act on patients' views. While the aim is not to replace existing mechanisms for providing feedback and making complaints about health care services, such as the NHS model complaints procedure, the public will be able to contact the Patient Safety Commissioner regarding concerns about patient safety.

The policy contributes to the National Outcome for Health, in improving the safety of health care treatments. In developing this policy the Scottish Government is mindful of the three needs of the Public Sector Equality Duty (PSED):

• eliminate unlawful discrimination, harassment and victimisation;
• advance equality of opportunity between people who share a protected characteristic and those who do not; and
• foster good relations between people who share a protected characteristic and those who do not.

Where any negative impacts have been identified, we have sought to mitigate/eliminate these. We are also mindful that the equality duty is not just about negating or mitigating negative impacts, as we also have a positive duty to promote equality. We have suggested ways that the Patient Safety Commissioner may seek to do this, recognising that although the Commissioner will be an independent office they will have their own obligations under the public sector equality duty.

Who will it affect?

The policy relates to an area – health – where there are known inequalities associated with a range of factors including:

• socio-economic deprivation;
• poor health literacy;
• low levels of attainment;
• disability; and
• issues disproportionately affecting ethnic minority groups.

The policy will indirectly benefit the population of Scotland as a whole, regardless of geographical location, socio-economic standing or inclusion in any of the protected characteristic groups, by making improvements to safety in the healthcare system over time.

In particular it will directly benefit those who currently find it difficult to raise concerns about the safety of their care with healthcare professionals, or who feel that their concerns are not listened to.

There is no direct statistical evidence that people with particular protected characteristics or who live in areas of socio-economic deprivation are at greater risk of unsafe healthcare. Similarly, there is no evidence that healthcare in particular geographical areas of Scotland is less safe than average. However, it is reasonable to suggest that some groups, such as those with disabilities, those from poorer backgrounds, and those who are older, may be more likely to require healthcare treatment, and therefore may have a higher chance of being exposed to potential harm from healthcare that is unsafe.

Stakeholders told us that patients and their families and carers find the current complaints system cumbersome and difficult to navigate. This is likely to be exacerbated in certain groups for the same reasons as above. For example, people with lower levels of educational attainment may find be less confident in articulating their concerns and more likely to be discouraged from pursuing their concerns if they do not receive a straightforward resolution or feel they have not been listened to.

To explore any potential negative impact on specific groups or individuals, we have engaged with groups representing people with protected characteristics by questionnaire.

What might prevent the desired outcomes being achieved?

The main factor that could prevent the desired outcome from being achieved is a lack of financial or staffing resource to allow the Patient Safety Commissioner to carry out their duties effectively with due regard to equalities. Further information on costs can be found in the Financial Memorandum which accompanies the Patient Safety Commissioner for Scotland Bill.

A lack of engagement, input and co-operation from healthcare providers and other organisations within the patient safety landscape, and from patients themselves, would also mean that the Commissioner would have difficulty in effecting change.

The Patient Safety Commissioner will have a range of core activities to carry out relating to promotion of the role and outreach, familiarisation with the Scottish health care system, strategies to raise the profile of the patient voice, research into patient safety issues, and investigation of safety concerns. It is likely that budget constraints will affect the number of staff the Patient Safety Commissioner can employ. This in turn is likely to have an impact on whether the Commissioner can meaningfully carry out their role.

In a meeting of the Patient Safety Commissioner Bill Advisory Group on 14 June, which focused on exploring equalities issues relevant to the Patient Safety Commissioner, a number of attendees mentioned the need for the Commissioner to have access to sufficient funding and staff resource to be able to perform their role meaningfully and effectively.

Stage 1: Framing

Results of framing exercise

Set out here a summary of the initial findings of your framing exercise which helped identify existing evidence and potential impacts

The Patient Safety Commissioner is intended to benefit all users of the healthcare system in Scotland, regardless of background, circumstances or location. However, there may be a risk that the Commissioner exacerbates existing inequalities if not set up correctly. The EQIA exercise identified the following ways this risk could be minimised:

• Communication: The Commissioner should take into account how they communicate to patients and the public, and how patients and the public can communicate with them. For example, some groups such as people from lower socio-economic backgrounds, older people and disabled people, and those who live in areas with poor connectivity, may be less able to use digital communication. Therefore the Commissioner should ensure information about their work is not solely available online and that there are alternative methods and information formats available for people who need them. This should include written formats that are accessible including community languages, easy read, British Sign Language, and telephone;
• Health literacy: The Commissioner should ensure that the information they present is accessible to all regardless of educational attainment or socio-economic standing, and also to those whose understanding may be affected by learning disabilities. Where applicable they should encourage healthcare providers to ensure that they do the same;
• Disabilities and health conditions: The Commissioner should ensure they understand how different disabilities and health conditions, particularly those which are rare but highly debilitating, can affect patients' ability and confidence in challenging healthcare professionals and institutions. For instance the stress of struggling to make their voice heard may exacerbate some people's already poor health;
• Rurality: The Commissioner should ensure that they are accessible to people in rural and island communities across Scotland as well as the Central Belt and urban areas. These communities are likely to face different challenges when accessing healthcare.

Extent/Level of impact assessment required

Following gathering and analysing your evidence of the (potential) impacts of your policy on each of the protected characteristics, set out here your consideration of the extent/level of assessment required.

Include any further evidence gathering and external engagement that is required to demonstrate that you are giving "due regard" to the equality duty of eliminating discrimination, promoting equality of opportunity and fostering good relations.

There is no available evidence about the prevalence of harm or adverse events resulting from unsafe care among people with protected characteristics and low-income and other groups in Scotland. Nor is there quantitative evidence about the ability of these groups to challenge health care providers when things do go wrong. The evidence below focuses on qualitative information from representatives of these groups.

