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Seldom heard people: Adult Social Care review

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The report of the Scrutiny Review of Equality and Inclusion in Adult Social Care and Health

Report by the Review Board:
Councillor John Ungar (Chair)
Councillor Nuala Geary
Councillor Penny di Cara
Councillor Trevor Webb


People Scrutiny Committee – 17 July 2023
Cabinet – 28 September 2023
Full Council – 10 October 2023

Recommendations

1. To continue to learn about and listen to seldom heard groups and people and share findings with key partners. The Department should prioritise resources to take actions and adapt services to remove barriers for these communities through:

  • the use of internal and external forums and advisory groups and through ongoing conversations with external partners and trusted people in the communities;
  • considering whether engagement has taken place with these communities and people by recording this in Equality Impact Assessments, where applicable;
  • giving feedback to seldom heard communities about how responses to engagement have been utilised through appropriate approved mechanisms in a timely manner including in print and online.

2. The Department to work closely with internal and external partners and trusted partners in the community, with expertise on working with seldom heard people and communities, to tackle stigma and lack of trust. Including (but not limited to):

  • collaborating with the Homeless Inclusion Health Service to make signposting/ referral to ASCH easier and simplified.
  • collaborating with Gypsy and Traveller Team to gain better inside knowledge into the communities they work with and to spread awareness about accessing ASCH services.

3. The Department to involve, engage and include communities by reaching out to them through community events with trusted partners in the communities in order to record, and disseminate feedback about effectiveness of services and policies within the Department to embed learning.

4. The Department to make use of links with people associated with ASCH including Members, volunteers, People Bank and Citizens Panel members and VCSE partners to support the sharing of information about ASCH services and programmes with wider residents.

5. The Department to work closely with ESCC’s Corporate Equality Diversity and Inclusion Board to support broader approaches to community engagement across the Council through:

  • co-ordinating mechanisms for engagement with communities identified as being seldom heard;
  • furthering best practice through the development of a community engagement framework, ensuring all communities, including seldom heard groups, are clear on how their feedback will be used and the outcomes of engagement work.

6. The Department to develop staff knowledge and skills through ensuring appropriate provision for:

  • the development of peer learning opportunities to enable staff to share knowledge and experience;
  • embedding knowledge and skills about working effectively with people from seldom heard communities into ESCC equality, diversity and inclusion training;
  • developing the equality, diversity and inclusion training offer to staff through training by expert partners, incorporating this into staff CPD, and ensuring that training is responsive to changing local need;
  • ensuring managers support and actively encourage staff to attend equality, diversity and inclusion training.

7. The Department should ensure that it raises awareness about its services and that communication is accessible and inclusive by:

  • undertaking further work to promote and support the use of ESCC interpretating and translation services to staff, and using this to respond to changing local need;
  • using a variety of all available and appropriate communication media and formats to target particular groups including non-text and translated versions, and including providing newsletters and information leaflets in different formats;
  • communicating clearly what the service and offer is in promotional material;
  • ensuring that the priorities identified in the Digital and Technology in Adult Social Care Review are considered in communications.

8. The Department to increase inclusivity at initial contact by adapting services to support the needs of communities and individuals, considering:

  • how to support people to access services;
  • the location, timing and staffing at meetings to support different needs, including being sensitive to cultural and religious values;
  • how information is presented to and gathered from people.

9. The Department to develop a systematic way of working with a range of partners in relation to seldom heard groups by:

  • building upon existing relationships and exploring new partnership work by regularly reviewing and expanding the list of identified VCSE partners to help build trust with seldom heard groups;
  • supporting partners to facilitate equality, inclusion and diversity conversations through guidance;
  • where possible, sharing data with other local authorities and groups to support people moving in and out of East Sussex.
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Introduction

The Adult Social Care and Health (ASCH) Department has developed an ASCH Equality and Inclusion Strategy, which is now in its third year of delivery. This sits within the broader One Council approach to equality, diversity and inclusion and focuses on actions which are more specific to ASCH services.

The strategy sets out how the Department will:

  • Tackle equality issues
  • Aim to eliminate discrimination
  • Create good relationships between communities
  • Ensure those from different backgrounds have similar life opportunities

At the People Scrutiny Committee meeting on 24 March 2022, the Department indicated it would welcome scrutiny consideration of this strategy, and the ongoing work to deliver it, to help identify any possible gaps in the approach and future priorities for the work. A Scoping Board met later in 2022 and heard about the mechanisms ASCH uses for engagement, including its use of consultations and equality impact assessments, and how the Department is trying to improve its engagement with seldom heard communities and people.

The Board concluded that, whilst they were encouraged by the work underway, there were issues that could benefit from closer examination by scrutiny through a review. The Board agreed to focus on the following lines of enquiry:

  • Defining and engaging with seldom heard groups:
    • Who are the key communities in East Sussex that ASCH seldom hears from in its engagement but should?
    • How could the Department improve its engagement with those groups?
  • Accessing services:
    • Building on previous research, what is the level of understanding and awareness of ASCH services among residents, including those from seldom heard groups, and are there ways this can be improved?
    • If residents, including those in seldom heard groups, are aware of ASCH services but choosing not to access them, why is that?
    • Are there barriers preventing residents, including seldom heard groups, approaching ASCH services?
      • Is lack of trust or confidence in services a barrier?
      • Is use of digital communication and services a barrier?
      • If there are barriers, how could they be addressed?

The review looked at a range of evidence including information provided by the Department, internal data, external reports and case studies, and heard from a range of witnesses.

The Department provided key evidence based on interviews with a number of partners including, but not limited to: NHS Sussex; ASCH Operational, Commissioning and Strategy teams; CET Libraries and Gypsy and Traveller Teams; VCSE partners including Healthwatch East Sussex, Groundwork - Together South project, East Sussex Recovery Alliance, Traveller Pride, ADFAM, African Community in Surrey and Sussex, Citizens Advice, Homeless and Inclusion Health Service, Refugee Buddy Project, Care for the Carers, Lewes Area Access Group, Eastbourne Dementia Action Alliance, East Sussex Refuge Service, Lewes District Food Partnership, East Sussex Seniors Association, Possability People, Sanctuary Café, Diversity Lewes, Diversity Resource International, Hastings Voluntary Action, Sussex Community Development Association, Eastbourne Rainbow Alliance, East Sussex Hearing, Eastbourne Blind Society, Tech Resort and many more individuals and key voices in the community as well as engagement forums.

