Equality & Human Rights Scheme 2010-13 Action Plan
1. The right to be alive
For example, being able to avoid premature death through disease, neglect, injury or suicide.
Human Rights reference: Article 3 – the Right to Life
Outcome
Actions to achieve
this
Department or
person responsible
How progress
is to be
measured
Baseline
Timescale
Link to
involvement
1.1 Fewer deaths
through intentional
self harm, suicide.
(a) Implement
Choose Life and
Suicide Prevention
Training
programmes aimed
at high risk groups
including teenage
and young gay men
aged 13-18, people
who are lesbian,
gay, bisexual or
transgender.
Strategic
Programme
Manager, Mental
Health
Wide range of
indicators
embedded in
these
programmes,
includes
HEAT target
indicators
See HEAT
monitoring
reports
Annually
Involvement
event 5
August 2009
(b) Promote
confidential
counselling,
Confidential
Director of Human
Resources &
Organisational
Development
Range of
indicators in
NHS Lothian
Human
Awaiting data
Choose Life
Implementation
Manager
Research:
Live to Tell,
Young Gay &
Bisexual Men
& Suicide
(Gay Men’s
Health, LGBT
Youth
Scotland
2003)
Co-ordinator,
Suicide Prevention
Training
Programme
November
2012
Equality &
Human Rights
Steering
Group 6 May
Unique ID: NHSL.
Author (s): James Glover
Category/Level/Type: POLICY
Version: 1
Status: Publication version
Authorised by: NHS Lothian Board
Date of Authorisation: 26 May 2010
Review Date: 31 March 2011
Date added to Intranet: 30 June 2010
Key Words: policy, strategy, scheme, equality, diversity, human rights, duty, duties, age, race, disability, gender, religion, faith, sexual orientation, LGBT, lesbian, gay, bisexual,
transgender, impact assessment, EQIA, monitoring, action plan
Comments: Publication version of Equality & Human Rights Scheme action plan.
Page 1 of 42
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
Contacts scheme
Resources &
to improve support
Organisational
for staff who may
Development
be suffering from
Strategy
stress, considering
2008-11
or carrying out self
harm or suicide.
1.2 Girls and boys
including disabled
children, children
from ethnic
minorities or from
poor socioeconomic
backgrounds do not
face inequity in
child protection
arrangements.
(a) Support UN
Convention on the
Rights of the Child,
implement
involvement and
training programme
set out in UNCRC
Child Health
Commissioner
(b) Implement
Getting It Right For
Every Child
strategies in
Primary Care
Lead Nurse
1.3 Improved life
expectancy for
people living in
Lothian
(a) Improve
accessibility of
health promotional
materials via NHS
Lothian
Communication
Strategy
(b) Target health
promotional work in
areas of socio
economic
deprivation and
communities of
interest.
2010
Consultation
response 6
May 2010
Baseline to be
determined
To be
determined
June 2011
Meeting at
Save the
ChildrenScotland 9
February 2010
GIRFEC,
PEACHIE
reports
To be
determined
June 2013
None
Communications
Department; Health
Promotion
Monitoring/
audit process
to be
developed.
No current
baseline
June 2011
Involvement
event 5
August 2009
Community Health
(& Care)
Partnerships, jointly
with the Minority
Ethnic Health
Inclusion Service
and Lothian
Range of
indicators
from Health
Promotion
service and
Public Health
Baselines to
be determined
June 2013
Involvement
event 14
December
2009
Strategic
Programme
Manager, Women
and Children
Edinburgh CHP
2
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
Community Mental
Health Deaf service
(c) Improve
accessibility of
preventative and
screening services,
including for
lesbian, gay,
bisexual and
transgender people
and in areas of
deprivation and to
groups who have
difficulty accessing
services
Director of Public
Health & Health
Policy
Family Planning
Breast Screening,
Bowel Screening,
Eye, Neonatal and
other services
Monitoring/
audit process
to be
developed,
including
focus on men
and women.
Baseline to be
determined
during 200910
June 2013
Involvement
events 5
August & 14
December
2009
Primary Care
Keep Well
programme
Equality &
Human Rights
Steering
Group 18
February 2010
Partnerships
through LGBT
Centre for Health
and Wellbeing and
Community Health
Initiatives.