The Scottish Government ran a public consultation from March to May 2021 which asked the following questions:

1. What are your views on how creating a Patient Safety Commissioner might affect the protected characteristics of age, disability, sexual orientation, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, and sex? and

2. The Fairer Scotland Duty places a legal responsibility on certain public bodies in Scotland to actively consider how they can reduce inequalities caused mainly by people's financial situation. What are your views on how having a Patient Safety Commissioner might affect this inequality?

Respondents to the first question generally felt that creating the Patient Safety Commissioner would have a positive impact on people with one or more of the protected characteristics, providing a dedicated route to raise concerns about safety and ensuring everyone's voices are heard. Specific points raised included:

• The Patient Safety Commissioner must ensure channels of communication and methods of contact are accessible to all groups, for example those who do not have access to online services or whose first language is not English;
• Anyone appointed to the role should have a good awareness of the issues facing protected characteristic groups and be ready to advocate for those groups, and that safety issues arising from inequality of treatment of those in those groups would be a matter for the Patient Safety Commissioner to investigate;
• Any risk of unconscious bias should be eliminated by ensuring individuals from all protected characteristic groups are listened to equally and fairly, and by promoting the perspectives of service users with specific needs;
• One respondent suggested that not having a Patient Safety Commissioner risked greater harm as an independent body was needed to address insufficient recognition of protected characteristics.

In response to the second question on Fairer Scotland Duty, a significant number of respondents felt that the Patient Safety Commissioner would not have a negative impact. Respondents mentioned that in the main the policy should have a positive impact, influencing the necessary changes so that people from poorer financial backgrounds are not discriminated against in terms of their health care. Other points made included:

• The role should be set up in such a way that financial constraints do not preclude people from poorer backgrounds, who may also have lower levels of health literacy, from engaging with the Patient Safety Commissioner;
• The Patient Safety Commissioner must ensure channels of communication and methods of contact are equally accessible to those who may lack the financial means for example to engage with digital services;
• The idea that the Patient Safety Commissioner could give an independent and impartial view of inequalities and discrimination in relation to patient safety was welcome;
• The Patient Safety Commissioner should embrace an inclusive human-centred design process in all their activities.

A meeting of the Patient Safety Commissioner Bill Advisory Group on 14 June 2022 focused specifically on questions around groups with protected characteristics, plus Fairer Scotland and health inequalities issues. In summary, participants made the following comments:

• The Patient Safety Commissioner should consider the needs of vulnerable groups;
• The Commissioner should proactively engage with groups with protected characteristics and be aware of the ways stigma can affect people's confidence and ability to interact with services;
• The Commissioner must be careful not to make assumptions about patients or their families and carers and must take account of how disabilities or long term health conditions might affect safe delivery of healthcare;
• The Commissioner must not focus their activities in central Scotland and must consider groups who are isolated, either geographically or in terms of their treatment, for instance in care homes or in specialist care;
• The Commissioner must be marketed appropriately across all age groups to encourage engagement;
• The Commissioner will need to be aware of how the population of Scotland changes – for instance the recent influx of refugees from Ukraine – and the potential impact on patient safety issues.

In May to July 2022 the Scottish Government sent a questionnaire with a series of questions on equalities in relation to the Patient Safety Commissioner to a selection of organisations representing groups with protected characteristics:

• Age Scotland;
• Young Scot;
• Inclusion Scotland;
• Scottish Trans Alliance;
• Flexibility Works;
• The National Childbirth Trust;
• Bliss;
• Sands UK;
• The Coalition for Racial Equality and Rights;
• Interfaith Scotland;
• Engender;
• The Equality Network; and
• Equal Civil Partnerships.

While all groups who responded felt that the establishment of the Patient Safety Commissioner was unlikely to cause any inequalities for any groups, they made some observations:

• Respondents from organisations relating to age told us:
  • 34% of over 60s in Scotland do not use the internet, and only half of over 60s in the most deprived areas use the internet, therefore it is important that the Commissioner ensures that alternative formats are available to those who require them;
  • Many older people are afraid to raise complaints about the standard of care they receive, either in a care home, in the community, or in hospital, in case it negatively impacts the support and services that they receive, so the Patient Safety Commissioner should consider barriers to effective complaints procedures in which patients and their advocates feel supported and safe;
  • Age Scotland felt that the policy is not likely to have a negative impact on older people provided steps are taken to ensure an age-inclusive approach.
• Respondents from organisations relating to religion and belief told us:
  • As long as the Commissioner's office treat all people with the same respect, equality of opportunity will be guaranteed;
  • It is hoped that any institutional bias within the healthcare sector against religious minorities will be brought to the Patient Safety Commissioner's attention;
  • If people see their problems being addressed in a fair way then good relations across communities will be fostered;
  • If a clear and open attitude is maintained in explaining how the processes work, including use of languages other than English, and the ability to adapt processes to the needs of those who bring complaints, there should be no negative impacts on people in relation to their religion of belief;
  • Some women may feel safe only in women-only settings;
  • Many people want to have a human relationship with someone they can trust so communication should not just be virtual;
  • Establishing trust will be a vital first step to make people able to share their cultural and religious beliefs without fear;
  • The Commissioner should work with faith leaders and peers to explain cultural significances and taboos and aid communication of medical concepts to people of different faiths.
• Respondents from organisations relating to pregnancy and maternity told us:
  • A safe birth should empower a parent with confidence to care for their baby;o The Patient Safety Commissioner must be accessible to patients who cannot speak for themselves and so must ensure families can have their voices heard on their behalf;
  • Pregnant women and new mothers who are not otherwise ill or injured are not 'patients' in the same sense and must not be excluded because of this;
  • Consideration must be given to ensuring the concerns of 'hidden populations' whose voice is not sufficiently heard such as people with rare health conditions or people from poorer backgrounds, and those who live in communities who are unable to get the right support to allow them to engage with services;
  • Any recommendation to offer different patterns of maternity care to try to address disparities of outcome (for example in rates of stillbirth) must be based on relevant and specific evidence;
  • The Commissioner should build relationships with advocacy and support organisations to facilitate communications and build trust with individuals and communities who have patient safety concerns, but who are less able to engage;
  • When engaging with patients and families directly, this must be done in a way that is practical for them, considering virtual/in-person, childcare, interpretation or advocacy support;
  • The Commissioner must be adequately resourced to enable them to carry out effective engagement work and amplify patient voices.

