Equality & Rights Action Plan 2013-17
This document outlines the actions we will take to work towards our Equality & Rights Outcomes.
Outcomes not processes
An outcome is an end result, for example having staff who are all aware of Equality and Rights issues and who can treat
all people with dignity and respect. A process is how to get there, for example a training plan or revising the contents of
the training course.
We have tried to focus the actions in this plan on outcomes as much as possible. Sometimes it is difficult to measure
outcomes, but during the life of this action plan we will develop ways of doing this.
The actions we have included here are in addition to equality activities mainstreamed in other plans. This means that we
have not referred to work set out elsewhere which will promote Equality and Rights. This is to ensure that the action plan
is as clear and concise as possible and addresses current gaps in services, information and evidence. The Equality Act
makes no specific reference to people on low incomes but all work subject to impact assessment as outlined in this
action plan takes account of the impact of socio-economic position on tackling health inequalities.
Unique ID: NHSL.
Author (s): JG, LB
Category/Level/Type: Category 1 Strategy
Version: 1
Status: Final version for publication
Authorised by: NHS Lothian Board
Date of Authorisation:27 March 2013
Review Date: Annually
Date added to Intranet & website: 24 April 2013
Key Words: policy, strategy, outcomes, equality, diversity, human rights, duty, duties, age, race, disability, gender, sex, religion, faith, sexual orientation, LGBT, lesbian, gay, bisexual,
transgender, marriage, civil partnership, pregnancy, impact assessment, EQIA, monitoring, action plan
Comments: Outcomes action plan supporting the Equality Outcomes required by specific duties of the Equality Act 2010, and published separately.
Page 1 of 13
International standards in equity for health care
The action plan is based on the International Standards for Equity of Health Care, developed by the World Health
Organization’s network of Health Promoting Hospitals & Health Care Services. You can find out more about these
standards here:
http://hphnet.org/index.php?option=com_content&view=article&id=291%3Atask-force-om-migrant-friendly-a-culturallycompetent-health-care&catid=20&Itemid=95
There are 5 separate Equity Standards which are described here:
 Standard 1: NHS Lothian is fair and equitable in the way it develops its policies and strategies, and in the way it
employs its workforce.
 Standard 2: Access to NHS Lothian’s healthcare services is equitable.
 Standard 3: NHS Lothian’s healthcare services deliver an equitable quality of care to all patients.
 Standard 4: NHS Lothian involves and consults with people in an inclusive and equitable way when developing
services or policies.
 Standard 5: NHS Lothian promotes equality and diversity in its work with partners, in its contracts and in its
procurement of goods and services.
For more information about how we identified these outcomes and actions, see the NHS Lothian Equality Outcomes
2013-17. You can find this on the NHS Lothian website at
http://www.nhslothian.scot.nhs.uk/YourRights/EqualityDiversity/KeyDocuments/Pages/default.aspx
2
Equality & Rights Action Plan 2013-17
Standard 1. NHS Lothian is fair and equitable in the way it develops its policies and strategies, and in the way it
employs its workforce
Outcome
Action
Output
Deliver
by end
of
Lead
General
Duty
reference
1.1 All
healthcare
developments,
policies and
plans take
account of the
diversity of
needs and
characteristics
of patients and
the community
Improve and review impact
assessment processes, including
monitoring, training, quality and
the performance of NHS Lothian
committees and services in
completing and acting on impact
assessments
Various compliance
performance measures,
impact assessment
action plan.
March
2015
EQIA Steering
Group
Advancing
equality of
opportunity
Assess the performance of key
services using the International
Equity Standards taking a riskbased approach, with stakeholder
involvement
Number of services
subjected to assessment
and follow up actions
completed
March
2017
Equality leads
Establish a policy to ensure that
senior decision makers address
equality & diversity in their
performance management
arrangements
Policy approved,
objectives in place for all
relevant managers
March
2016
Director of
Human
Resources &
Organisational
Development
Develop effective processes to
gather evidence and data about
equality, poverty and all protected
characteristics
Evidence bank
accessible to all staff to
support impact
assessment and service
improvement.
Implementation of
March
2017
Director of
Public Health
& Health Policy
Human &
Children’s
Rights
reference
Supports
development
of a Human
Rights and
Children’s
Rights
based
approach
3
1.2 The NHS
Lothian
workforce better
reflects the
diversity of the
population it
serves, and
staff with
protected
characteristics
are represented
appropriately at
all levels of the
organisation.
1.3 The pay gap
between staff of
different
genders,
ethnicity and for
disabled staff is
reduced.
