The health inequalities self-audit tool provides prompts and questions to help you to mitigate inequalities in your speech and language therapy services.
Read more about the tool and work through the prompts on this page or download an editable template to record your reflections.
About the tool
A crucial part of the speech and language therapist’s role is understanding not just the ‘norms’ of development and communication breakdown in English, but also the norms of development and communication breakdown in other languages and cultures – as well as thorough understanding of the implications of food modification for those with dysphagia.
An SLT must be able to provide personalised and equitable care to all service users who require it, thus understanding each individual’s preferred language, culture, religion, family setup, attitudes toward their health status, beliefs on approaches to play, language or rehabilitation is imperative. Having well-planned, accessible, equitable, and appropriate care pathways, resources, assessment materials and workforce are all essential to mitigating health inequalities.
In addition, SLTs must avoid the risk of stereotyping or assuming that all service users from particular communities hold the same beliefs or share the same experiences. SLTs should also demonstrate inclusivity and allyship to those from under-served communities, which should be reflected in their approach and resources.
There will always be changes in how language, religion and/or culture impacts on communities and the individuals who live within them. This may be as a result of generational changes or other impacts. Therefore, SLTs must develop ‘cultural humility’ and commit to working reflexively across their careers. SLTs will need to constantly adapt their practices to best meet the communities that they work with.
Cultural humility can be defined as: “A lifelong process of self-reflection and self-critique whereby the individual not only learns about another’s culture, but one starts with an examination of her/his own beliefs and cultural identities.” (Yeager and Bauer-Wu, 2013, p 251).
As individuals ourselves, we all have different needs (eg which languages we wish to communicate in), values, and beliefs which we hope will be explored and respected. In providing personalised care, we should apply these principles to those we work with.
When working with our diverse caseloads, it is therefore essential that we move to a more flexible approach, applying the research we have where this exists. We have to be aware that much of our research may exclude some of the more vulnerable in our society – including monolingual English-speaking communities living in areas of deprivation, those who are from Black and minority ethnic backgrounds, those who may speak no English or have English as an additional language, or those who are LGBTQ+ or have disabilities. Thus, we also have a role in contributing to the evidence-base in these areas.
How to use this tool
We would encourage you to use this tool in the context of your team environment as well as in clinical excellence networks (CENs) to consider in the light of the particular clinical conditions.
This tool can be used by SLTs in the NHS and in non-NHS settings, including research and the higher education sector, and we would encourage you to adapt it to your own settings.
You can work through the prompt questions online or download an editable version of the tool (Word), which provides you with space to note your reflections and actions for next steps.
You might also find the AHP Health inequalities framework helpful. It provides ideas on how to view and consider health inequalities and suggests breaking each area down into how you can improve your awareness of health inequalities, what action you can take and how you can be an advocate.
This tool should be used alongside the health inequalities guidance and resources.
Part one: Understanding your community
The only way to really evaluate if your service is providing inclusive and equitable care is to understand the community you’re working with in the first place – both on a local level, and in terms of the clinical population.
How do you know if you’re seeing who you should expect to be seeing in your service? It is the very first and fundamental step in exploring whether your service is inclusive and equal.
Use the prompts below to examine what you know about the community you do and don’t serve.
Understanding your local population
- Do you know the general makeup of your local population (e.g. age, gender, ethnicity, religion, language spoken)? Take a look at the data provided by Public Health England for your area Public Health profiles, the Northern Ireland Census, the Scotland Census, StatsWales or the Office of National Statistics for UK wide data on a range of variables.
- Do you know the general socio-economic landscape of your local population (eg percentage of children on free school meals, index of multiple deprivation in England?
- Do you know about any particular health inequalities raised in your area (eg local reports such as joint strategic needs assessments)?
- Do you know the prevalence of specific under-served groups in your locality who may face particular challenges accessing healthcare, eg refugees or asylum seeking families, or those who are homeless?
Understanding your caseload
- Do you know the demographic and socioeconomic breakdown of your caseload?
- Do you systematically collect service user data including characteristics such as ethnicity, religion, languages spoken?
- Do you systematically evaluate your service user data to examine whether the expected demographics are reflected in your caseloads?
- Do you collect data about appointment/service take-up and map this to your demographic information?
Awareness of prevalence and incidence
- Do you know the general incidence and prevalence of the clinical conditions you come across in your caseload? (see ‘statistics’ sections in RCSLT guidance, eg aphasia).
- Do you know if there are any specific statistics regarding incidence and prevalence of clinical conditions among populations with specific characteristics (eg prevalence among a given gender, ethnicity, socioeconomic background)?
- Do you systematically evaluate your patient data to examine whether the expected prevalence and incidence of clinical conditions (broadly and among specific populations) are reflected in your caseloads?
Part two: Access and equity
We know there are some clear blocks for some people accessing services which need to be addressed, but examining some of the subtler reasons why they may not be accessible is also important. It’s also important to understand who is accessing what kind of service to scrutinise whether there are any inequalities. The following questions will help to guide your thinking about how accessible and equitable your service is.
- Do you know the waiting list figures for assessment and therapy for your general caseload, and specifically for those from typically under-served groups?
- Do you know the accessibility (in terms of proximity and usage) of general and specialist services to your local community, and specifically for those from under-served groups?