Finally, policy officials examined the health inequalities impact assessment that was carried out in 2016 for the proposed introduction of the NHS model complaints handling procedure, as some of the equalities issues relevant to complaints handling are similar to those related to engaging with the Patient Safety Commissioner. A workshop was held in August 2016 with attendance for people with a range of specialist knowledge and experience including:

• Direct experience of working with people with various protected characteristics in acute care settings;
• Clinical experience of providing mental health services, including in the forensic sector;
• Experience and expertise in working with and supporting older people, including those with dementia and their families and carers;
• Working with and advocating for young people, families and carers, including those who are living in poverty;
• Experience of supporting people with disabilities or who are living with long-term health conditions to be in the driving seat of their care;
• Experience of working with people from different faith backgrounds;
• Expertise in overcoming barriers to communication, including those experienced by people with a learning disability, sensory impairment, or who are not English speakers;
• Expertise in complaints handling;
• Expertise in independent advocacy; and
• Legal expertise.

Key findings from this exercise reflect the benefits of the Patient Safety Commissioner as an advocate for the patient voice: having a figurehead to focus on patient safety issues, alleviating distress caused when patients feel their voices are not heard, acknowledging the needs of all protected characteristic groups in a non-discriminatory manner, and reducing risk that health inequalities could increase, as services would reflect the voices only of those who felt able or confident in raising concerns.

Stage 2: Data and evidence gathering, involvement and consultation

Include here the results of your evidence gathering (including framing exercise), including qualitative and quantitative data and the source of that information, whether national statistics, surveys or consultations with relevant equality groups.

Age^[1]

Evidence gathered and strength/quality of evidence

• 34% of over 60s in Scotland do not use the internet, and only half of over-60s in the most deprived areas use the internet
• Many older people are afraid to raise complaints about the standard of care they receive, either in a care home, in the community, or in hospital, in case it will negatively impact the support and services that they receive
• Older people with less computer literacy may struggle to use online information and communication
• Care home residents are a community with specific needs and are at risk of being overlooked in terms of patient safety
• Children and young people may prefer to contact services using social media.
• Older people with a cognitive impairment may require additional support to raise a concern
• Medication errors are more likely in older people^[2]
• Older people are more likely to experience harm in both acute hospitals and primary care, and particular causes of harm include falls, pressure damage, infections, medication errors and inadequate nutrition and hydration^{[3] [4]}

Source

Age Scotland

Public consultation

Patient Safety Commissioner Bill Advisory Group

NHS Model Complaints Handling Process HIIA

(UK) NHS Patient Safety Strategy EQIA

Disability

Evidence gathered and strength/quality of evidence

• Stigma can affect people's confidence and ability to interact with services
• Disabilities or long term health conditions can affect safe delivery of health care
• People with disabilities or long term health conditions can become isolated and less likely to engage with services
• People with a disability may need access to additional support to raise concerns
• Certain groups with learning disabilities may be more at risk of patient safety incidents in acute NHS hospitals due to their vulnerable status^[5]

Source

Patient Safety Commissioner Bill Advisory Group

NHS Model Complaints Handling Process HIIA

(UK) NHS Patient Safety Strategy EQIA

Sex

Evidence gathered and strength/quality of evidence

• Some women may feel safe only in female settings. This may not be seen as equality promotion by others.
• The procedure of raising concerns needs to accommodate people who may have had a negative experience with a healthcare professional of a specific sex.

Source

Interfaith Scotland

NHS Model Complaints Handling Process HIIA

Pregnancy and maternity

Evidence gathered and strength/quality of evidence

• Pregnant women and new mothers who are not otherwise ill or injured are 'maternity service users' rather than 'patients' and must not be excluded from 'patient safety' because of this
• Some 'patients' are unable to speak for themselves and rely on families and/or carers to do this, such as unborn children and neonates
• Some people in this category, especially those living in rural areas, may be reluctant to raise concerns, due to concerns that this may impact on the future relationship with a care provider
• Others may need additional reassurance that their concerns will be taken seriously
• New mothers with small babies can find it difficult to engage

Source

National Childbirth Trust

Bliss for babies born premature or sick

NHS Model Complaints Handling Process HIIA

Sands (Stillbirth and Neonatal Death)

Gender reassignment

Evidence gathered and strength/quality of evidence

• Stigma can affect people's confidence and ability to interact with services
• Failure to recognise transgender people as the gender they identify as may impact negatively on the successful early resolution of their concerns

Source

Patient Safety Commissioner Bill Advisory Group

Sexual orientation

Evidence gathered and strength/quality of evidence

• Stigma can affect people's confidence and ability to interact with services
• Staff attitude and behaviours, if not supportive, can be a barrier to LGBT individuals raising concerns

Source

Patient Safety Commissioner Bill Advisory Group

NHS Model Complaints Handling Process HIIA

Race

Evidence gathered and strength/quality of evidence

• 7.4% of people aged 3 and over use a language other than English at home in Scotland

• People whose first language is not English will require information and communication in their first language
• Some black and ethnic minority staff who raise concerns are treated less favourably than white staff and are more likely to experience bullying/harassment and be referred to professional regulators^{[6] [7]}
• Black African and Caribbean people are disproportionately detained under the Mental Health Act and more likely to be subject to the most coercive powers under the Act, such as forcible restraint^[8]