Develop more targeted training for
members of interview panels in
equal opportunities
Additional Support
Needs and protected
characteristic data
collection workstream
across all services.
Number of staff
completing equal
opportunities in
recruitment training by
job family and pay band
March
2015
Establish a programme to improve
workforce monitoring across all
protected characteristics
% disclosure of
protected characteristics
increases
Develop provision of mentoring,
coaching and other support for
staff with protected characteristics
once they are in post.
Various outputs
including number of staff
supported by protected
characteristics, by pay
band, job family
Improve the knowledge and skills
of Employee Relations staff so
that they are better able to provide
support when an employment
issue concerns equality & diversity
Improved monitoring of
Employee Relations
cases by protected
characteristic; improved
reported outcomes
Prepare and publish an equal pay
statement for NHS Lothian
Statement published
with demonstrable staff
and Partnership
involvement
Deliver equal pay plan in priority
pay bands and job families.
Identify and review horizontal and
vertical occupational segregation
March
Narrower % pay gap and 2015
gender imbalance in key
job families between
male and female staff
Director of
Human
Resources &
Organisational
Development
Advancing
equality of
opportunity,
eliminating
discrimination,
improving
relations
between
groups
Human
Rights
Article 3: No
torture or
humiliating
or degrading
treatment.
Article 4: No
slavery or
forced
labour.
Article 8:
Right to a
private and
family life.
Article 9:
Freedom of
religious
belief.
Director of
Human
Resources &
Organisational
Development
Eliminating
discrimination
Supports
development
of a Human
and
Children’s
Rights
based
approach
March
2015
March
2015
March
2015
March
2014
4
1.4 There is
improved
dignity at work
for all staff and
volunteers.
For disabled staff and
BME staff
March
2017
Launch and publicise a revised
Dignity at Work policy and clear
organisational values
Organisational Values
programme delivered,
Dignity at Work policy
revised, Management
Culture plan delivered,
NHS Scotland annual
staff survey
March
2017
Facilitate the establishment of
robust staff-led networks for
LGBT, disabled and BME staff
Staff networks in place,
number of meetings and
members
March
2015
Implement Gender-Based
Violence policy and develop
monitoring system for staff
reporting and ensure appropriate
training, support and referral
pathway.
Policy and procedures in
place, monitoring system March
developed
2015
Director of
Human
Resources &
Organisational
Development
Eliminating
discrimination,
improving
relations
between
groups
Human
Rights
Article 3: No
torture or
humiliating
or degrading
treatment.
Article 8:
Right to a
private and
family life.
Article 9:
Freedom of
religious
belief.
5
2. Access to NHS Lothian’s healthcare services is equitable
Outcome
Action
Output
2.1 Access to
health services
is more
equitable for
people with
protected
characteristics
Develop data gathering on how
people access primary and acute
health services
Establishment of
baseline and robust data
set to include all
protected characteristics
Deliver
by end
of
March
2017
Lead
Director of
Public Health &
Health Policy
Equality Leads,
Public
Involvement Coordinators,
Development
Managers,
Public Health
Practitioners
Develop and implement
programme of training and
awareness raising with GP
surgeries on registration policies,
equality & diversity and
communication. To include all
protected characteristics.
Patients report improved
experience (e.g. through
Better Together survey);
other measures e.g.
number of GPs and
reception staff trained.
March
2017
Review of interpreting &
communication support
arrangements, implement
development plan including
awareness-raising and training for
staff in working with interpreters,
and participation in NHS 24 pilot
on videoconferencing for BSL
interpreters
Plan will include various
measures; improved
level of service data will
identify areas for further
improvement. Number of
staff trained; improved
patient and interpreter
experience.
March
2016
All patients who need support
receive this to encourage
improved access to health
services and anticipatory health
care, through cultural bridging.
Through use of service
ethnicity data; review of
referrals, attendance etc
by all protected
characteristics and
additional needs;
Ongoing Director of
Public Health &
Health Policy,
Equality Leads
General
Duty
reference
Advancing
equality of
opportunity
Human
Rights
reference
Supports
development
of a Human
and
Children’s
Rights
based
approach.
Senior
Manager, Staff
Bank
6
2.2 NHS
Lothian has
minimised
architectural,
environmental
and
geographical
barriers to its
services
2.3 Health
promotion and
public health
interventions
are inclusive,
reach all
intended
audiences and
address stigma
in the
community
monitoring of patients
supported by Minority
Ethnic Health Inclusion
Service.