(d) Implement
Health Care Action
Plan to address
health inequalities
for adults and
children with
Learning
Disabilities
Service leads
Health Inequalities
– Learning
Disability Project
Manager
Disability
Equality
Steering
Group 13
August 2009.
Plan has a
range of
indicators and
monitoring
processes.
See the plan
for information
June 2012
None
Strategic
Programme
Manager –
Disabilities
Lothian Learning
Disability
3
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
Partnership Board
1.4 Fewer deaths
through injury
(a) Implement
Gender Based
Violence routine
enquiry and training
programmes along
with Child and
Adult Protection
strategies.
Gender Based
Violence Steering
Group
See plan
See plan
June 2013
None
POVA/Child
protection
management
structures
Associate Director
of Occupational
Health Services
Associate Director
of Employee
Relations
(b) Provide
services to people
who have identified
as victims of
childhood and adult
sexual abuse via
Mental Health and
Wellbeing strategy.
Strategic
Programme
Manager – Mental
Health
Indicators in
Mental Health
& Wellbeing
Strategy
See strategy
June 2013
None
(c) Work with
partners to address
the needs of
perpetrators to
reduce risks of
sexual abuse and
gender based
violence.
Gender Based
Violence Steering
Group
See plan
See plan
June 2013
None
(d) Work with
partners to reduce
Public Health
Rates of
accidents will
Current
baseline data
June 2013
None
4
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
levels of childhood Health Promotion
be reduced
is available
accidents
though ISD
5
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
2. The right to live in physical security
For example, being free from violence and abuse including race, sexual, disability, emotional and identity-based violence.
Human Rights reference: Article 5 – the Right to Liberty & Security
Outcome
Actions to achieve
this
Department or
person
responsible
How progress
is to be
measured
Baseline
Timescale
Link to
involvement
2.1 People in long
term care are safer
and protected from
violence and
abuse.
(a) Implement
Protection of
Vulnerable Adults
training
programme across
Lothian, as for
1.3(c) above. To
include Human
Rights awareness
Training
Department
Number of staff
trained.
June 2012
Service leads,
Continuing
Care/Care of
the Elderly
Evaluation of
training.
Number for
2008-9:
awaiting data
Involvement
event 5 August
2009
2.2 Improved
security of car
parks, NHS
premises and open
spaces for
patients, staff,
carers and other
visitors.
(a) Revise security
policies for NHS
Lothian premises
via impact
assessment
Estates/
Facilities
Department
Impact
assessments
completed
No baseline set
June 2012
Involvement
event 5 August
2009
2.3 Improved
community
cohesion and
better relations
between different
groups, particularly
racial groups
(a) Work with
partners in public
and voluntary
sector to increase
community
cohesion and
integration.
Community
Health
Partnerships
No baseline
available
June 2013
None
Monitoring/
audit process to
be developed
Implement
social capital
tool-kit in
Edinburgh.
Health
Inequalities
Review funding
Manager, CHPs applications to
and REAS
ensure that all
6
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
sectors of the
community are
being included
where
appropriate and
barriers to
access have
been identified
and addressed.
7
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
3. The right to be healthy
For example, being able to:
 attain the highest possible standard of individual physical and mental wellbeing, including sexual and reproductive health
 access timely and impartial information about health, wellbeing and healthcare options
 access healthcare, including non-discrimination in access to healthcare
 be treated medically, or subject to experiment, only with informed consent
 maintain a healthy lifestyle including exercise and nutrition
Human Rights reference: none
Outcome
Actions to achieve
this
Department or
person
responsible
How progress is Baseline
to be measured
Timescale
Link to
involvement
3.1 Staff are
aware of and have
positive attitudes
to equality,
diversity & Human
Rights issues
(a) Develop
existing training
framework for
NHS Lothian staff.
Include Human
Rights awareness
in the framework.
Explore potential
to use disabled
people, Black &
Minority Ethnic
people, and
lesbian, gay,
bisexual and
transgender
people to deliver
relevant equality
training.
Training
Department
Equality
Training
Framework
produced
June 2011
Disability
Equality
Steering Group
13 August
2009.
