Consultation outcome

Equality impact assessment - minimum service levels in event of strike action: ambulance services

Updated 6 November 2023

Introduction

The general equality duty that is set out in the Equality Act 2010 requires public authorities, in the exercise of their functions, to have due regard to the need to:

• eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the act
• advance equality of opportunity between people who share a protected characteristic and those who do not
• foster good relations between people who share a protected characteristic and those who do not

The general equality duty does not specify how public authorities should analyse the effect of their existing and new policies and practices on equality but doing so is an important part of complying with the general equality duty.

Intended outcomes

The Department of Health and Social Care sought views on introducing regulations on minimum service levels in ambulance services in England, Scotland and Wales in parallel to the passage of the Strikes (Minimum Service Levels) Act 2023 (‘the act’), which received Royal Assent in July 2023.

The act gives the government the power to set minimum levels of service in certain services within key sectors, including health. The intention of minimum service levels (MSLs) is to protect the public from harm while ensuring there is not a disproportionate impact on the ability for ambulance workers to strike. These regulations set out the detail of how MSLs operate in the ambulance service during strike action.

Rationale for intervention

When ambulance workers take industrial action, it can impact on employers as industrial action means they are unable to provide services to the same extent as they would normally.

In ambulance services, industrial action could put the lives and health of the public at risk, given their essential role in responding to life threatening and emergency incidents. Currently, the use of voluntary derogations between employers and trade unions to agree levels of service (that is, to provide working cover for essential services in ambulance services) has been inconsistent across the ambulance trusts and across days of strike action and comes with significant uncertainty.

The introduction of MSL regulations for ambulance services in the event of strike action would enable the service to better ensure the continuation of ambulance services during strike action to protect the lives and health of the public. This is intended to provide a balance between the ability of workers to strike with the rights of the wider public to access ambulance services when they need them.

Policy objectives

The policy intention is to protect lives and the health of the public by introducing MSLs during strikes. It would seek to strike a balance between the ability of unions and their members to strike with the need to protect the lives and health of the wider public.

The proposed MSL is that on each day of strike, where a work notice is issued that all calls are answered and triaged as they would be if the strike was not taking place, and a response is organised and provided for calls triaged or escalated to life threatening, or for which there is no reasonable clinical alternative to clinical assistance being provided to the patient at the scene of an incident or by transporting the patient to a healthcare facility (or both), as it would be if a strike were not taking place that day.

In relation to healthcare professional (HCP) and inter-facility transfer service (IFT) requests, those received on the day of strike should be triaged as they would be if the strike were not taking place. In relation to the non-emergency patient transport service (NEPTS), the MSL is that on strike days, requests for transportation are triaged as they would be if the strike was not taking place, and transportation is provided to high dependency patients. High dependency patients are those for whom it is clinically necessary for them to receive health services on the day of the strike and will include those who have cancer, require renal dialysis or receive palliative care. 

Consultation

A consultation on the scope of the implementation of ‘minimum service levels’ in event of strike action for ambulance services ran from 9 February 2023 to 9 May 2023. The Welsh language version ran from 14 March to 6 June 2023. We also ran stakeholder engagement workshops alongside the consultation and subsequent meetings with key stakeholders. Analysis of the consultation helped to inform decisions as to whether ambulance services should be subject to minimum service levels and the detail and scope of the proposed MSL.

Effect on employers

The introduction of MSLs for the ambulance service is expected to provide more certainty to employers on staff available to meet base staffing levels on strike days.

Employers, do however, have obligations not to discriminate against their employees under Part 5 (Work) of the Equality Act 2010 and need to comply with the public sector equality duty as part of the exercise of their public functions. Any decisions taken around which members of staff to issue work notices to for any period of strike action would need to take account of equalities considerations.

Effect on employees working for the ambulance service

Within England, there are 10 trusts providing NHS ambulance services and the Isle of Wight NHS Trust.

Employees will be affected by the new legislation if, following notice of strike action by a trade union, their employer issues a work notice identifying the employee as required to work during the strike to secure minimum levels of service. 

Effect on people accessing health services

The most significant impact of this proposal will be on ambulance service employees whose ability to strike could be restricted. People who need to use ambulance services including vulnerable people, disabled or elderly may also be affected.

Ambulance services in England respond to emergency 999 calls in accordance with patient need. They also provide other services, such as transporting patients to and from or between hospitals, NHS 111, inter-facility transfer services and non-emergency patient transport services. The exact range of services provided can vary. 

Ambulance services in England work to the Ambulance Response Programme, a set of national standards, implemented in 2017 to ensure that the sickest patients get the fastest response, and that patients receive the right response first time.