Develop the way that Estates &
% of estate assessed as
Facilities assess and improve the
non-compliant. Grading
accessibility of all NHS Lothian
of buildings identifies
buildings, including improving links areas requiring
to local access panels and making improvement; capital
better use of service data in
plan addresses these.
implementation plans.
Develop and implement specific
health promotion activities in a
range of subjects for people with
protected characteristics (e.g.
sexual health, tobacco, substance
misuse).
Interventions delivered,
service data
demonstrates reach
through analysis of
results using equality
and diversity monitoring.
March
2017
Director of
Facilities &
Estates
Eliminating
None.
discrimination
March
2015
Director of
Public Health
and Health
Policy
Advancing
equality of
opportunity
Human
Rights
Article 8:
Right to a
private and
family life.
Children’s
Rights
Articles 24:
Right to
health and
28: Right to
education
7
3. NHS Lothian’s healthcare services deliver an equitable quality of care to all patients
Outcome
Action
Output
Deliver
by end
of
March
2017
Lead
3.1 Patients
with protected
characteristics
have a more
personalised,
individualised
service where
they are better
able to
exercise their
independence
, control and
autonomy with
an advocate if
needed, and
where their
rights are
protected.
Develop the Compassionate
Care and Delivering Better Care
programmes to improve the way
services involve patients, family
and carers in decisions about the
care of patients with protected
characteristics.
Patient feedback, patient
experience quality
indicators generate data by
protected
characteristic/additional
need
Services use patient data to
See additional needs
ensure that care is personworkstream in outcome 1.1
centred, making use of additional
support needs and equality data.
This includes provision of
information.
March
2017
Director of
Public Health &
Health Policy
Carry out a strategic review of
Human & Children’s Rights risks
and opportunities.
Review complete, report
published, actions identified
and monitored.
March
2014
Equality Leads
3.2 People in
Lothian are
more assured
that health
services will
respect their
dignity and
identity.
Communications and
awareness-raising activities to
encourage service users to selfidentify their protected
characteristics or additional
support need.
Patient feedback, Better
Together surveys etc.
Increase in recording of
patient protected
characteristics and
additional needs – see
outcome 1.1
March
2017
Equality Leads
Implement Gender-Based
Violence Strategy, to include
further development of routine
enquiry and awareness-raising
Service monitoring data
demonstrates
implementation.
Annual reporting of
March
2017
Nurse Director,
Director of
Public Health &
Health Policy
Chief Nurse,
Quality &
Professional
Standards
General
Duty
reference
Advancing
equality of
opportunity.
Human
Rights
reference
Supports
development
of a broad
Human and
Children’s
Rightsbased
approach.
Eliminating
discrimination,
improving
relations
between
groups.
Human
Rights
Article 2:
Right to life.
Article 3: No
torture or
humiliating
or degrading
treatment.
Article 8:
Right to a
private and
8
3.3 Staff are
better
equipped to
deliver health
care that
takes into
account
patients’
protected
characteristics
, health
literacy needs
and dignity
of the risk of Gender-Based
Violence in relation to forced
marriage, Female Genital
Mutilation and Human
Trafficking.
progress to achieve
measurable outcomes
Review training provision to
allow for more targeted provision
and content, including:
 developing understanding
about the intersections/
overlaps in people’s identities
e.g. disabled LGBT people
 understanding of the equality
& diversity contexts that may
inform a service user’s health
engagement
 understanding about Do Not
Attempt Resuscitation
policies for people with lifelimiting conditions
 recognition of age-related
transitions in service
provision
 training in how to ask patients
questions about protected
characteristics or about their
family, significant other or
next of kin
 training in the implementation
of a Human Rights and
Children’s Rights approach
Training completion data
shows increased takeup in
specified staff
groups/services.
Service data and patient
experience demonstrate
improvement. Increased
recording of patient data
including protected
characteristic and additional
needs. MEHIS reports
number of staff supported
to provide culturally
competent services through
building their capacity.
family life.
March
2017
Director of
Human
Resources &
Organisational
Development
Children’s
Rights
Article 19:
protection
from
violence and
abuse
Eliminating
Supports
discrimination, development
advancing
of a broad
equality of
Human and
opportunity,
Children’s
improving
Rightsrelations
based
between
approach.
groups.
Equality Leads
9
4. NHS Lothian involves and consults people in an inclusive and equitable way when developing services or
policies
Outcome
Action
Output
Deliver
by end of
Lead
General Duty
reference
4.1 NHS Lothian
involves with
people in a more
inclusive and
equitable way,
including people
with all protected
characteristics
and from across
the socioeconomic
spectrum
Review and develop
arrangements for planning,
monitoring and evaluating
patient and public
engagement to improve
inclusivity and effectiveness.