During this review the Board found that there were several groups which could have better engagement with ASCH and a number of barriers which may be preventing people within these groups from accessing ASCH services. The review identified who seldom heard groups were, what some of the barriers are to accessing services, and explored potential solutions to remove these barriers and increase engagement. The Review Board found that some of these barriers were relevant across different community groups and recommendations put forward in this report are therefore aiming to increase engagement across multiple groups and be as far reaching as possible to support the Department and the wider Council in offering an accessible and inclusive service overall.

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Background - local and national context

National legislation

The Equality Act was introduced in 2010 to protect people’s rights and encourage equal opportunities, as well as provide an updated, simplified and accessible framework of discrimination law.

Under the Act, people are not allowed to discriminate, harass or victimise anyone because of the following ‘protected characteristics’:

  • age 
  • disability 
  • gender reassignment 
  • marriage and civil partnership 
  • pregnancy and maternity 
  • race 
  • religion and belief 
  • sex 
  • sexual orientation

Two additional characteristics that ESCC recognises are:

  • carers
  • rurality

The Equality Act includes an equality duty for public bodies. It says that public bodies, including councils, must show ‘due regard’ to the need to:

  • eliminate discrimination, harassment and victimisation
  • advance equality of opportunity
  • foster good relations between people who share a protected characteristic and those who don’t

East Sussex County Council (ESCC) has a One Council approach to equality, diversity and inclusion, ensuring a consistent and co-ordinated approach across the organisation, whilst also recognising that there are service specific needs and issues which are appropriate to take forward at departmental level. A single Corporate Equality, Diversity and Inclusion Action Plan supports the development of equality, diversity and inclusion strategies across the Council, and, where relevant, individual departments take forward specific action plans which address more service specific issues. This includes the ASCH Equality and Inclusion Strategy and Action Plan.

Adult Social Care and Health

ASCH provides support to adults, communities and networks to enable people to live as healthily and independently as possible and for as long as possible. Services offer a range of support including with care, housing, safety, and living a healthy lifestyle. An overview of the range of ASCH services and support is detailed on the Adult social care and health pages.

Adult Social Care and Health Equality and Inclusion Strategy

The ASCH Equality and Inclusion Strategy is a three-year strategy that sets out the Department’s commitment to promoting equality and diversity across all its services and within the workforce. As part of this strategy, ASCH has identified five key priorities:

  • Know our communities
  • Have inclusivity at the heart of service development and strengthening engagement with communities
  • Create a safe, fair and inclusive work environment
  • Use robust data collection from service users and use of data for equality analysis
  • Strengthen ASCH staff practice and knowledge on all aspects of equality and human rights as they connect with ASCH work

To further ‘strengthening engagement with communities’, outlined in priority 2, ASCH identified the need to enhance understanding of people and communities they seldom hear from and are creating an Action Plan to address some of the identified barriers to this engagement.

Equality data for East Sussex

East Sussex recorded a population of 545,800 in the 2021 census. The Census also provided updated data in relation to a number of characteristics protected under the Equality Act.

Demographics

People aged 65 and over make up 26.1% of the county’s population. This is considerably higher than the national picture where 18.6% of the population in England is aged 65 and over. East Sussex continues to have the second-highest proportion of over-85s in the country, just behind Dorset.

East Sussex has consistently had a higher life expectancy for both men and women than the national average, however there is a gap in life expectancy between the most and least deprived areas of East Sussex, with the biggest causes of death associated with these gaps being circulatory diseases, cancers, and respiratory diseases.

East Sussex population by age and gender
Male Female
65 to 69 47% 53%
70 to 74 47% 53%
75 to 79 46% 54%
80 to 84 44% 56%
85 to 89 40% 60%
90 and over 52% 68%

53% of the adult population in East Sussex is female, and 47% is male. 49% of the working age adult population is male, and 51% is female. 45% of the older people population is male, and 55% is female.

 As age increases the proportion of the population that is female generally becomes higher. The table below shows an overview of the spilt between male and female in 5-year increments.

8% of the adult population in East Sussex is from an ethnic minority background including White minority groups, although there are notable variations by area. This compares to 18.8% in England.

In Census data 96.3% of usual residents* of East Sussex aged three years and over cited English as their main language in 2021. A further 3.2% of the overall population were proficient in English, and said they spoke English either "well" or "very well", but did not speak it as their main language. Additionally, 0.5% could not speak English well, and a small percentage (0.1%) of the overall population could not speak English at all.

* A usual resident is anyone who on Census Day, 21 March 2021, was in the UK and had stayed or intended to stay in the UK for a period of 12 months or more or had a permanent UK address and was outside the UK and intended to be outside the UK for less than 12 months

The number of people stating that they have no religion in East Sussex increased to 44.7% in 2021 from 29.6% in 2011. 45.9% of usual residents of East Sussex identified as Christian down from 59.9% in 2011 and the proportion of the population stating they were Muslim increased from 0.8% in 2011 to 1.1% in 2021.

The 2021 Census shows 89.2% of the population aged 16 and over identify as straight or heterosexual and 3.3% identify with an LGBT+ orientation. 7.5% of people did not answer the voluntary question.

73.7% of the population in East Sussex live in an urban area, with the remaining 26.3% living in a rural area.

The 2021 Census showed 34.8% of households in East Sussex had at least one member identifying as disabled. Local projections suggest that by 2033 there will be over 119,000 disabled people in East Sussex and 12,340 older people (65+) are projected to have dementia (up 7.2%) by 2025.

Projecting Older People Population Information data suggested that by 2028, around 20,000 more people in East Sussex, compared with the needs of the population in 2018, will be living with two or more long term health conditions, increasing the need for support from unpaid carers and the health and social care system.

Adult Social Care and Health

ASCH supports a large number of the population in East Sussex. In 2022/23, 27,335 people were supported by ASCH and 9,369 clients were supported with Long Term Support.