Source

Census 2011

Public consultation

(UK) NHS Patient Safety Strategy EQIA

Religion or belief

Evidence gathered and strength/quality of evidence

• Some women may feel safe only in female settings, which may not be seen as equality promotion by others
• If people see their problems being addressed in a fair way then good relations across communities will be fostered
• Many people want to have in-person interactions and relationships with someone they can trust
• Establishing trust will be the vital first step to make people able to share their cultural and religious beliefs without fear
• Support for languages other than English is important
• Faith leaders and peers should be consulted to explain cultural significances and taboos to the Patient Safety Commissioner, and aid communication of medical concepts to their believers
• The sex of the person raising the concern, and that of the person they are raising the issue with or about, may be an issue for some faith groups

Source

Interfaith Scotland

NHS Model Complaints Handling Process HIIA

Marriage and civil partnership

(the Scottish Government does not require assessment against this protected characteristic unless the policy or practice relates to work, for example HR policies and practices - refer to Definitions of Protected Characteristics document for details)

Evidence gathered and strength/quality of evidence

n/a

Source

n/a

For people experiencing socio-economic disadvantage or from low socio-economic backgrounds

Evidence gathered and strength/quality of evidence

• Financial constraints should not preclude people from poorer backgrounds, who may also have lower levels of health literacy, from engaging with the Patient Safety Commissioner and the Commissioner must ensure channels of communication and methods of contact are equally accessible to those who may lack the financial means to engage with digital services.
• People from poorer backgrounds tend to have reduced health literacy and worse general health, leading to higher levels of exclusion and difficulty negotiating or challenging 'the establishment'.
• "Health inequalities are strongly influenced by underlying inequalities in power, money and wealth which in turn influence access to other resources, facilities, services and opportunities."
• In January 2022 97% of residential properties in Scotland had at least 10Mbit/s fixed broadband services available to them. For higher speeds the statistics are 94% superfast services^[9]; 60% Gigabit-capable; 32% full fibre. These statistics reflect the availability of connectivity, note that this does not mean all these residential properties can afford fixed broadband services or choose to use them, so the number with home broadband services is likely to be somewhat lower.
• 87% of households in the 20% most deprived areas had access to the internet whereas almost all households (99%) in the 20% least deprived areas had access to the internet; 83% of adults in the 20% most deprived areas used the internet, compared to 96% of adults in the 20% least deprived areas.
• 21% of social rented households did not have access to the internet at home, while only 5% of owner occupied households and 2% of private rented households had no access to the internet at home
• In January 2022 57-74% of Scotland had 4G coverage across all mobile network operators and 68-82% had voice and text coverage [note again this does not mean everyone in these areas can afford a mobile phone or data so the number with mobile broadband or text/voice is likely to be lower]
• People in the most deprived areas are less likely to think they can influence decisions affecting their local area (22%) than those in the least deprived areas (29%)
• 43.5% of young people living in the most deprived areas achieve one or more Higher when leaving school compared to 79.3% of young people living in the least deprived areas.

Source

Public consultation

NHS Health Scotland 'Health Inequalities – Access to Services', 2014 NHS_Health_Scotland_-_Access_to_Services.pdf

Ofcom Connected Nations Update, May 2022

Scottish Household Survey 2020

The Poverty-Related Attainment Gap: a review of the evidence The Poverty Alliance 2021

People with rare and/or long term health conditions

Evidence gathered and strength/quality of evidence

• Stigma can affect people's confidence and ability to interact with services
• Disabilities or long term health conditions can affect safe delivery of health care
• People with rare and/or long term health conditions can become isolated and less likely to engage with services
• People with a long-term illness were less likely (20%) to feel that they can influence decisions affecting their local area than those without (26%).

Source

Patient Safety Commissioner Bill Advisory Group

Scottish Household Survey 2020

Looked after children and young people

Evidence gathered and strength/quality of evidence

• Some people in this group may find the experience of raising a concern particularly intimidating due to existing adverse experiences with care and other services

Source

NHS Model Complaints Handling Process HIIA

Refugees & asylum seekers

Evidence gathered and strength/quality of evidence

• 2,078 people were resettled in Scotland in the five years to March 2022
• There were 4,667 asylum seekers receiving support from Scottish local authorities on 31 March 2022
• Stigma can affect people's confidence and ability to interact with services
• Scotland's changing population gives rise to issues relating to health conditions, language barriers, religious and cultural beliefs and how to keep track of and engage with these new groups

Source

UKG asylum and resettlement datasets

Patient Safety Commissioner Bill Advisory Group

Minority ethnic people (includes Gypsy/ Travellers, non-English speakers)

Evidence gathered and strength/quality of evidence

• Across Scotland 4% of people identify as non-white ethnic minority, with the highest rates in the four following large urban areas: Glasgow City (12%), the City of Edinburgh (8%), Aberdeen City (8%), and Dundee City (6%)
• 7.4% of people aged 3 and over use a language other than English at home in Scotland
• Of the 1.5% of people in Scotland who were born in EU accession countries, 75.2% could speak, read and write English^[10]
• Of the 2% of people in Scotland who were born in the Middle East or Asia, 88.8% could speak, read and write English.
• People whose first language is not English will require information and communication in their first language
• Patients of minority cultural and language backgrounds may be disproportionately at risk of experiencing "preventable adverse events"' while in hospital "compared with mainstream patient groups", due to the "critical relationship that exists between culture, language and safety"^[11]

Source

Census 2011

Public consultation

(UK) NHS Patient Safety Strategy EQIA

Homeless people

Evidence gathered and strength/quality of evidence

• 29,894 people were assessed as homeless or threatened with homelessness in 2018-2019
• Homeless individuals have worse physical and emotional health status than the general population, including those from deprived neighbourhoods – risk factors include early life poverty, substance misuse, poor nutrition, exposure to communicable diseases, harsh living conditions, high rates of victimisation and unintentional injuries and increased rates of tobacco use. These are exacerbated by poor access to healthcare and challenges in adherence to medication.
• People with no fixed address may be part of a set of 'hidden' communities whose voice is not heard
• One third of rough sleepers are not registered with a GP; attendance at accident and emergency is at least eight times higher than the housed population (2017)
• Young homeless people lack relationship and independent living skills, formal support and struggle to access services
• People with a history of complex trauma, including the chronically homeless, may behave in a range of ways that suggest underlying difficulties with trusting relationships
• "[Homeless people] don't want to go to their GP because they feel like there's a stigma"
• "Stigma related to homelessness contributes to the significant health inequalities experienced by this group"