- Do you offer options to those on your caseload for where they are seen (where possible/relevant), to ensure you are able to meet the needs of everyone?
- Do you provide communications (including appointment notifications and clinical reports) in accessible formats (eg different languages, braille, spoken rather than written etc) to ensure those from under-served groups fully understand their needs and their care?
- Do you systematically compare service user data of those accessing specialist provision with those accessing generalist provision across that community that you serve, to identify whether there is unwarranted variation (specifically in relation to under-served groups)?
- Do you know how to request and work with interpreters, when required?
- Do you reflect on any planned advice/intervention to ensure there are no assumed prerequisites on resources to be provided by a family (eg a fixed address, money to purchase telephone credit, data for telehealth appointments, living space to carry out intervention)?
Part three: Your service provision
Thinking about what you know about the health inequalities or under-served groups in your local population, how can you apply that in your provision of a service?
The following questions may be used as prompts to evaluate the degree to which your service is reaching all communities.
Appropriateness of service provision
- Do you have access to interpreters to enable you to provide effective support in both the home language of the patient and English?
- Do you have access to interpreters with all the languages you require?
- Do you ensure people are aware of their right to request an interpreter?
- Do you know how to gather information about the service user and family holistically including finding out about religious or cultural beliefs, parental/family arrangement, family practices and attitudes and how this may relate to their understanding of your service (eg cultural norms related to play, or religious beliefs about illness and intervention, view on disabilities or mental health)?
- Do you discuss and consider all elements of a service user’s identity when planning assessment, goals and intervention (eg that may support participation in religion, faith and spirituality, LGBTQ+ community activities etc)?
- Do you have access to other services or resources to enable you to provide appropriate support that is sensitive to holistic needs (eg religious counsellors)?
- If relevant, do you have access to eg thickener products or meal plans that are sensitive to various dietary requirements and relevant for authentic dishes from a range of countries?
- Do you have appropriate assessment tools or techniques to reliably and validly assess the needs of under-served groups (eg fully evidence-based, linguistically and culturally translated and standardised tests?)
- Do you have appropriate therapy approaches or techniques to support the needs of under-served groups who are represented on your caseload?
- Do you have access to a range of materials and resources that are appropriate to different needs (eg culturally appropriate, representing Black or minority ethnic people, LGBTQ+ families etc) to support your assessment or intervention?
- Do you know what to do/where to go/who to ask if you do not have appropriate assessment of therapy materials to support the needs of diverse caseloads (eg line manager, head of service)?
- Are the materials, promotional materials and information on display in your environment that show diversity (eg minority ethnic, Black, same-sex couples, trans people, people with physical differences or disabilities)?
Enabling service user involvement
- Do you ask your service users about their pronouns, names or honorifics, and implement this?
- Do you engage service users appropriately in goal setting, planning meaningful intervention and evaluating outcomes in an inclusive manner?
- Do you encourage and provide opportunities for children/their families to share experiences to support ‘oral tradition’ common among cultures and embed this in provision/planning, where appropriate?
- Are these explained to families/carers with space for feedback and adjustments to suit their needs?
- Do you regularly provide opportunities for your service users and their communities to get involved in audits, service evaluations and improvement projects or research?
- Do you regularly provide opportunities for your service users and their communities to support universities or services with teaching, applicant interviews and conversation partner schemes?
- Ensure you seek feedback from diversely represented community members.
Outreach to communities
- Do you/your service outreach to local communities? (eg via an advocate or local religious institutions, ie mosque, synagogue, or charities)
- Do you have a member of staff in your service who could serve as a cultural interpreter for outreach activities?
- Do you work with the community to help identify barriers to accessing your service?
- Do you collect feedback from your service users about their experiences of healthcare, ensuring avenues to do so are fully accessible and in a range of languages?
Part four: SLT workforce
As health professionals you are encouraged to reflect regularly on your practice and own values, skills and knowledge.
Take the time to broaden your own understanding of health inequalities by looking at some of the references and the AHP Health Inequalities framework. You might also find the RCSLT anti-racism reading list useful.
Use the following questions to reflect as individuals or as teams.
Professional development and allyship
- Do you seek/are provided appropriate and regular training from your organisation that supports you to address the needs of the community you work in?
- Do you ask your colleagues what their pronouns are and implement this?
- Do you engage with different networks representing the needs of under-served groups? (eg National Trans and Gender Diverse Voice and Communication CEN, UK SLT Pride Network, bilingualism CENs)
- Do you share your learning with colleagues and encourage staff to be allies to under-served groups?
- Do you demonstrate your allyship visibly to service users (eg pride lanyards, Black Lives Matter badges)?
- Does your service provide equality and diversity training for staff?
- Does your service engage staff and students on placement in conversations and provide opportunities to ask questions or feedback about equality, diversity and inclusion in a safe space?
- Is there a clear process for reporting concerns in your workplace and specific support around issues of equality, diversity and inclusion?
- Do you discourage staff and service users from using racially inappropriate terms/language or other discriminatory behaviours if it occurs (including helping people to understand how this impacts others)?
- Do you encourage Black, Asian and minority ethnic people, LGBTQ+, including trans and non-binary, people and people with a disability to apply for posts by specifically inviting people from these communities?
- Does your service employ bilingual assistants?
- Does your service evaluate the diversity of staff teams?