Number of people receiving long term support
Date Older people (65+) Working age people (18 to 64)
2022 to 2023 6,102 3,267
2021 to 2022 5,865 3,194
2020 to 2021 6,186 3,078

Compared to 2022, by 2025 it is predicted that, in East Sussex, there will be 41,060 older people (age 65+) projected to have a limiting long-term illness whose day to day activities are limited a little (up 6.5%) and 31,450 people’s day to day activities will be limited a lot (up 6.8%), indicating that demand for ASCH support will continue to increase.

5,760 carers received support from ASCH (including information and advice) in 2020/21. These carers were providing care for 5,838 people, highlighting that some carers provide care for more than one person. 40% of carers are 26-64 years old and 48% are 65-85 years old.

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Review Board Findings

Identifying and defining seldom heard groups

To address the Review’s first line of enquiry, the Review Board sought to define and understand the term ‘seldom heard’, and to identify who this term relates to. The ASCH Department defines seldom heard as:

“under-represented people who use or might potentially use health or social care services and who are less likely to be heard by these service professionals and decision-makers”

‘Seldom heard’ has replaced the term ‘hard to reach’ (which can suggest that the problem lies within the group, rather than within services’ approach to them) and emphasises the responsibility of agencies to reach out to excluded people, ensuring that they have access to health and social care services and that their voices can be heard. Although this review focuses on engagement with seldom heard groups, the Department recognised the importance of enhanced engagement with, and inclusion of, people from all communities and of all identities in their work.

The Board found that the Department had carried out extensive work to understand the needs of its service users and identify people it seldom hears from. This included data gathering, internally and from partners from the voluntary, community and social enterprise sector (VCSE), staff engagement sessions and engagement with intermediaries representing seldom heard communities.

This work helped to identify key groups who may be less likely to engage with services including people protected under the Equality Act including:

  • Older people
  • Unpaid carers
  • People from ethnic minorities, particularly people who do not speak English as their main language, or do not speak it ‘well’ or ‘very well’
  • Disabled people, including those with invisible disabilities, sensory impairment or a mental health condition
  • Lesbian, gay and bisexual people
  • Trans and non-binary people
  • Gypsy, Roma and Traveller communities
  • People in rural areas

Communities which are seldom heard due to social circumstances were also identified, including:

  • Homeless people
  • People in prison
  • People with low levels of literacy
  • People who are digitally excluded
  • People in recovery from drug and alcohol addiction, and their families
  • People who have experienced domestic abuse

Community engagement for the new Adult Social Care Strategy identified additional groups including men at risk of suicide, people in the armed forces and veterans, and people with unmet need or not yet eligible for ASCH support.

It was agreed that seldom heard people may be different for each service and/or department but the above list applies to most public services. In light of the wide range of groups identified the Board agreed, for the purposes of the review, to focus on a sub-set in order to explore the lines of enquiry and identify potential recommendations which may have broader relevance. The Board’s research included, Gypsy, Roma and Traveller communities, homeless people, ethnic minority groups and communities (including refugees and asylum seekers), older people, adults who are digitally excluded and unpaid carers.

Other issues and barriers, which cut across several groups, were considered more generally as part of the Review.

Information provided by the Council’s Equality Manger stressed that the people who are seldom heard may change over time and that it was important to note the different layers of identity and to consider intersectionality; how different aspects of people’s identities (such as ethnicity, gender, age, disability and so on) can interact and affect how we experience the world and how we are seen and treated.

ASCH communicates with a number of groups through relationships with partners. The Board questioned how the Department knew those partners were reaching the right people in the community and heard in response that, to mitigate the risk of over reliance on organisations to communicate with groups, the Department uses a variety of methods to engage, including through the use of a diverse VCSE sector and District and Borough and Parish and Town councils, to ensure there is not a singular reliance on any organisation. ASCH is continually seeking to build upon these networks to ensure they are increasing their reach in the community.

Members recognised that who is seldom heard will change over time and concluded that it would be important to continue engagement work to not only address barriers, but to continue to identify groups and people they seldom hear from, moreover engagement when developing services was critical across the whole community. Evidence from the Council’s Equality Manager and the ASCH Policy Development Manager stressed the importance of ongoing conversations with groups through the use of forums, advisory groups and with external partners. This work needs to be considered at the right stages of projects and service changes, and its effectiveness monitored.

Recommendation 1

To continue to learn about and listen to seldom heard groups and people and share findings with key partners. The Department should prioritise resources to take actions and adapt services to remove barriers for these communities through:

  • the use of internal and external forums and advisory groups and through ongoing conversations with external partners and trusted people in the communities;
  • considering whether engagement has taken place with these communities and people by recording this in Equality Impact Assessments, where applicable;
  • giving feedback to seldom heard communities about how responses to engagement have been utilised through appropriate approved mechanisms in a timely manner including in print and online.

Having reviewed evidence on the engagement undertaken to date, the Board concluded that this had been extensive and had been thorough in identifying potentially seldom heard groups. Moreover, this work was informing ongoing actions. The Board therefore focused the review primarily on the second area of enquiry, understanding and addressing barriers. This was informed by the existing robust analysis of seldom heard groups and sought to build on this and gain a deeper understanding.

Understanding and addressing barriers

Understanding barriers

Work to understand the barriers to residents engaging with ASCH is ongoing, with the Department recognising that a minority of people intentionally do not want to interact with public services. The Board drew on a range of sources to assess and explore levels of understanding, including information from staff, based on their experience of working with clients and carers, case studies and research locally and in other parts of the country, and by talking to a range of people working with specific groups of people within the county who may be seldom heard.

ASCH staff engagement sessions highlighted a number of barriers facing some residents, including:

  • a lack of trust in ASCH
  • stigma around accessing services
  • poor literacy skills
  • digital exclusion
  • a fear of social services/a lack of understanding about ASCH
  • cultural differences
  • mental health issues
  • a lack of plain English in communications and inaccessible forms

Interviews with external partners undertaken by ASCH similarly noted barriers of trust, stigma, feeling excluded from the wider community, a lack of understanding of what services are available, the inability to access services and/or frustrations with lengthy processes.