For people accessing ambulance services, MSLs for ambulance service workers could help lower the risk for patients and service users because of the increased certainty of having staff available to meet a base staffing level on strike days.

Other affected groups include:

• trade unions
• all workers within ambulance services
• NHS ambulance services employers
• other NHS and health service employers
• representative organisations and professional bodies
• devolved governments

The extent of the regulations is GB-wide; however, the geographical application of regulations is limited to England only.

Evidence

Evidence has been drawn from the March 2023 NHS England publication on staff working in NHS trusts and core organisations in England.

Evidence was also obtained from the analysis of the ambulance service MSL consultation summary. We received 150 responses to the online consultation from ambulance and wider health worker organisations, and the public. We also received 11 off-platform responses and held 4 workshops with:

• NHS Employers
• NHS Providers
• trade unions and ambulance unions
• patient representative groups

The consultation contained 2 questions on equality as follows.

1. Are there particular groups of people, such as (but not limited to) those with protected characteristics, who would particularly benefit from the proposed minimum service levels for ambulance services? 

There were 150 responses to this question, which were as follows:

	Total (and percentage)
Yes	20 (13%)
Don’t know	47 (31%)
No	83 (55%)

Over half (55%) answered there were not any particular groups of people who would benefit from MSLs for ambulance services. Around one third (31%) answered ‘don’t know’ and 13% answered ‘yes’, with protected characteristics would benefit from the proposed minimum service levels for ambulance services.

2. Are there particular groups of people, such as (but not limited to) those with protected characteristics, who would particularly be negatively affected by the proposed minimum service levels for ambulance services?

Respondents who thought MSLs might negatively impact people thought the ambulance workforce, general patients and public would be most affected.

Responses from wider organisations on possible negative impact of MSLs in the ambulance service

Service users, including those with protected characteristics under the Equality Act 2010 would not particularly benefit from the proposed MSL for ambulance services because service users are best served by an ambulance service that is not afflicted with retention issues.

People with particular protected characteristics under the Equality Act 2010 are overrepresented in the healthcare workforce. Attempts to impose levels of minimum service in ambulance services could have a disproportionate and negative impact on the rights of these workers to participate in lawful industrial action.

If proposals are carried out, it would disproportionately affect women and ethnic minorities workers; the majority of NHS workforce are women (75%) and that trade union membership is highest among black or black British staff (29%). It is important to clarify or note that this is specifically referencing black and black British employees, and about union membership nationally rather than anything healthcare or ambulance specific, but might still be of interest - see a March 2023 briefing on the Strikes (Minimum Service Levels) Bill from NHS Providers.

Concern was also expressed that following a report by the Joint Committee on Human Rights that, in their current form, plans to impose minimum service levels on public services during strike action, could pose a risk on the grounds of human rights compatibility

When there is a risk of strikes, older people may feel unprioritised and a sense that they are not a priority, when, for example, involved in a fall.

Respondents that thought MSLs might be beneficial, said they would be more likely to benefit those who need an ambulance, including anyone who has a disability or long-term health condition, is elderly, pregnant or is otherwise vulnerable.

Summary of general risk identified at workshops

How we define MSLs will impact those not covered in the legislation, for example long-term disabled people and people with chronic illnesses.

Importance of messaging (including clearly stating who should receive an ambulance response under an MSL) should regulations be implemented, should be paramount.

Unions are worried about culture across the ambulance service citing poor leadership and bullying. They are worried that some managers may deliberately target people (that is, trade union representatives) to name them on work notices, thus requiring them to work, cross picket lines and/or sanction and discipline them. Safeguards would need to be built into the process to avoid these unintended consequences. The Department for Business and Trade (DBT) are producing guidance for trade unions on ‘reasonable steps’ that should be taken by unions in relation to work notices given by employers under provisions inserted in the Trade Union and Labour Relations (Consolidation) Act 1992 (the Act) by the Strikes (Minimum Service Levels) Act 2023.

The Strikes (Minimum Service Levels) consultation impact assessment also looked at the wider impacts including a section covering the public sector equalities duty assessment. This assessment considered the potential impact of the proposal taking into account information gathered during the consultation.

Efficient transport of non-emergency patients is crucial for ambulance service providers to cope with increased demand.

Analysis of impacts

The evidence contained in the consultation only covers staff in England and therefore we have not considered breakdowns of the devolved nations.

Disability

Currently 6% of professionally qualified ambulance staff and 7% of support to ambulance staff report that they are disabled compared to 78% of professionally qualified ambulance staff and 79% of support to ambulance staff that are not disabled.