Source

Public Health Scotland website

Fazel et al, "The health of Homeless People in High-Income Countries"

Patient Safety Commissioner Bill Advisory Group

NHS Model Complaints Handling Process HIIA

Bliss for babies born premature or sick

The Impact of Homelessness on Health, Local Government Authority

Hard Edges Scotland, Bramley et al 2019

A systematic review of the effect of stigma on the health of people experiencing homelessness, Riley & Williamson 2022

People involved in the criminal justice system

Evidence gathered and strength/quality of evidence

• People in contact with the criminal justice system tend to have significantly poorer health than the general population, with high levels of mental ill-health and substance use and multiple co-morbidities.
• An arrival in prison is three times more likely to come from the most deprived 10% of areas in Scotland

Source

NHS Scotland Police Care Network Healthcare in Police Custody

Scottish prison population: statistics 2019 to 2020

People with low literacy/numeracy

Evidence gathered and strength/quality of evidence

• Stigma can affect people's confidence and ability to interact with services

Source

Patient Safety Commissioner Bill Advisory Group

Carers (include parents, especially lone parents; and elderly carers)

Evidence gathered and strength/quality of evidence

• Carers may find it hard to make time to engage
• Child carers may be fearful their concerns will be dismissed

Source

NHS Model Complaints Handling Process HIIA

People in remote, rural and/or island locations

Evidence gathered and strength/quality of evidence

• Transport links, weather and cost can make it harder for people living in remote or island communities to access services at a distance from home
• Digital connectivity can be lower in remote, rural and island communities
• In January 2022 97% of residential properties in Scotland had access to at least 10Mbit/s fixed broadband services (94% superfast services; 60% Gigabit-capable; 32% full fibre)
• In January 2022 57-74% of Scotland had 4G coverage across all mobile network operators and 68-82% had voice and text coverage; 11% of Scotland has no voice or text coverage at all

Source

Patient Safety Commissioner Bill Advisory Group

Ofcom Connected Nations Update, May 2022

The right to freedom of expression

(qualified right)

Evidence gathered and strength/quality of evidence

• The Patient Safety Commissioner will provide an independent channel for patients and their families who, for reasons set out elsewhere in this assessment, find it difficult or do not want to engage with health services providers.

Source

Public consultation

Patient Safety Commissioner Bill Advisory Group

The right not to be discriminated against

Evidence gathered and strength/quality of evidence

• People from poorer backgrounds tend to have reduced health literacy and worse general health, leading to higher levels of discrimination

Source

Public consultation

Stage 3: Assessing the impacts and identifying opportunities to promote equality

Having considered the data and evidence you have gathered, this section requires you to consider the potential impacts – negative and positive – that your policy might have on each of the protected characteristics and on people experiencing socio-economic disadvantage. It is important to remember the duties are also positive – that we must explore whether the policy offers the opportunity to promote equality and/or fosters good relations between groups in relation to the protected characteristics.

Do you think that the policy impacts on people because of their age?

	Positive	Negative	None	Reasons for your decision
Eliminating unlawful discrimination, harassment and victimisation	X			The Patient Safety Commissioner will help to eliminate discrimination by amplifying the voice of the patient in relation to patient safety concerns, by raising greater awareness of the range of patient experiences and varying needs, and by bringing together different types of evidence to enable the healthcare system to identify systemic issues that may affect patients.
Advancing equality of opportunity	X			The Patient Safety Commissioner will advance equality of opportunity by providing an independent function through which all patients can communicate their experiences, thus enabling more patients to raise concerns about the safety of their care hold the healthcare system to account for its responsibilities to deliver safe care and to listen to patients, regardless of their background, circumstances or location.
Promoting good relations with other groups	X			In raising awareness and understanding of the issues faced by people of different ages, the Patient Safety Commissioner will help to promote good relations within this group and with other population groups.

Do you think that the policy impacts disabled people?

	Positive	Negative	None	Reasons for your decision
Eliminating unlawful discrimination, harassment and victimisation	X			The Patient Safety Commissioner will help to eliminate discrimination by amplifying the voice of the patient in relation to patient safety concerns, by raising greater awareness of the range of patient experiences and varying needs, and by bringing together different types of evidence to enable the healthcare system to identify systemic issues that may affect patients.
Advancing equality of opportunity	X			The Patient Safety Commissioner will advance equality of opportunity by providing an independent function through which all patients can communicate their experiences, thus enabling more patients to raise concerns about the safety of their care hold the healthcare system to account for its responsibilities to deliver safe care and to listen to patients, regardless of their background, circumstances or location.
Promoting good relations with other groups	X			In raising awareness and understanding of the issues faced by disabled people, the Patient Safety Commissioner will help to promote good relations within this group and with other population groups.

Do you think that the policy impacts on men and women in different ways?

	Positive	Negative	None	Reasons for your decision
Eliminating unlawful discrimination, harassment and victimisation	X			The Patient Safety Commissioner will help to eliminate discrimination by amplifying the voice of the patient in relation to patient safety concerns, by raising greater awareness of the range of patient experiences and varying needs, and by bringing together different types of evidence to enable the healthcare system to identify systemic issues that may affect patients.
Advancing equality of opportunity	X			The Patient Safety Commissioner will advance equality of opportunity by providing an independent function through which all patients can communicate their experiences, thus enabling more patients to raise concerns about the safety of their care hold the healthcare system to account for its responsibilities to deliver safe care and to listen to patients, regardless of their background, circumstances or location.
Promoting good relations with other groups	X			In raising awareness and understanding of the issues faced by men and by women, the Patient Safety Commissioner will help to promote good relations between men and women and with other population groups.