To further explore the local position, the Board discussed the findings from the Activmob report East Sussex County Council, Adult Social Care & Health: Experience during Covid-19 lockdown: What can we learn from population groups? A key finding in this report was that the majority of participants (people from ethnic minority backgrounds, younger people, older people, and men) responded that they had ‘absolutely no idea or very little awareness at all of what ASCH can offer’. For those who did know, there was a negative view regarding accessing support and many would only do so if someone told them to get help from the service. The ASCH Policy Development Manager confirmed to the Board that evidence suggested the main barrier to people accessing services was a lack of awareness.

The Board heard from a number of witnesses who were able to provide greater insight into barriers preventing groups they worked with from accessing services. Although not every seldom heard group was represented, the Board were presented with a range of insights from witnesses who work with specific groups in the community and it became apparent to the Board that many of the barriers cited in relation to specific communities shared similar themes and applied to multiple groups. A systematic view of these barriers was developed by the Department and grouped into four main categories:

  • Organisational barriers - which impacts on the seldom heard if they are unable to find, or have difficulty accessing services, for example some clients may find forms or fast paced meetings challenging, or have insufficient funds to travel.
  • Cultural barriers - including a stigma associated with using or needing services.
  • Practical barriers - if there are not practical steps in place to help people access services, for example information translated into languages.
  • Attitudinal and behavioural barriers - relating to attitudes of people and staff, including unconscious biases. This can lead to a relationship which is disempowering between staff and clients.

Examples of Organisational barriers

“People who need support the most, have the least access” - Homeless and Inclusion Health Service

The Board heard from the Head of the Homeless and Inclusion Health Service (HIH), which provides outreach care for homeless people and rough sleepers in Eastbourne. The HIH offers pop up services in the community on a regular basis, aiming to build trust through continuity of staffing and creating a friendly and safe space. The Head of HIH felt that there was a general lack of knowledge and awareness of ASCH within the homeless community, and amongst related health professionals, which may prevent some people from engaging with and accessing services. This included information about who supports homelessness preventative initiatives, including the Rough Sleepers Initiative and Changing Futures. The Board was also informed of the need for local authorities to share information to ensure continuity of care for transient communities. Lengthy processes for referrals and delays in being offered an assessment were also cited as significant barriers for this transient population.

This lack of awareness was also highlighted by the ASCH Practice Manager in relation to support for the prison population. The Board heard that the proportion of prisoners (at HMP Lewes) accessing ASCH services is low, and although this is mainly due to basic support for daily living being offered through the prison service, it is also due to prison officers not being consistently aware of the support available from ASCH.

Examples of Cultural barriers

The Board heard from the Council’s Gypsy and Traveller Team Manager who highlighted a range of issues affecting these communities, including poor health, low levels of literacy, and inequalities in access to healthcare (particularly mental health services). Many within Gypsy, Roma, and Traveller communities report feeling excluded from society, both at a national and local level and, due to negative portrayals in the media, many find it hard to build trust with people outside of their community. The Board also heard that communication with these communities is extremely difficult, and it often takes many years for teams to build trust; this is additionally challenging when families and individuals are likely to move and when staff change in teams or roles are restructured.

“Information presented is in a complex language; people don’t understand it” - Diversity Lewes

The Board asked about barriers facing people coming to the UK and heard from a Senior Outreach & Community Engagement Officer at Groundwork South about his own experiences as a refugee, as well as working with refugees in East Sussex. He told the Board that cultural differences impacted on some people’s opportunities to integrate locally and utilise local services. Moreover, although there is English for speakers of other languages (ESOL) provision in colleges and schools in East Sussex, many providers do not understand the background of these communities and the additional barriers many are facing, including mental health problems and trauma.

Cultural barriers were also presented as a barrier to carers accessing support. The Board heard from the Chief Executive of Care for the Carers (CftC) about the role of carers in East Sussex. Caring can involve taking on a number of supporting roles for family, friends or neighbours for reasons such as frailty, substance misuse, disability or mental health problems. Caring cuts across all communities and every role is different; it is estimated that unpaid carers match the number of NHS workers in the UK, with most people taking on caring roles at some point in their lives. The Chief Executive of CftC informed the Board that there is often a reluctance from carers to identify as a ‘carer’ (this is even more prevalent in certain cultures) which results in some people being unaware of the support available to them.

The Board reviewed the report ‘Understanding unpaid carers and their access to support’ by the Health Foundation (2023), which suggests that only a small proportion of carers request support from their local authority. Evidence suggests that barriers facing many carers include feelings of isolation, cultural stigma around care, and, for many, financial pressures.

“People are too proud to ask for help” - East Sussex Seniors Association

The Chair of East Sussex Seniors Association (ESSA) told the Board that some older people were too proud to ask for help, feeling that support was not for them. The Board heard that it is a struggle to get information out, to break down this stigma and to make people aware that support is available to everyone. The Chair also informed the Board that some older people had moved to rural parts of East Sussex to retire but had left social groups behind and now felt isolated, especially those who had become carers or had been bereaved. This isolation, coupled with difficulties getting online or travelling into towns, often results in older people not being able to engage with events and services.

Examples of Practical barriers

The Head of HIH highlighted a number of barriers facing the homeless community including, for some, mental health problems, substance misuse, and the significant barrier of not having a fixed address. This can prevent some individuals accessing primary care, including receiving medicine, and supporting this community is increasingly challenging when individuals move around, including in and out of local authorities.

The Board noted similar barriers affecting other transient communities like people from Gypsy, Roma, and Traveller backgrounds, as well as an inconsistency of support when people move across counties.

The Board heard from the Senior Outreach & Community Engagement Officer at Groundwork South that being unable to communicate in English is a significant barrier for many refugees trying to access local services. This language barrier, and lack of alternative options, often results in people being unable to fill out paperwork, or read information in letters and leaflets, and needing to seek assistance from others.

The Chair of the ESSA told the Board of her experiences of supporting older people, including that only around 13% of ESSA members were online, with many older people not trusting online services (including banking). She indicated that in rural areas many were now struggling to access in person services due to a reduction in bus services and the closure of banks, and that a lot of older people felt very left behind with rapid changes to service delivery. She explained that when people don’t see an associated phone number to access a service, and only a website or email address, that can be the biggest barrier to asking for help.