A survey commissioned by the Care Quality Commission (CQC) of more than 4,000 people aged 65 and over found that, among those who had used health or social care services, people living in the most deprived areas were more likely to report that they had a long-term condition, disability or illness (70%),

People with disabilities report worse access to healthcare, with transportation, cost and long waiting lists being the main barriers. During strike action, they may face longer waits than usual and therefore be more likely to experience suffering or harm to their health than when services are running normally. The introduction of MSLs will provide more certainty and reassurance of the levels of ambulance services available during a strike. Therefore, disabled people would benefit from MSLs if services continued to run efficiently on strike days.

For ambulance staff there is a risk that work notices will mean staff with disabilities may have shifts disrupted and must work when they were not expected to. For this group there is also a risk that reasonable adjustment will not be made to meet the MSL.

Sex

We note that many hospital services are predominantly staffed by women. However, in the ambulance service staffing is much more evenly matched, with a slight majority of men, 53% men to 47% women, among professionally qualified ambulance staff. Conversely there are slightly more women (55%) than men (45%) providing support to ambulance staff. Given how close these figures are to 50% we can infer that the impact of the legislation will be roughly even across the sexes.

We do not have data to suggest a difference in users of ambulance services by sex. Responses will be based on clinical need regardless of sex.

Sexual orientation

Around three-quarters of both professionally qualified ambulance staff (74%) and support to ambulance staff (78%) report that they identify as heterosexual or straight. Seven per cent of professionally qualified ambulance staff and 8% of support to ambulance staff are gay, lesbian or bisexual. This leaves 19% of professionally qualified ambulance staff and 15% of support to ambulance staff who either did not disclose or whose sexual orientation is not recorded. According to the 2021 Census, 89% identified as straight or heterosexual, with around 3.2% identifying as LGBT+ orientation with the remaining people (7.5%) did not answer the question.

There is a difference in numbers in staff identifying as heterosexual or straight 74% and 78% respectively compared to the general population 89% but as MSLs will apply to everyone in the same way we do not consider that the introduction of MSLs would have an impact on this group of staff or users of different sexual orientations.

Race

NHS workforce ethnicity facts and figures show that 95.8% of professionally qualified clinical ambulance staff are white. The remaining staff are spread across Asian, black, and mixed groups - 1.4% Asian, 0.7% black, 0.2% Chinese, 1.5% mixed and 0.4% other

In the general population (in England and Wales according to the 2021 Census constituency data), 81.7% identify as white, while 4% of the general population identified as black, including African, Caribbean and other black. Almost one tenth (9.3%) of people identified as Asian, including Indian, Bangladeshi, Chinese, Pakistani and other Asian.

However, for example, a survey of 2,600 people in Great Britain, including a weighted sample of 1,000 people from ethnic minority backgrounds, carried out by Savanta ComRes for the RSA found that 52% of Asian and 50% black respondents reported that they face discrimination when accessing local services - compared to 19% of the white population. Based on the evidence gathered so far, there is no reason to believe that MSLs would lead to higher risks for minority staff or that this might happen, we therefore assess that the likelihood is low.

Age

Older people and those with long-term health conditions are more likely to use acute hospital services than other age groups (see the British Geriatrics Society Silver Book) and are therefore more likely to rely on ambulance services. Falls represent the greatest and most frequent serious type of accident for people aged over 65. There were 700,000 calls from older people to ambulance services from people who have fallen each year, which accounts for 10% of total calls to ambulance services - see ‘Stop falling: start saving lives and money’ on the Age UK Falls prevention resources page. MSLs mean that ambulance services maintain a minimum service level benefiting older people as they will have more certainty over services during a strike.

In March 2023, the total number of professionally qualified ambulance staff was just over 20,000 with a third of these (32%) in the 25 to 34 age bracket. Support to ambulance staff were slightly more evenly spread across the age brackets. We have considered the evidence gathered and consider there is no likelihood of a difference in impact for ambulance users or the ambulance workforce based on age.

Gender reassignment (including transgender)

According to the 2021 Census, in the general population 48,000 (0.10%) identified as a trans man, 48,000 (0.10%) identified as a trans woman, 30,000 (0.06%) identified as non-binary and 18,000 (0.04%) wrote in a different gender identity. See the House of Commons Library article What do we know about the LGBT+ population?

There is no national standard for monitoring gender reassignment within ambulance trusts. We have considered how MSLs could affect this group for both users of ambulance services and workers within the service, but as MSLs will apply to everyone in the same way as with other protected characteristics, we do not consider that MSLs will have an impact on people with this protected characteristic. MSLs will apply to everyone in the same way therefore following consideration of this user group and staff groups we do not believe MSLs will impact on them differently.

