Equality Analysis – Radiation Protection Policy
Equality Analysis is a process of systematically analysing a new or existing policy or service to identify what impact or likely impact it will have on different groups within the community. The primary concern is to identify any discriminatory or negative consequences for a particular group or sector of the community. Equality Analysis can be carried out in relation to service delivery as well as employment policies and strategies.
This template has been developed to use as a framework when carrying out an Equality Analysis on a policy, service or function. It is intended that this is used as a working document throughout the process, with a final version being published on Gateshead Health NHS Foundation Trust website.1) Policy / function details
Directorate: Trust - wide / Department/Service: / Lead:Jeanette Bowes - ADM
Clinical Support & Screening Services
Details of people involved in the policy / function development or review
Members of the Radiation Protection Committee / Start date:
Name of policy / function / Radiation Protection Policy
Scope of the policy / function / The policy covers any situation where a person may be exposed, either intentionally or unintentionally, to radiation due to its use in the Trust, other than where the exposure is outside the control of the Trust, its employees, or other staff working under the Trust’s Policies
Purpose of policy / function / The function of this policy is to put in place appropriate systems of work in order to consistently achieve optimum benefit from radiation techniques whilst minimising deleterious consequences, and to ensure the Trust’s compliance with the recommendations of the International Commission of Radiological Protection (ICRP), as enacted in UK legislation.
2) Stage Two: scoping and analysing equality information
List the sources of evidence you have for different people from each protected group (age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, sexual orientation?
Use qualitative or quantitative data, research or reports
Source of information
A good practice guide on all aspects of ionising radiation in the clinical environment. IPEM 2002 (Medical and Dental Guidance Notes, MDGN).
Trust Policy OP27. Policy for the Development, Management and Authorisation of Policies and Procedures.
Ionising Radiations Regulations 1999 (SI 1999 No 3232)
Ionising Radiation (Medical Exposure) Regulations 2000 (SI 2000 No 1059) together with Notes on Good Practice (IR[ME]R 2000).
BS EN 60825-8:1999 Safety of laser products. Guidelines for the safe use of medical laser equipment.
BS EN 60825-1:1994 Safety of laser products. Equipment classification, requirements and user’s guide.
BS EN 60825-8:1999 as above.
BS EN 207:1999 Personal eye protection. Filters and eye protectors against laser radiation (laser eye protectors)
IEC TR 60825-14:2004 Safety of laser products. A user’s guide.
BS EN 11145:2001 Optics and optical instruments. Laser and Laser-related equipment. Vocabulary and symbols.
Guidelines for Magnetic Resonance Equipment in Clinical Use (with particular reference to safety). MHRA, December 2002.
Principles for the Protection of Patients and Volunteers During Clinical Magnetic Resonance Diagnostic Procedures. NRPB 1991
Facilities for Diagnostic Imaging and Interventional Radiology. HBN 6, NHS Estates.
The Physical Agents (Artificial Optical Radiation) Directive (2006/25/EC), 2009.
Datix incident reports relating to radiation incidents. / Legislation and the policy are designed to protect people from the adverse effects of radiation, while providing patients with the opportunity to receive the beneficial effects of radiation when required.
There is legal duty on NHS organisations to involve people and their representatives in decisions about services.
Provide details of feedback from people who are affected by the policy/ function, and any consultation or engagement activities undertaken: / This policy has been developed by the members of the Radiation Protection Committee
Does the evidence suggest the policy / function affects or is likely to affect any of the following groups differently (either positively or negatively)
Specific rules in all departments using radiation require pregnant staff members to notify line manager in writing so that additional risk assessment can be carried out and additional radiation monitoring conducted if necessary. Generally pregnancy is not a problem and staff continue to work as normal.
Age / Policy based on Ionising Radiation Regulations 1999 which specifically hassections relating to Employee of 18 yrs of age or above and separate rules for trainees aged under 18yrs.
Disability / Training in radiation safety must be provided to everyone working with radiation. Managers will need to assess suitability for the role based on physical and mental impairment.
Gender reassignment / No
Marriage and Civil Partnership / No
Pregnancy and maternity / Specific rules in Nuclear Medicine and Radiopharmacy apply to lactating mothers based on IRR1999 & MDGN. These state they should not take part in procedures with significant risk of contamination such as cleaning up large spill of a longer lived radioisotope.
Race / No
Religion or belief / No
Sex / No
Sexual orientation / No
If there is a greater effect on one group, is that consistent with the policy aims? / There is no greater effect, as there is the capacity to have individual risk assessments which will take into consideration the relevant specific needs of individuals
How does the policy / function meet the aim to promote equality of opportunity on the grounds of …? / The Policy is designed to ensure compliance with legislative requirements and should have no adverseimpact with regards to equality of opportunity
How does the policy /function meet the aim of eliminating discrimination on the grounds of …? / N/A
How does the policy / function meet the aim of fostering positive relations between people of different groups? / N/A
To apply core human rights values, such as equality, dignity, privacy, respect and involvement, to all organisational service planning and decision making / The fundamental aim of the policy is to protect staff and patients from the adverse effects of radiation, while providing patients with the beneficial effects of radiation
3) Stage Three: monitoring and review
No major change:The analysis demonstrates that the policy or decision is robust, the evidence shows no potential for discrimination, and that all appropriate opportunities to advance equality and foster good relations between groups have been taken / √
Adjust the policy – This involves taking steps to remove barriers or to better advance equality. It can mean introducing measures to mitigate the potential effect. It is lawful under the Equality Act to treat people differently in some circumstances, for example taking positive action or putting in place single-sex provision where there is a need for it. It is both lawful and a requirement of the general equality duty to consider if there is a need to treat disabled people differently, including more favourable treatment where necessary.
Attach the action plan to this equality analysis
Continue the policy – This means adopting the proposals, despite any adverse effect or missed opportunities to advance equality, provided the decision-maker is satisfied that it does not unlawfully discriminate. In cases where you believe discrimination is not unlawful because it is objectively justified, it is particularly important that you record what the objective justification is for continuing the policy, and how you reached this decision.
Attach details of the objective justification to this equality analysis
Stop and remove the policy – If there are adverse effects that are not justified and cannot be mitigated, the decision-maker should consider stopping the policy altogether. If a policy shows unlawful discrimination it must be removed or changed.
How will you monitor the impact of the policy / function? / Any issues relevant to the impact of the policy will likely be identified through Datix reporting, however no impact is expected.
Policy Sponsor / Jeanette Bowes
Assistant Divisional Manager
Clinical Support & Screening Services
Approving Committee / Radiation Protection Committee
Date of approval / March2015