The Board explored digital exclusion further and how being digitally excluded may prevent some adults from accessing and engaging with ASCH services. The Being Digital Delivery Manager informed the Board that the ability to access ASCH services in East Sussex was not reliant upon internet usage, however, people who could use digital technologies would be able to access information and advice more quickly and easily given that all the information published in leaflets and factsheets is available instantaneously on the ESCC website, removing the need to phone for information, or obtain a paper leaflet.

Conversations with witnesses highlighted that low levels of literacy amongst certain groups further impacted on their understanding and awareness of services, as well as acting as a barrier to accessing those services. The Board explored this further and heard from a Librarian who runs the ESCC Library Service programme ‘Step into Reading’, which provides one to one phonics reading sessions to adult learners. They heard that the demographic of learners was varied, including people of all ages, and sessions were taking place across the county. Most learners had complex needs including a special educational need and/or a neurodiversity issue which impacted on process and recall of language.

In relation to the prison population, security and systems can also be a practical restriction on the ability to provide care to prisoners, with incidents such as lockdowns preventing care workers accessing clients. The Board heard that the Department was working to increase the uptake of social care support by prisoners by continuing to liaise with the prison’s inclusion officer and using communication mechanisms that are in plain English and Easy Read to help promote offers to the prison population, many of whom have low levels of literacy. The Board suggested that relationships could also be built with VCSE organisations working in the prison to spread awareness of ASCH support.

Examples of attitudinal and behavioural barriers

“We just want to be respected and accepted as who we are” - Eastbourne Rainbow

The Board heard some examples of barriers relating to attitudes or lack of representation in communications. For instance, HOPE G in Hastings, who represent older people from ethnic minorities, had reported to ESSA discrimination in that there can be language and cultural barriers when accessing services, with some information too complex or perceived as unrepresentative.

A case study on Greater Manchester’s ‘Improving access to health services in the LGBT community’ highlighted that previous discriminatory experiences with health services had resulted in some LGBT people feeling reluctant to access council services and that staff were not knowledgeable enough of their specific needs. Lack of representation of LGBT people in communications and promotional material also acted as a barrier to accessing services in this study.

The Board noted the feelings of being disrespected and discriminated against that people from minoritised communities, including those from ethnic minority backgrounds and LGBTQ+ people, can face. These can impact negatively on people’s ability to access services.

Lack of trust and stigma around using services

Evidence from interviews with external partners and witnesses, and from broader case studies, suggested that stigma around accessing services or identifying in a certain way, and a lack of trust in government or council services were key barriers for many groups. This lack of trust often stemmed from previous negative experiences with services, societal discrimination, and/or a lack of confidence in the Council’s understanding of cultural differences.

The Head of HIH reiterated that the issue of trust in council services presents a barrier for many homeless people, and it is important for professionals to engage with people in the community through outreach.

ASCH interviews with external partners, recorded in The Seldom Heard People Report, included conversations with a number of organisations working with marginalised groups. The issue of trust featured in most conversations. Groundwork Together South, who work with refugees and asylum seekers, suggested that people were reluctant to speak openly with authorities due to past experiences and fear that they may receive poor treatment, moreover ESCC was viewed in the same way as all other government organisations including the Home Office.

The organisation African Community in Surrey and Sussex highlighted the role stigma plays in some communities accessing support and cultural differences in attitudes towards mental health. The Chief Executive of Care for the Carers also noted that attitudes towards care could differ amongst cultures, resulting in some people being reluctant to seek support where caring was viewed as an expected role within the family. Organisations, including ESSA, also cited stigma as a barrier for many older people who could be reluctant to ask for support, or fearful that engagement with social services could result in being judged or moved from their home.

The Board concluded that the more the Council understands about different communities and potential barriers, the more work it can do to address these.

Recommendation 2

The Department to work closely with internal and external partners and trusted partners in the community, with expertise on working with seldom heard people and communities, to tackle stigma and lack of trust. Including (but not limited to):

  • collaborating with the Homeless Inclusion Health Service to make signposting/ referral to ASCH easier and simplified.
  • collaborating with Gypsy and Traveller Team to gain better inside knowledge into the communities they work with and to spread awareness about accessing ASCH services.

Addressing barriers

Witnesses and evidence presented to the Board suggested several possible ways to further build on work to address some of the barriers identified.

The Board identified and explored the following key themes in these approaches:

  • Community engagement
  • Enhancing staff knowledge
  • Effective and inclusive communication
  • Inclusive services
  • Knowledge and data sharing
  • Relationships with external partners

Community engagement

Community engagement work has been conducted throughout the Council through a variety of projects and with a range of communities. The Board heard from the ASCH Policy Development Manager on the community engagement work when developing the new ASC Strategy; the Council’s Equality Manager on wider engagement work within ESCC; the Gypsy and Traveller Team Manager on his team’s continued engagement with Gypsy, Roma, and Traveller communities, as well as ASCH’s work with partners. Learning from a range of community engagement activities demonstrated the importance of ongoing conversations and engaging with groups in the most appropriate format and setting.

Engagement work to inform the development of the new ASC Strategy focused on listening to residents’ priorities through the use of interviews, surveys and focus groups. This included work to reach people who may need care and support in the future, or those who needed help now but may not be getting it for a range of reasons, to ensure their voices were also considered. Advice was sought internally and from the VCSE sector to identify communication channels, organisations, community spaces, and events to help engage with seldom heard groups.

The ASCH Policy Development Manager noted that an ongoing, co-production approach is important with seldom heard groups, in order to deepen engagement and to maintain connections, and that time and resource needs to be allowed within projects for this. The Board agreed that ongoing conversations with groups and partners would help tackle some of the barriers identified.

The Head of HIH also noted the benefits of reaching groups in community settings; for the homeless community that means providing health services where people can also access food and shelter. By providing services in places where people feel safe, teams are able to build trust and learn about the wider needs of the community.

Recommendation 3

The Department to involve, engage and include communities by reaching out to them through community events with trusted partners in the communities in order to record, and disseminate feedback about effectiveness of services and policies within the Department to embed learning.