Do you think that the policy impacts on women because of pregnancy and maternity?

	Positive	Negative	None	Reasons for your decision
Eliminating unlawful discrimination, harassment and victimisation	X			The Patient Safety Commissioner will help to eliminate discrimination by amplifying the voice of the patient in relation to patient safety concerns, by raising greater awareness of the range of patient experiences and varying needs, and by bringing together different types of evidence to enable the healthcare system to identify systemic issues that may affect patients.
Advancing equality of opportunity	X			The Patient Safety Commissioner will advance equality of opportunity by providing an independent function through which all patients can communicate their experiences, thus enabling more patients to raise concerns about the safety of their care hold the healthcare system to account for its responsibilities to deliver safe care and to listen to patients, regardless of their background, circumstances or location.
Promoting good relations with other groups	X			In raising awareness and understanding of the issues faced by pregnant women and new parents, the Patient Safety Commissioner will help to promote good relations within this group and with other population groups.

Do you think your policy impacts on people proposing to undergo, undergoing, or who have undergone a process for the purpose of reassigning their sex? (NB: the Equality Act 2010 uses the term 'transsexual people' but 'trans people' is more commonly used)

	Positive	Negative	None	Reasons for your decision
Eliminating unlawful discrimination, harassment and victimisation	X			The Patient Safety Commissioner will help to eliminate discrimination by amplifying the voice of the patient in relation to patient safety concerns, by raising greater awareness of the range of patient experiences and varying needs, and by bringing together different types of evidence to enable the healthcare system to identify systemic issues that may affect patients.
Advancing equality of opportunity	X			The Patient Safety Commissioner will advance equality of opportunity by providing an independent function through which all patients can communicate their experiences, thus enabling more patients to raise concerns about the safety of their care hold the healthcare system to account for its responsibilities to deliver safe care and to listen to patients, regardless of their background, circumstances or location.
Promoting good relations with other groups	X			In raising awareness and understanding of the issues faced by trans people, the Patient Safety Commissioner will help to promote good relations within this group and with other population groups.

Do you think that the policy impacts on people because of their sexual orientation?

	Positive	Negative	None	Reasons for your decision
Eliminating unlawful discrimination, harassment and victimisation	X			The Patient Safety Commissioner will help to eliminate discrimination by amplifying the voice of the patient in relation to patient safety concerns, by raising greater awareness of the range of patient experiences and varying needs, and by bringing together different types of evidence to enable the healthcare system to identify systemic issues that may affect patients.
Advancing equality of opportunity	X			The Patient Safety Commissioner will advance equality of opportunity by providing an independent function through which all patients can communicate their experiences, thus enabling more patients to raise concerns about the safety of their care hold the healthcare system to account for its responsibilities to deliver safe care and to listen to patients, regardless of their background, circumstances or location.
Promoting good relations with other groups	X			In raising awareness and understanding of the issues faced by people of all sexual orientations, the Patient Safety Commissioner will help to promote good relations within this group and with other population groups.

Do you think the policy impacts on people on the grounds of their race?

	Positive	Negative	None	Reasons for your decision
Eliminating unlawful discrimination, harassment and victimisation	X			The Patient Safety Commissioner will help to eliminate discrimination by amplifying the voice of the patient in relation to patient safety concerns, by raising greater awareness of the range of patient experiences and varying needs, and by bringing together different types of evidence to enable the healthcare system to identify systemic issues that may affect patients.
Advancing equality of opportunity	X			The Patient Safety Commissioner will advance equality of opportunity by providing an independent function through which all patients can communicate their experiences, thus enabling more patients to raise concerns about the safety of their care hold the healthcare system to account for its responsibilities to deliver safe care and to listen to patients, regardless of their background, circumstances or location.
Promoting good relations with other groups	X			In raising awareness and understanding of the issues faced by people from different racial backgrounds, the Patient Safety Commissioner will help to promote good relations within this group and with other population groups

Do you think the policy impacts on people because of their religion or belief?

	Positive	Negative	None	Reasons for your decision
Eliminating unlawful discrimination, harassment and victimisation	X			The Patient Safety Commissioner will help to eliminate discrimination by amplifying the voice of the patient in relation to patient safety concerns, by raising greater awareness of the range of patient experiences and varying needs, and by bringing together different types of evidence to enable the healthcare system to identify systemic issues that may affect patients.
Advancing equality of opportunity	X			The Patient Safety Commissioner will advance equality of opportunity by providing an independent function through which all patients can communicate their experiences, thus enabling more patients to raise concerns about the safety of their care hold the healthcare system to account for its responsibilities to deliver safe care and to listen to patients, regardless of their background, circumstances or location.
Promoting good relations with other groups	X			In raising awareness and understanding of the issues faced by people of different religions and beliefs, the Patient Safety Commissioner will help to promote good relations within this group and with other population groups

Do you think the policy impacts on people because they have a low income?

	Positive	Negative	None	Reasons for your decision
Eliminating unlawful discrimination, harassment and victimisation	X			The Patient Safety Commissioner will help to eliminate discrimination by amplifying the voice of the patient in relation to patient safety concerns, by raising greater awareness of the range of patient experiences and varying needs, and by bringing together different types of evidence to enable the healthcare system to identify systemic issues that may affect patients.
Advancing equality of opportunity	X			The Patient Safety Commissioner will advance equality of opportunity by providing an independent function through which all patients can communicate their experiences, thus enabling more patients to raise concerns about the safety of their care hold the healthcare system to account for its responsibilities to deliver safe care and to listen to patients, regardless of their background, circumstances or location.
Promoting good relations with other groups	X			In raising awareness and understanding of the issues faced by people with low incomes, the Patient Safety Commissioner will help to promote good relations within this group and with other population groups.

Do you think the policy impacts on people because they come from a deprived area?