Associate
Director of Pay
and Workforce
Modernisation
Number of staff
trained in
equality,
diversity &
Human Rights
annually
Training
evaluations
Awaiting
number of staff
trained in
equality,
diversity &
Human Rights
issues in 20089
Audit of
Personal
Development
Plans regarding
Knowledge &
Skills
Framework
Core dimension
6, 1-4.
Involvement
events 5 August
& 14 December
2009.
Learning
Disability
workshop 22
July 2009, user
group meeting
17 February
2010.
Equality &
Human Rights
8
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
Steering Group
18 February
2010
Lothian Minority
Ethnic Health
Forum 18
March 2010
West Lothian
Disability
Equality Forum
26 April 2010
Involving
People Group
15 April 2010
(b) Promote
training in
equality, diversity
& Human Rights
to contracted
services (e.g.
GPs, primary
care, voluntary
organisations) and
in partnership with
Local Authorities.
Include Human
Rights awareness
in this.
Contracting
teams
Community
Health
Partnerships
Monitoring of
agreement
compliance
Feedback from
patients, carers
and family
members,
community
representtatives
No current
baseline
June 2013
Involvement
events 4 August
and 14
December 2009
9
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
(c) Include training Contracting
Condition
No current
June 2013
outcomes in
teams.
included in
baseline
standard
Community
Service Level
agreements with
Health
Agreements
contracted
Partnerships
Monitoring of
services
compliance as
Involvement
events 4 August
and 14
December 2009
for 3.1(b) above
(d) Publicity and
promotional
materials promote
positive attitudes
to equality,
diversity & Human
Rights
Communication
Department, via
NHS Lothian
Communications Strategy
Strategy
revised to
include specific
actions
No current
baseline
June 2011
Disability
Equality
Steering Group
13 August 2009
Service leads
Monitoring/
audit process to
be developed
3.2 Promotional
materials and
written information
should be
accessible to
disabled people,
including Deaf
people and people
with a learning
disability, people
with literacy
difficulties and
people for whom
English is not a
first language
(a) Revise
Communication
Strategy
See 3.1(d)
above
See 3.1(d)
above
See 3.1(d)
above
See 3.1(d)
above
See 3.1(d)
above
(b) Promote
Communication
Strategy across
NHS Lothian,
targeting staff who
produce
information &
promotional
materials
Communications
Department
Monitoring/
audit process to
be developed
No current
baseline
June 2011
Involvement
event 14
December 2009
(c) Implement
Clinical
Information for
Patients
Framework
Associate
Nurse Director,
Strategic
Development
Range of
indicators in
Framework
To be
determined
June 2012
Involvement
event 14
December 2009
3.3 Premises
(a) Improve
Facilities
Monitor number
Number of
June 2012
Disability
Involvement
event 14
December 2009
10
providing health
services are more
accessible to
patients, carers,
family members
and other visitors,
as well as staff
and volunteers
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
availability and
Department
of loops fitted or working loops
maintenance of
made available. as at summer
Equality Leads
hearing loops
2009
across NHS
Lothian premises,
GP practices,
dentists, other
primary care
premises
Equality
Steering Group
10 July 2009.
Develop
monitoring
processes to
evaluate progress.
(b) Roll out
training
programme for
staff in use of loop
systems as part of
training framework
See action
3.1(a)
(c) Continue
Estates/
programme of
Facilities
modifications to
Department
buildings and
equipment to meet
requirements of
the DDA 1995 &
develop
monitoring/ audit
process
See action
3.1(a)
See action
3.1(a)
See action
3.1(a)
See action
3.1(a)
Number of
access audits
completed.
Awaiting data
on number of
access audits
completed
2006-9
June 2012
Midlothian
workshop 15
June 2009
Other indicators
to be
developed.
Edinburgh
Equalities
Network
seminar 16
June 2009
Involvement
event 5 August
2009
Consultation
response 6 May
11
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
2010
(d) Revise the Car
Parking Strategy
to make improved
provision of
parking spaces for
disabled car users
Estates/
Facilities
Department
Monitor number
of spaces for
disabled car
users
Access audits
Awaiting data
on number of
spaces for
disabled car
users as of end
2009
June 2011
Midlothian
workshop 15
June 2009
Disability
Equality
Steering Group
10 July 2009
Feedback from
disabled people
Involvement
event 5 August
2009
West Lothian
Disability
Equality Forum
26 April 2010
Consultation
response 10
May 2010
(e) Work with
Acute services to
ensure that
children are
examined and
treated in facilities
appropriate to
their age and size.