Case studies on work carried out by other local authorities and organisations also highlighted the success from community engagement projects using trusted intermediaries, including the use of ‘community connectors’ (residents with roots in their communities who were recruited to address issues which may be affecting the health and wellbeing of individuals), community forums, and community workshops and events in partnership with local organisations. The Board discussed the successful use of community connectors at Wirral Council and suggested that this model could support digital inclusion in the older population; using older people who were more confident with digital technology to advocate for it to older people who are less confident or unable to access online services.

The Department informed the Board of the current work of the People Bank (145 residents, clients, carers who give feedback on services), and it was suggested that there was potential to enable these volunteers to be part of ASCH’s voice in the community. ESCC elected Members could also play a key role in sharing information about services to residents.

Recommendation 4

The Department to make use of links with people associated with ASCH including Members, volunteers, People Bank and Citizens Panel members and VCSE partners to support the sharing of information about ASCH services and programmes with wider residents.

Although community engagement work was noted as a key method to hear from seldom heard groups, the Council’s Equality Manager informed the Board that it was important to note that these groups are often the most vulnerable, with limited resources, time and capacity to engage. Engagement work needs to be properly planned and funded, with groups being supported throughout the process and their needs considered at all times.

In response to evidence suggesting that engagement work should be ongoing, the Board enquired how engagement work across the Council could be shared to support continued engagement with groups in a systematic way. The ASCH Policy Development Manager informed the Board that findings and practical learning from the ASC strategy engagement could be shared with colleagues in other parts of the Council to help build wider understanding of needs and reduce the potential for duplication. In addition, the development of a community engagement framework could bring together good practice examples and advice for engaging with seldom heard groups as well as wider communities and partner organisations.

The Board concluded that effective community engagement was key to addressing barriers for seldom heard groups and people and that, where possible, this engagement should be based on shared learning and best practice to increase its impact, avoid duplication and best support the needs of vulnerable groups.

Recommendation 5

The Department to work closely with ESCC’s Corporate Equality Diversity and Inclusion Board to support broader approaches to community engagement across the Council through:

  • co-ordinating mechanisms for engagement with communities identified as being seldom heard;
  • furthering best practice through the development of a community engagement framework, ensuring all communities, including seldom heard groups, are clear on how their feedback will be used and the outcomes of engagement work.

Enhancing staff knowledge

In identifying solutions to barriers facing seldom heard groups, it was noted that staff play an important role in addressing some of these barriers. The Board explored ways in which staff can identify and break down barriers.

The Council’s Equality Manager informed the Board that staff could develop their skills in this area using a variety of resources, including formal and informal learning. It is important to build understanding of why ESCC needed to hear people’s voices and to develop a greater understanding of the impact cultural differences may have in how people access services. One approach was peer learning, where staff were able to share experiences and skills on, for example, how to ask equality, diversity and inclusion related questions, or engage with communities. The Board heard about communities of practice that are being developed across the Council, looking at a variety of topics and bringing colleagues together for peer learning practices. For example, a data monitoring group bringing together data analysts to share knowledge and experiences.

The impact of increasing staff knowledge was considered in the case study example from Greater Manchester where Pride in Practice work had been launched to improve LGBT friendly practices. Working with the LGBT Foundation and local NHS and councils in the region, staff were given one-hour training covering language and terminology, inequalities experienced by LGBT communities in healthcare and offered practical advice on how to develop inclusive services. Feedback from clients and LGBT champions since the launch of this programme had been very positive, with one woman reporting:

“staff may ask sensitive questions about marital status or next of kin as heterosexuality is not assumed. My wife is included in all my health care decisions and is recognised as a carer. This is very different than it was”

Work to develop staff knowledge and skills within ESCC is progressing: in ASCH and Children’s Services (CS) equality champions and allies have been identified to share how teams are supporting equality work and responding to issues; an ASCH Equalities Allies Group, made up of equality leads in teams, provides an opportunity to raise questions to support their work; staff training now includes details of using peer learning; and there are Yammer groups across the Council to facilitate information and good practice sharing. However, it was noted that more could be done to share good practice amongst wider staff.

The Board concluded that increasing staff knowledge and skills on equality, diversity and inclusion would support the commitment to an inclusive service and would help to develop understanding of seldom heard groups and ways to overcome barriers to accessing services. This would particularly help staff to learn about and discuss emerging issues, for example recent increased media coverage of issues relating to transgender people.

Interviews with partners also highlighted the benefits of staff receiving specialised training to enhance their knowledge of client and family member needs and their ability to provide compassionate care. For example, the Eastbourne Dementia Action Alliance suggested increased dementia awareness training amongst staff to build a holistic and person-centred approach to working with clients. The LGA guide ‘Care and support and homelessness’ recommends councils ensure staff not only receive specialist training, but learn from each other to better understand each other’s roles and responsibilities in order to provide appropriate care.

The Board discussed with the Department how equality, diversity and inclusion training could be incorporated into staff Continuing Professional Development (CPD) plans. The ASCH Assistant Director for Planning, Performance and Engagement noted that training needs to be responsive to changing local need.

Recommendation 6

The Department to develop staff knowledge and skills through ensuring appropriate provision

  • the development of peer learning opportunities to enable staff to share knowledge and experience;
  • embedding knowledge and skills about working effectively with people from seldom heard communities into ESCC equality, diversity and inclusion training;
  • developing the equality, diversity and inclusion training offer to staff through training by expert partners, incorporating this into staff CPD, and ensuring that training is responsive to changing local need;
  • ensuring managers support and actively encourage staff to attend equality, diversity and inclusion training.

Effective and inclusive communication

The Board heard evidence of a lack of knowledge about the ASCH offer, and what support services may be available, amongst some seldom heard people. Some people may find language used in communication inaccessible and formats are not appropriate for people’s varying needs. During the review, the Board identified some ways in which inclusive communication could be further developed, building on what is already in place.

The Board heard that the use of the Council’s interpreting and translation service could be maximised by raising awareness of it amongst wider staff in the Department, to ensure effective communication between clients and staff. The ESCC Sensory Impairment and Reablement Team noted that interpreting and translation services need to be responsive and consistent, with staff understanding the importance of using translation and interpreting, as well as understanding the process better. The Refugee Buddy Project also highlighted the need to have clear, simple information in relevant languages to tell people what support is on offer.