Evaluations and data from
engagement activities
demonstrate improvement
in services.
March
2015
Associate
Director of
Communications
Advancing
equality of
opportunity,
improving
relations
between
groups.
March
2014
Gender
Reassignment lead
specialist in
Public Health
4.2 NHS Lothian
ensures that any
individual can
provide feedback
or make a
complaint and this
is addressed
equitably and
transparently
Develop existing
mechanisms to measure the
patient experience so that
they are sufficiently detailed
to link data to protected
characteristics or additional
support needs.
As for outcome 3.1
March
2017
Director of
Public Health
& Health
Policy
Review arrangements for
encouraging feedback and
suggestions so that all
patients have an opportunity
to provide these.
Monitoring of feedback and
suggestions demonstrates
improvement by protected
characteristic.
March
2015
Chief Nurse,
Quality &
Professional
Standards
Develop complaints
procedures so that
Monitoring of complaints
demonstrates takeup and
March
2015
Director of
Human
Transgender patient and
staff group established
Establish ongoing
arrangements for patient
involvement in Gender
Reassignment pathway
Eliminating
discrimination.
Human
Rights
reference
Supports
development
of a broad
Human and
Children’s
Rights-based
approach.
Human
Rights Article
6: Right to a
fair hearing.
Article 10:
Freedom of
expression.
Children’s
Rights Article
12: Respect
for the views
of children
10
complaints relating to
discrimination are
demonstrably treated
seriously
resolution by protected
characteristic
Resources &
Organisational
Development
11
5. NHS Lothian promotes equality & diversity in its work with partners, in its contracts and in its procurement of
goods and services
Outcome
Action
Output
5.1 NHS Lothian’s
partner
organisations and
suppliers operate
in a way that is
consistent with its
approach to the
promotion of
equality
Review and update standard
contractual terms and
conditions and Service Level
Agreements to include
specific requirements
relating to promotion of
general duty.
5.2 Individuals
and communities
who are
vulnerable to, or
victims of hate
Deliver
by end of
Lead
General Duty
reference
Contracts and agreements
March
revised to specify how they
2015
will take account of the
needs of people with
protected characteristics
and those on low incomes.
Monitoring provides baseline
for ongoing development
work with suppliers and
contractors.
Health &
Social Care
Partnerships,
Director of
Finance,
Director of
Strategic
Planning
Eliminating
discrimination,
advancing
equality of
opportunity,
improving
relations
between
groups.
Identify key partner
organisations and support
them to monitor protected
characteristics of service
users, and use the resulting
data to evaluate the
accessibility and
effectiveness of these
services and improve the
extent to which they
promote equity, build social
capital and address poverty.
Monitoring and reviewing
service data demonstrates
improvement in accessibility
and outcomes and identifies
any barriers to access.
March
2016
Equality
Leads
Improved knowledge and
understanding of hate
incidents and hate crimes
and reporting mechanisms
including the involvement of
Issue of hate incidents/hate
crime are integrated within
both mainstream and
equalities training, and in
HR policies.
March
2014
Director of
Human
Resources &
Organisational
Development,
Human
Rights
reference
Supports
development
of a broad
Human and
Children’s
Rights-based
approach.
Social capital outcomes in
service level agreements
contribute to building
community cohesiveness
and community safety
Eliminating
discrimination,
improving
relations
between
Human
Rights Article
2: Right to
life.
Article 3: No
12
crime feel safer
and more secure
police when necessary,
through greater integration
of hate crime issues in
mainstream staff training.
Increased reporting of hate
incidents and hate crimes on
DATIX system. Monitoring of
referrals to support
organisations and police
Director of
Public Health
& Health
Policy,
Equality
Leads
Joint Hate Crime campaigns
make better use of local
data.
As above.
March
2016
Equality
Leads
Improved publicity for joint
hate crime arrangements
with other organisations,
e.g. police.
As above
Ongoing
Equality
Leads
NHS Lothian representation
on Hate Crime Strategic
Development Groups and
the Community Safety
Partnerships
Increased reporting and
monitoring of hate crimes
reported through multiagency groups
2016
Equality
Leads
groups.
torture or
humiliating or
degrading
treatment.
Article 8:
Right to a
private and
family life.
Article 9:
Freedom of
religious
belief.
Children’s
Rights Article
19: Protection
from violence
and abuse
13