Unintended impacts: using Equality Impact Assessments to understand how technology can impact mental health inequalities

Innovations help us to tackle the biggest challenges in health and care, but it is not always obvious how the spread and adoption of new technology affects people in terms of widening or diminishing health inequalities.

In this blog, we hear from Karen West and Cameron Baker of patient monitoring company Oxehealth about how a Health Innovation Network-supported equality assessment helped them understand and improve the equity of their solution.

The inequality challenge for mental health care providers

Inequality in mental healthcare is nothing new. It’s been flagged as an issue since it was reported on over 50 years ago[1]. Recent reports show staggering rises in restraints of black people in NHS care, disproportionate levels of face-down restraints used with girls and women as well as overrepresentation of minority groups dealing with mental health challenges.

As a result, mental healthcare providers, and the integrated care systems they are now a part of, are focusing efforts to tackle inequality. By March 2024, providers will be required to draw up their own Patient and Carer Race Equality Framework (PCREF) and appoint an executive lead for PCREF at board level.  And they must report on their performance against core measures like detentions under the Mental Health Act, their provision of access to services for ethnic minorities, and the diversity of their workforce.

But the mental healthcare landscape is not static. Technology is rapidly emerging. For example, today there are an estimated 20,000 mental healthcare apps in existence.  Technology has the potential to transform the way healthcare is accessed and delivered, but what about its potential to impact inequality?

How technology can impact equality

As a technology provider, we recognise the tremendous impact technology can have when it comes to supporting staff to deliver better and safer patient care. Right from the start, we involved both patients and staff to help us develop products and services that not only addressed clear challenges in mental health but were broadly accessible. Oxehealth recognises that we need to be part of the solution to tackle inequality and this starts with taking responsibility to ensure our products and services create a positive impact, rather than exacerbate the problem.

Lord Victor Adebowale, Chair of NHS Confederation, takes this point further, amplifying the need for digital to be supportive of access and equity:

As far as I’m concerned, there are only 3 challenges facing most first world health systems; they are equity, access and digital - in that order. And the reason why they are in that order is that if digital isn’t helping you with the first two, then why are you using it?

Lord Victor Adebowale, Chair, NHS Confederation

Image showing equality and equity using different bikes as a metaphor - not everyone can ride the same bike in the same way

Those reading carefully will note the use of the word equity rather than equality. It's important to recognise the distinction as illustrated in the image (credit: Robert Wood Johnson Foundation) shown above. Although we often seek equality, this can lead to exclusion rather than inclusion: the same bike doesn’t fit everyone. But by providing a bike that fits their needs enables everyone to ride. What this means for us as technology providers is that we need to think not only about the aim of equality but also about how we make that happen by providing the “right bike” for everyone.

A little bit about Oxevision

Our patient monitoring technology - Oxevision - is designed to support clinicians in mental health inpatient settings and is currently deployed in half of NHS England’s mental health trusts. Oxevision uses an infrared-sensitive camera, which operates with regulated medical device software, to enable privacy-controlled vision into the room and contact-free measurements of pulse and breathing rate. This enables clinicians to check patients are well without disturbing them at night. The system also provides ward teams with actionable insights which can inform care planning and prompt staff to intervene proactively.

Oxevision is ideal in a space where wearable pulse oximeters would not be appropriate and provides a far wider range of benefits in comparison to these wearables. This includes consistent accuracy with different skin tones, a common and concerning issue with wearable pulse oximeters.

Assessing equality impact

Following a discussion with the Health Innovation Network, we realised we needed to understand the potential impacts of Oxevision on equality. This led to us conducting an Equality Impact Assessment (EQIA) which looked specifically at inequality impacts in relation to the nine protected characteristics covered by the Equality Act. This sort of evaluation is commonplace in the public sector, but is rarely carried out by private companies.

Our EQIA covers all aspects of the Oxevision product as well as Oxehealth’s implementation services, including training, engagement, service monitoring and benefits realisation. For each area of work, we analysed the impact across all protected characteristics, providing a clear assessment to show if implementing Oxevision might enhance or potentially adversely affect equality.

We also asked several NHS stakeholders, including the Health Innovation Network, to provide feedback and to challenge our assessment. The current assessment is very much a working document, subject to regular reviews to ensure it reflects the latest evidence.

A summary of our current findings is below:

How the assessment has impacted our work

As a result of the assessment, we have made several improvements, including:

  • improving the accessibility of documentation by creating easy read versions of staff and patient information on the technology and its use in inpatient settings
  • collecting more detailed evidence of staff and patient experience across different demographics; and
  • incorporating feature and design considerations into future product development plans

Taking a structured approach to equality

Equality has always been a fundamental consideration in developing and implementing our technology. But the EQIA enables us to think more broadly and in a structured way about equality. Before starting any new initiatives, we always think about the impact on equality. Using the EQIA framework helps us to identify how evidence of impact will be collected,  assessed and actioned to ensure we address any adverse impacts.

Technology partners in healthcare invariably have good intentions to help patients and staff, but understanding the real-world implications of their innovation in terms of how it might exacerbate or reduce inequalities requires proper consideration and analysis. Companies would do well to follow the path Oxehealth has set out; a process driven approach to creating positive social change. They exemplify how companies should take accountability beyond supplying a product and improve equality outcomes as part of their mission and in their business practices.

Aileen Jackson, Head of Mental Health, Health Innovation Network

Technology has a fantastic opportunity to transform healthcare, particularly in areas poorly served such as mental health. As part of that transformation, companies need to consider the wider impacts of change and play an active part in ensuring that change benefits everyone, equally.

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[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9746991/#:~:text=People%20from%20ethnic%20minority%20groups%20in%20the%20UK%20have%20poorer,reported%20for%20over%2050%20years.