This was also highlighted in feedback from staff engagement sessions where staff suggested that communication needs to be in plain language and clear about what services are and who they for; moreover, messaging needs to help breakdown stigma.

The Board heard there is a need for a consistent approach in ensuring best practice in communication and community engagement which can be delivered through equality impact assessments and staff forums. Digital inclusion should also be included in staff inductions to raise awareness of these issues amongst new staff.

The Board heard that communication with adults with low levels of literacy was more challenging, with most written information inaccessible. The Librarian who delivers the Step into Reading programme highlighted the need for non-text versions of communication, for example through apps and social media or videos, such as a video created to communicate the Step into Reading programme to learners.

Communication should not only be accessible, but reflective of the communities it is trying to reach. In the Greater Manchester LGBT case study, feedback showed that when LGBT friendly posters were displayed 24% of LGBT people were more likely to disclose their sexual orientation and 21% their trans status. In doing this they said services were much more likely to meet their needs.

The Board heard that when communicating with seldom heard groups, it was important for staff to listen to the views of groups, as well as informing them about services. This should be achieved through ongoing community engagement work outlined above.

Recommendation 7

The Department should ensure that it raises awareness about its services and that communication is accessible and inclusive by:

  • undertaking further work to promote and support the use of ESCC interpretating and translation services to staff, and using this to respond to changing local need;
  • using a variety of all available and appropriate communication media and formats to target particular groups including non-text and translated versions, and including providing newsletters and information leaflets in different formats;
  • communicating clearly what the service and offer is in promotional material;
  • ensuring that the priorities identified in the Digital and Technology in Adult Social Care Review are considered in communications.

Inclusive services

Although ASCH already adapts services to meet access needs of individuals, the Board explored how inclusion could be developed, including through the location for service provision, consideration of cultural differences and through building equality, diversity and inclusion considerations into service design and commissioning. Research by the Department suggested that some people would rather approach the VCSE sector for help as community organisations could be flexible and adapt their approach for different people’s needs, whereas public services could be viewed as bureaucratic rather than relational, demonstrating the need to develop inclusive approaches and raise awareness of this.

The Board heard examples of flexible approaches working in practice. The Head of HIH highlighted the importance of offering services in inclusive spaces that are welcoming to everyone; he noted that support for homeless people was often situated in churches which could act as a barrier to people from another religion or none. However, offering services in community spaces where rough sleepers were accessing other services, including food, was very effective. This was reiterated by the Gypsy and Traveller Team Manager who informed the Board of the need to work with Gypsy, Roma and Traveller communities outside of council buildings and bringing support, such as Wi-Fi and education, to traveller sites.

The Gypsy and Traveller team were providing a range of support, including a community room on a traveller site to support client appointments, as well as wider community work, which it was hoped would address the issue of some people not wanting to enter council buildings to access services. The Board heard that the community room was providing a crucial space to allow external agencies, as well as other council services, to engage with the community in their own space, building trust and allowing for ongoing conversations, for example with local police around hate crime.

The Board heard from Groundwork South the importance of taking time to learn about and understand cultural differences and adapting services to incorporate those differences. Examples included considering the location of and time of meetings, and a recognition of what may be considered culturally appropriate, such as in some cases women members of staff interacting with women clients, which would increase engagement.

The Board was keen to explore how the Department could not only adapt specific services to meet the needs of seldom heard groups, but how it could embed equality, diversity and inclusion thinking into all areas of work. The Council’s Equality Manager highlighted that it is important for these considerations not to be viewed as separate but integrated into day-to-day business. Elected Members could support this process by asking questions about accessibility and outcomes, ensuring that equality impacts have been considered in decision-making, and modelling inclusive approaches and respect for difference in their meetings and engagement.

The Board concluded that work was already in place to further develop the integration of equality considerations into day-to-day business in ASCH and across the Council. In terms of specific services, the Board noted that, where possible, the Department should adapt service delivery and maximise flexibility as there was evidence that could help meet the needs of users and increase engagement with seldom heard groups.

Recommendation 8

The Department to increase inclusivity at initial contact by adapting services to support the needs of communities and individuals, considering:

  • how to support people to access services;
  • the location, timing and staffing at meetings to support different needs, including being sensitive to cultural and religious values;
  • how information is presented to and gathered from people.

Relationships with external partners, including knowledge and data sharing

Effective working with partners was discussed at all meetings with most witnesses and evidence suggesting that this is critical to help build trust with seldom heard groups and to continue to develop engagement. As described earlier, ASCH works with a wide range of external partners to engage with and support seldom heard groups.

The Board explored the challenges of supporting transient groups through sharing information with other local authorities. The Gypsy and Traveller Team Manager acknowledged the difficulty with this in relation to Gypsy, Roma and Traveller communities, as there is minimal national support and the role of councils in supporting these communities varies across authorities; many only provide provision for sites and enforcement and do not support with health and wellbeing. However, ESCC works positively with councils in Brighton & Hove and West Sussex to provide support to people coming in and out of the county from these areas.

The Board heard that there was no formal arrangement for local authorities to connect and share information in relation to homeless people moving between areas. However, work was ongoing with other authorities and the Local Government Association to improve support to transient communities. The Being Digital Delivery Manager informed the Board that ESCC will be taking part in a pilot on developing the use of Plexus, a data tool which will provide relevant staff with access to a person’s Shared Care Record. However, there is currently no function allowing other local authorities to view information about clients moving in and out of the county.

The Board explored the opportunity to increase joint working with partners. The ASCH Policy Development Manager informed the Board of the importance of strong relationships with VSCE groups and partnership boards to maintain conversations with seldom heard communities. The Council’s Equality Manager noted the successes of good partnership work in supporting vulnerable people, citing the work of the cross-sector Financial Inclusion Group which is responding to cost-of-living.

The Board heard evidence that to engage with adults with low levels of literacy, relationships with external partners, as well as communication to friends and family, was key to gaining referrals and building trust. However, it was important to raise awareness of this issue with partners first, as many adults were able to mask problems with literacy, making it more difficult to identify the need for support. Guidance has been created by the Library Service to increase staff awareness of the potential complex needs of learners and to increase staff confidence in talking about literacy needs.