	Positive	Negative	None	Reasons for your decision
Eliminating unlawful discrimination, harassment and victimisation	X			The Patient Safety Commissioner will help to eliminate discrimination by amplifying the voice of the patient in relation to patient safety concerns, by raising greater awareness of the range of patient experiences and varying needs, and by bringing together different types of evidence to enable the healthcare system to identify systemic issues that may affect patients.
Advancing equality of opportunity	X			The Patient Safety Commissioner will advance equality of opportunity by providing an independent function through which all patients can communicate their experiences, thus enabling more patients to raise concerns about the safety of their care hold the healthcare system to account for its responsibilities to deliver safe care and to listen to patients, regardless of their background, circumstances or location.
Promoting good relations with other groups	X			In raising awareness and understanding of the issues faced by people from deprived areas, the Patient Safety Commissioner will help to promote good relations within this group and with other population groups.

Do you think the policy impacts on people because of the social class they come from?

	Positive	Negative	None	Reasons for your decision
Eliminating unlawful discrimination, harassment and victimisation	X			The Patient Safety Commissioner will help to eliminate discrimination by amplifying the voice of the patient in relation to patient safety concerns, by raising greater awareness of the range of patient experiences and varying needs, and by bringing together different types of evidence to enable the healthcare system to identify systemic issues that may affect patients.
Advancing equality of opportunity	X			The Patient Safety Commissioner will advance equality of opportunity by providing an independent function through which all patients can communicate their experiences, thus enabling more patients to raise concerns about the safety of their care hold the healthcare system to account for its responsibilities to deliver safe care and to listen to patients, regardless of their background, circumstances or location.
Promoting good relations within communities	X			In raising awareness and understanding of the issues faced by people from different social classes, the Patient Safety Commissioner will help to promote good relations within this group and with other population groups.

Do you think the policy impacts on people because they have rare and/or long-term health conditions?

	Positive	Negative	None	Reasons for your decision
Eliminating unlawful discrimination, harassment and victimisation	X			The Patient Safety Commissioner will help to eliminate discrimination by amplifying the voice of the patient in relation to patient safety concerns, by raising greater awareness of the range of patient experiences and varying needs, and by bringing together different types of evidence to enable the healthcare system to identify systemic issues that may affect patients.
Advancing equality of opportunity	X			The Patient Safety Commissioner will advance equality of opportunity by providing an independent function through which all patients can communicate their experiences, thus enabling more patients to raise concerns about the safety of their care hold the healthcare system to account for its responsibilities to deliver safe care and to listen to patients, regardless of their background, circumstances or location.
Promoting good relations	X			In raising awareness and understanding of the issues faced by people with rare or long-term health conditions, the Patient Safety Commissioner will help to promote good relations within this group and with other population groups

Do you think the policy impacts on people because of their refugee or asylum status?

Age	Positive	Negative	None	Reasons for your decision
Eliminating unlawful discrimination, harassment and victimisation	X			The Patient Safety Commissioner will help to eliminate discrimination by amplifying the voice of the patient in relation to patient safety concerns, by raising greater awareness of the range of patient experiences and varying needs, and by bringing together different types of evidence to enable the healthcare system to identify systemic issues that may affect patients.
Advancing equality of opportunity	X			The Patient Safety Commissioner will advance equality of opportunity by providing an independent function through which all patients can communicate their experiences, thus enabling more patients to raise concerns about the safety of their care hold the healthcare system to account for its responsibilities to deliver safe care and to listen to patients, regardless of their background, circumstances or location.
Promoting good relations within communities	X			In raising awareness and understanding of the issues faced by refugees and asylum seekers, the Patient Safety Commissioner will help to promote good relations within this group and with other population groups.

Do you think the policy impacts on people because they come from an ethnic minority?

Age	Positive	Negative	None	Reasons for your decision
Eliminating unlawful discrimination, harassment and victimisation	X			The Patient Safety Commissioner will help to eliminate discrimination by amplifying the voice of the patient in relation to patient safety concerns, by raising greater awareness of the range of patient experiences and varying needs, and by bringing together different types of evidence to enable the healthcare system to identify systemic issues that may affect patients.
Advancing equality of opportunity	X			The Patient Safety Commissioner will advance equality of opportunity by providing an independent function through which all patients can communicate their experiences, thus enabling more patients to raise concerns about the safety of their care hold the healthcare system to account for its responsibilities to deliver safe care and to listen to patients, regardless of their background, circumstances or location.
Promoting good relations within communities	X			In raising awareness and understanding of the issues faced by people of different ethnicities, the Patient Safety Commissioner will help to promote good relations within this group and with other population groups

Do you think the policy impacts on people because they are homeless?

Age	Positive	Negative	None	Reasons for your decision
Eliminating unlawful discrimination, harassment and victimisation	X			The Patient Safety Commissioner will help to eliminate discrimination by amplifying the voice of the patient in relation to patient safety concerns, by raising greater awareness of the range of patient experiences and varying needs, and by bringing together different types of evidence to enable the healthcare system to identify systemic issues that may affect patients.
Advancing equality of opportunity	X			The Patient Safety Commissioner will advance equality of opportunity by providing an independent function through which all patients can communicate their experiences, thus enabling more patients to raise concerns about the safety of their care hold the healthcare system to account for its responsibilities to deliver safe care and to listen to patients, regardless of their background, circumstances or location.
Promoting good relations	X			In raising awareness and understanding of the issues faced by homeless people, the Patient Safety Commissioner will help to promote good relations within this group and with other population groups

Do you think the policy impacts on people because they are in the criminal justice system?