Religion or belief

Around one quarter of professionally qualified ambulance staff (27%) and support to ambulance staff (24%) identify as atheists. Around one third (36%) of professionally qualified ambulance staff and 40% of support to ambulance staff identify as Christians making it the most common religion. Around one third (37%) of professionally qualified ambulance staff and 36% of support to ambulance staff either identified with another religion, did not disclose or did not record this information. The evidence does not suggest people with different religious beliefs who use ambulance services will be treated differently and therefore we do not consider that MSLs likely to have an impact on people with this protected characteristic.

Pregnancy and maternity

Pregnant women, both workers and in the general population will rely on ambulances in an emergency, life-threatening situation or if the birth is not going to plan. For people accessing ambulance services, MSLs could help lower the risk to these patients by bringing certainty to the number of skilled staff available on strike days.

Marriage and civil partnership

Given the unpredictable timing of strikes it is impossible to know whether this policy would have an impact on married couples, civil partnerships or people getting married. Employees could face short-term pressure caused by being named in an MSL. Staff could be rostered to work during key family transitions

We have no reason to believe that married couples or people in civil partnerships will be affected by the introduction of MSLs use of ambulance services and consider that this legislation is unlikely to have an impact on staff or users of ambulance services with this protected characteristic.

Other identified groups

Deprivation

The survey commissioned by the Care Quality Commission (CQC) of more than 4,000 people aged 65 and over found that, of those surveyed, people living in the most deprived areas who had used health or social care services were more likely to report that they had a long-term condition, disability or illness compared with the average for all survey respondents of 65%. Traditionally, the ambulance service has fulfilled an informal role in helping people from deprived communities to navigate the health system (for example, GPs and urgent treatment centres) and therefore access the care they need, when they need it.

From this we can infer that the introduction of minimum service levels may have a bigger impact on people from more deprived areas by increasing services during strike periods.

Engagement and involvement

Engagement with stakeholders in gathering evidence and testing the evidence available

We gathered evidence from the consultation on the scope of the implementation of minimum service levels in event of strike action by ambulance services that ran from 9 February 2023 to 9 May 2023. We also held workshops with stakeholders as part of this consultation process. See annex A for a list of workshop participants.

Responses were received from wider health worker organisations and the public and we analysed off-platform responses to the consultation from 4 workshops with:

• NHS Employers
• NHS Providers
• trade unions and ambulance unions
• patient representative groups

We engaged with NHS England, NHS Providers, representatives of the devolved governments and officials from other government departments.

The online consultation resulted in 150 responses from ambulance and wider health organisations, and the public. 

Engagement with stakeholders in shaping the policy

We have received input from NHS England on a broad range of clinical and operational questions. We have also engaged with other government departments who cover key services within the act.

Summary of analysis

The rationale for introducing MSLs regulations for ambulance services in the case of strikes is to protect the lives and health of the public and provide a balance between the ability of workers to strike with the rights of the wider public to access health care services when they need them. Inevitably, strikes will cause some disruption and some procedures may be cancelled causing backlogs.

We note for pregnant women, both workers and in the public, MSLs could help lower the risk to these patients by bringing certainty to the number of skilled staff available on strike days. We expect older people and disabled people in the workforce or who rely on ambulance services may benefit as these services can run more effectively due to MSLs during strike action. 

Overall impact

The policy aims to maintain a reasonable balance between the ability of ambulance workers to strike with our obligation to protect the lives and health of the public. Analysis of the equality impacts for ambulance staff or ambulance users with protected characteristics has not found evidence to support that the introduction of MSLs will impact on those people.

Addressing the impact on equalities

Our assessment has not identified negative impacts on people with protected characteristics.

Monitoring and evaluation

We will look into how we can monitor the policy and develop more detailed plans.

Annex A: list of workshop participants

Patient experience workshop

• Healthwatch - discussion facilitators and representatives from Portsmouth, Sheffield and Sandwell
• St John Ambulance Cymru
• MIND
• Age UK
• Stroke Association
• Epilepsy Society
• Women’s Aid
• South Asian Health Network

Employers workshop

• AACE
• NHS Providers
• NHS Employers

Ambulance union workshop

• UNISON
• GMB
• Unite

Wider union workshop

• UNISON
• GMB
• Unite
• Royal College of Nursing (RCN)
• British Medical Association (BMA)
• British Dental Association

Further written submissions by organisations to the consultation

• NHS England
• NHS Providers
• AACE
• CQC
• Trades Union Congress
• The Health and Care Professions Council
• College of Paramedics
• BMA
• UNISON
• RCN
• Unite
• GMB
• Stroke Association
• Pupils 2 Parliament
• Barnet, Enfield and Haringey Mental Health NHS Trust and Camden and Islington NHS Foundation Trust
• University Hospitals Sussex NHS Foundation Trust
• Future Directions CIC