Equality leads
No current
measures in
place. To be
determined
during the
lifetime of the
Scheme.
No current
baseline, but
specifications
will be
developed for
new build
programmes
June 2012
Disability
Equality
Scheme
Consultation
response
November 2009
Involvement
event 14
December 2009
12
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
(f) Develop an
Facilities
To be
To be
June 2011
updated
determined
determined
programme of
access audits of
premises run by
NHS Lothian and
contracted
partners, e.g. GP
surgeries
3.4 It is easier for
people to
communicate with
health services
Involvement
events 5 August
2009 and 14
December 2009
(g) Develop
flexibility of
opening times for
clinics and
surgeries,
particularly to
increase
accessibility by
night time
economy workers
and men
Primary Care
contracting
team
Monitoring of
opening hours
and service
takeup as part
of contractual
arrangements
To be
determined
June 2013
None
(a) Implement
Interpreting,
Translation &
Communication
Support Policy to
promote
availability to all
NHS Lothian
services
Equality Leads
Monitor
expenditure,
number of
bookings,
services
booking,
number of
hours
Expenditure,
number of
hours, number
of bookings for
2008-9
June 2011
Involvement
events 5 August
& 14 December
2009
Associate
Nurse Director,
Strategic
Development
Human Rights
workshop 13
October 2009
Equality &
Human Rights
Steering Group
meetings 16
November 2009
& 18 February
13
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
2010
(b) Develop
See 3.1(a)
existing training
framework for all
NHS Lothian staff
- see action
3.1(a). To include
awareness
training in symbols
and plain English.
See 3.1(a)
See 3.1(a)
See 3.1(a)
Involvement
events 5 August
& 14 December
2009
Learning
disability
workshop 22
July 2009 &
user group
meeting 17
February 2010
Equality &
Human Rights
Steering Group
meetings 16
November 2009
& 18 February
2010
3.5 NHS Lothian
has a clearer
picture of how
people use its
services and
benefit from them
(c) Implement
Clinical
Information for
Patients
Framework
See 3.2(c)
above
See 3.2(c)
above
See 3.2(c)
above
See 3.2(c)
above
(a) Incorporate
“Happy to Ask,
Happy to Tell”
training
programme into
training framework
See 3.1(a)
above
See 3.1(a)
above
See 3.1(a)
above
See 3.1(a)
above
(b) Implement
diversity
monitoring
Ethnic Coding
Task Force
Monitored via
SMR data
reports supplied
Routine
recording of
age and
December 2012
None
14
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
strategy 2009-12
Mutuality &
by Scottish
gender.
Equality
Government
Ethnicity
Governance
Health
recording: 5%
Committee
Department
of patients at
end Sept 2009
No figures for
religious belief,
disability,
sexual
orientation
3.6 NHS Lothian
has improved
compliance with
its equality impact
assessment
policies and has
reviewed these to
include Human
Rights
(a) Implement
impact
assessment
communication
plan
Head of
Equality &
Diversity
Range of
indicators
including
number of
impact
assessments
completed by
service
98 Rapid
Impact
Assessments
and full EQIAs
completed to
end December
2009, 48 of
which were
completed in
2009.
June 2011
Equality &
Human Rights
Steering Group
18 February
2010
(b) Develop
impact
assessment
training provision
as part of training
framework – see
action 3.1(a)
See action
3.1(a)
See action
3.1(a)
See action
3.1(a)
See action
3.1(a)
See action
3.1(a)
(c) Develop
Quality
Improvement
processes so that
they can be used
to monitor the
Clinical
Governance
Manager
Monitored by
Clinical
Governance
Standards
framework and
Quality
None at present June 2011
None
15
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
outcomes of
Improvement
impact
Programmes
assessments
3.7 NHS Lothian
has built equality,
diversity and
Human Rights into
its performance
management and
quality
improvement
processes
(d) Improve quality Consultant in
of impact
Public Health &
assessments
Health Policy
produced by NHS
Lothian using
quality proofing
process
Monitored using
quality criteria
agreed by
Board’s
Equality &
Diversity
Steering Group
To be
determined
during 2010
June 2011
None
(a) Develop Local
Delivery Plan to
monitor equality
outcomes and
risks arising from
HEAT
programmes
Associate
Director of
Strategic
Planning
Monitored using
Risk Register
and established
HEAT target
measures
2010/11 first
year that
equality risks
have been
incorporated
into LDP
June 2012
None
(b) Develop
Quality
Improvement
programmes and
structures to
embed equality &
diversity
performance
monitoring in
these
Associate
Nurse Director,
Strategic
Development
Monitored by
developing
established
Quality
Improvement
mechanisms
Quality
Improvement
Programme
template
revised 2010.