Age	Positive	Negative	None	Reasons for your decision
Eliminating unlawful discrimination, harassment and victimisation	X			The Patient Safety Commissioner will help to eliminate discrimination by amplifying the voice of the patient in relation to patient safety concerns, by raising greater awareness of the range of patient experiences and varying needs, and by bringing together different types of evidence to enable the healthcare system to identify systemic issues that may affect patients.
Advancing equality of opportunity	X			The Patient Safety Commissioner will advance equality of opportunity by providing an independent function through which all patients can communicate their experiences, thus enabling more patients to raise concerns about the safety of their care hold the healthcare system to account for its responsibilities to deliver safe care and to listen to patients, regardless of their background, circumstances or location.
Promoting good relations	X			In raising awareness and understanding of the issues faced by people in the criminal justice system, the Patient Safety Commissioner will help to promote good relations within this group and with other population groups

Stage 4: Decision making and monitoring

Identifying and establishing any required mitigating action

If, following the impact analysis, you think you have identified any unlawful discrimination – direct or indirect – you must consider and set out what action will be undertaken to mitigate the negative impact. You will need to consult your legal team in SGLD at this point if you have not already done so.

We have noted above some actions that the Patient Safety Commissioner may take to improve the positive impact on inequality, summarised below:

• The Commissioner should ensure that information about their work is not solely available online and that there are a variety of methods of contacting them, including online, by telephone and by post;
• The Commissioner should ensure that the information they present is accessible to all regardless of their English language ability, educational attainment or socio-economic standing (and therefore differing levels of health literacy). Where applicable they should encourage healthcare providers to do the same;
• The Commissioner should ensure they understand how different disabilities and health conditions, particularly those which are rare but highly debilitating, can affect patients' ability and confidence in challenging healthcare professionals and institutions.
• The Commissioner should have a good awareness of the issues facing protected characteristic groups and be ready to advocate for those groups
• The Commissioner should be accessible to people in rural areas across Scotland as well as the central belt and urban areas;
• The Commissioner should proactively engage with groups with protected characteristics and low socio-economic standing and advocacy groups, and be aware of the ways stigma can affect people's confidence and ability to interact with services;
• The Commissioner should listen to all groups equally and fairly, and should promote the perspectives of vulnerable service users;
• The Commissioner should embrace an inclusive human-centred design process in all their activities;
• The Commissioner should be marketed appropriately across all age groups to encourage engagement;
• The Commissioner must be accessible to patients who cannot speak for themselves and so must ensure families can have their voices heard on their behalf;
• The Commissioner will need to be aware of how the population of Scotland changes – for instance the recent influx of refugees from Ukraine – and the potential impact on patient safety issues.

Have positive or negative impacts been identified for any of the equality groups?

One of the Patient Safety Commissioner's key functions is to amplify the voices of patients so we assess this will bring about a positive impact for all groups. The Commissioner will provide an independent, supportive channel for all population groups to challenge the healthcare sector in relation to patient safety concerns

No negative impacts have been identified as long as the Commissioner takes care to recognise and understand all the different equality groups. As a public body the Patient Safety Commissioner will be subject to the public sector equality duty, and it will be for Parliament to monitor compliance.

Is the policy directly or indirectly discriminatory under the Equality Act 2010^[12]?

The policy is not directly or indirectly discriminatory under the 2010 Act

If the policy is indirectly discriminatory, how is it justified under the relevant legislation?

n/a

If not justified, what mitigating action will be undertaken?

n/a

Describing how Equality Impact analysis has shaped the policy making process

While the overall policy aim and principles have remained the same, there are some particular areas where we have made specific changes :

• We have looked at the definition of a 'patient' to ensure it also encompasses those groups who may not be unwell but who are still users of the health service, such as pregnant women and people having routine scans;
• In our cost estimates for creating the office we have not assumed that the Commissioner and their staff will be based in cities or the central belt, and we have estimated travel costs to reflect the need to travel across Scotland to engage with stakeholders; and
• To assist people who wish to serve on the Commissioner's advisory group but may be precluded due to being on a low income, we have included scope for paying a daily fee to members who are unemployed or in insecure or low-paid work. This will particularly help individuals who are unable to work due to health issues.

We will also work with the Scottish Parliament Corporate Body to ensure the job description for the Patient Safety Commissioner includes references to skills and experience related to equalities where appropriate.

Although the Patient Safety Commissioner will be independent of government and the NHS, and so the Scottish Government cannot directly influence how they choose to carry out their role and functions, we consider the Commissioner may find it helpful to:

• Have representation of a range of equalities groups within their advisory group;
• Take time to understand the health inequalities experienced by different groups in Scotland;
• Proactively engage with representative groups; and
• Make every effort to be visible and available to members of these groups.

Altogether these considerations will enable the Patient Safety Commissioner to develop better, fairer outcomes for people and communities across Scotland.

Monitoring and Review

The Patient Safety Commissioner will be accountable to the Scottish Parliament and will prepare a strategic plan every four years, and produce an annual report of their activity - both of which will be laid at Parliament.

Stage 5: Authorisation of Impact Assessment

Please confirm that:

• This Equality, Fairer Scotland Duty and Health Inequalities Impact Assessment has informed the development of this policy:

Yes X

No

• Opportunities to promote equality in respect of age, disability, gender reassignment, pregnancy and maternity, race, religion or belief, sex and sexual orientation have been considered, i.e.:
  • Eliminating unlawful discrimination, harassment, victimisation;
  • Removing or minimising any barriers and/or disadvantages;
  • Taking steps which assist with promoting equality and meeting people's different needs;
  • Encouraging participation (e.g. in public life)
  • Fostering good relations, tackling prejudice and promoting understanding.

Yes X

No

• Opportunities to promote equality of outcomes for groups experiencing socioeconomic disadvantage have been considered:

Yes X

No

• If the Marriage and Civil Partnership protected characteristic applies to this policy, the Equality Impact Assessment has also assessed against the duty to eliminate unlawful discrimination, harassment and victimisation in respect of this protected characteristic:

Yes

No

Not applicable X

Declaration

I am satisfied with the Equality, Fairer Scotland Duty and Health Inequalities impact assessment that has been undertaken for the Patient Safety Commissioner Bill and give my authorisation for the results of this assessment to be published on the Scottish Government's website.

Name: Lynne Nicol

Position: Deputy Director Planning and Quality

Authorisation date: 26/08/2022