The Board also learned of the potential to use partner volunteers to signpost and refer people to services as described by the Lewes District Food Partnership. A suggested script, or training package, could support volunteers who come across a safeguarding case, and enable them to refer for support.

Case Studies considered by the Board also highlighted the value of working with partners. Nottingham City Council for example, explored a place-based approach to engaging with ethnic minority people, working with community groups, networks, and charities to host a series of workshops to identify which ethnic minority networks, groups and organisations existed in the area and to understand the key issues for each community. Gateshead County Council also worked with partners to communicate with refugees and asylum seekers. This partnership not only built trust with the refugee community, but also aided with translation needs.

The Board recognised the importance of strong working relationships with a range of partners and agreed that the Department does this very well. It was noted that this engagement needs to be ongoing so the Department would need to continue to build new, and develop existing, partnerships so partners can continue to provide much needed services and support to seldom heard East Sussex residents.

Recommendation 9

The Department to develop a systematic way of working with a range of partners in relation to seldom heard groups by:

  • building upon existing relationships and exploring new partnership work by regularly reviewing and expanding the list of identified VCSE partners to help build trust with seldom heard groups;
  • supporting partners to facilitate equality, inclusion and diversity conversations through guidance;
  • where possible, sharing data with other local authorities and groups to support people moving in and out of East Sussex.
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Conclusions

The Review has considered a broad range of evidence and Members concluded that there is a strong commitment to providing an inclusive and equitable service, and that the Department is working hard to expand its reach to seldom heard groups. The Review Board recognised that this work needs to adapt constantly to respond to changing need, including who is identified as seldom heard, and therefore work on this needs to be ongoing and sustainable.

The Board heard that lack of trust, stigma around using services, and a lack of complete understanding of what services ASCH offers are the biggest barriers for seldom heard people and communities. The Board has made a number of recommendations to support ongoing work to help overcome those barriers.

The Board considered that, where possible, data, experience, and best practice should be shared with colleagues across the Department and Council to maximise its impact and make best use of resources. This joined up approach will also protect vulnerable groups from being asked to engage multiple times unnecessarily.

There are a number of positive initiatives and projects already underway, including good examples of peer learning and relationships with external partners; this should be developed where possible. Learning from partners, as well as case studies of work carried out by other local authorities, provides new opportunities to consider how to engage with seldom heard groups and encourage them to use services.

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Appendix

Scope and terms of reference of the review

Terms of Reference

On the recommendation of the Scoping Board, the People Scrutiny Committee agreed that this review should explore how the Department engages with seldom heard communities and whether residents of all backgrounds know how to access ASCH services.

Members agreed that this would be explored through the following key lines of enquiry:

  • Who are the key communities in East Sussex that ASC seldom hears from in its engagement but should?
  • How could the Department improve its engagement with those groups?

Accessing services

  • Building on previous research, what is the level of understanding and awareness of ASC services among residents, including those from seldom heard groups, and are there ways this can be improved?
  • If residents, including those in seldom heard groups, are aware of ASC services but choosing not to access them, why is that?
  • Are there barriers preventing residents, including seldom heard groups, approaching ASC services?
    • Is lack of trust or confidence in services a barrier?
    • Is use of digital communication and services a barrier?
    • If there are barriers, how could they be addressed?

Board Membership and project support

Review Board Members: Councillors John Ungar (Chair), Penny di Cara, Nuala Geary and Trevor Webb.

The Project Manager was Rachel Sweeney, Senior Policy and Scrutiny Adviser with additional support provided by Kaveri Sharma, Strategic Commissioner (Equality and Inclusion), and Lucy Owen, Policy Development Intern.

Paul Hussey, Interim Assistant Director, Planning, Performance and Engagement, Sarah Russell, Assistant Director, Planning, Performance and Engagement, and Justin Foster, Team Manager Waste Services provided ongoing support to the Board throughout the review.

Review Board meeting dates

Scoping Board meeting – 1 July 2022
First Review Board meeting – 28 February 2023
Second Review Board meeting – 22 March 2023
Third Review Board meeting – 3 May 2023
Fourth Review Board meeting – 13 June 2023
Final Review Board meeting – 26 June 2023

Witnesses providing evidence

The Board would like to thank all the witnesses who provided evidence:

ESCC officers

Alex Callaghan, Being Digital Delivery Manager
Bill Hargood, Policy Development Manager ASCH
Sarah Tighe-Ford, Equality Manager
Mark Hendricks, Head of Partnerships ASCH
Jim Alexander, Manager Gypsy and Traveller team
Emily Taylor, Librarian

External Witnesses

Dr Neil Singh, GP (Homeless Inclusion Health Service)
Jennifer Twist, Chief Executive, Care for the Carers
Pierre Matate, Outreach and Engagement Officer, Groundwork South
Lin Neeve, East Sussex Seniors Association

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Evidence papers

Evidence papers
Item Date considered
Overview of ASCH Equality and Inclusion strategy 01/07/2022
ASCH Equality and Inclusion strategy 01/07/2022
ASCH Equality and Inclusion Action Plan 01/07/2022
Seldom heard people: What do we know about them in East Sussex? 17/02/2023
Executive summary – Activmob research 17/02/2023
ASCH presentation on barriers and community engagement 22/03/2023
Insights into barriers facing GRT community 22/03/2023
ESCC Equality Work presentation 03/05/2023
The Health Foundation Understanding unpaid carers and their access to support 03/05/2023
ESCC Digital Inclusion presentation 03/05/2023
National Research (Case Studies) 13/06/2023
ASCH presentation on potential solutions to barriers 13/06/2023
Interview with Emily Taylor (Step into Reading) 13/06/2023
LGA Care and support and homelessness 13/06/2023
ASCH Report Seldom Heard People interviews with partners 13/06/2023
Centre for Public Scrutiny Men Behaving Badly Report 13/06/2023

Contact officer: Rachel Sweeney, Senior Policy and Scrutiny Adviser E-mail: rachel.sweeney@eastsussex.gov.uk

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