Monitoring
processes to be
developed
June 2012
None
(c) Incorporate
equality &
diversity risks into
corporate risk
register and
relevant
Equality leads
Established risk
management
processes,
including risk
register and
Datix system
No specific
equality risks
identified as of
May 2010 in
risk register.
Lothian-wide
June 2012
None
LDP Core
Group
Clinical
Governance
Support Team
16
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
monitoring
(for racial and
Datix figures for
processes
sexual
racial and
harassment
sexual
issues). Datix
harassment
incidents
issues.
monitored by
Disability,
Quality
sectarian,
Improvement
religious,
Teams.
homophobic
and age-related
monitoring to be
added to Datix
system.
3.8 NHS Lothian’s
governance
structures are able
to ensure that
people have
equitable access
to health services
and employment
(a) Work with the
Head of
Board and its
Equality &
committees to
Diversity
develop
understanding,
scrutiny and
decision making in
respect of
equality, diversity
and Human Rights
Scrutiny of
Board and
Committee
papers
Baseline
scrutiny
planned for
2010/11
June 2013
None
(b) Revise gender
reassignment
treatment pathway
with support from
Transgender
patients to
improve
responsiveness
and patient
experience
Clinical
outcomes
Awaiting data
December 2010
None
Department of
Public Health &
Health Policy
Patient
experience
monitoring
17
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
18
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
4. The right to be knowledgeable, to understand and reason, and to have the skills to participate in society
For example, being able to:
 attain the highest possible standard of knowledge, understanding and reasoning
 be creative
 develop the skills for participation in productive and valued activities, including parenting
 access education, training and lifelong learning that meets individual needs, such as manual handling training for family
members and carers
 access information and technology necessary to participate in society, including assistive technology and communications
support to assist in independent living
Human Rights references: Article 9 – Freedom of Thought, Conscience and Religion
Article 2 of the First Protocol – Right to Education
Outcome
Actions to achieve
this
Department or
person
responsible
How progress
is to be
measured
Baseline
Timescale
Link to
involvement
4.1 People have
equal opportunities
to participate in
public life,
regardless of age,
disability, gender,
race, religion,
sexual orientation
or socio-economic
background
(a) Promote
mainstream
involvement
activities to diverse
audiences via
Involving People
Strategy, to
broaden
participation in
Patient Public
Forums and
related networks.
This to include
Gypsy/Traveller
communities.
Nurse Director
Monitoring of
participants in
involvement
activities
To be
determined
during 2009-10
June 2012
Involvement
event 14
December 2009
Director of
Public Health &
Health Policy
Director of
Strategic
Planning
Equality Impact
Assessment 6
May 2010
19
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
(b) Train staff who Head of Patient Monitor uptake No baseline for June 2011
organise
Focus Public
of equality,
staff carrying
involvement
Involvement
diversity &
out involvement
activities to make
Human
Rights
work
Training
sure that these are Department
training courses
accessible to a
Director of
diverse range of
Strategic
people – see
training framework Planning
3.1(a)
4.2 Girls and boys
as children and
young people have
(c) Promote
volunteering
opportunities to a
diverse range of
people
Associate
Nurse Director,
Strategic
Development
Diversity
monitoring of
NHS Lothian
volunteers
Level of
disability
among
volunteers:
18% (March
2009). Awaiting
other baseline
data.
June 2012
None
(d) Develop
capacity of
involvement
programmes to
monitor diversity of
participants more
consistently
Strategic
Programme
Managers
Diversity
monitoring of
participants in
involvement
activities
No current
baseline but
form available
for
implementation
in April 2010
June 2011
None
(e) Implement
plans to meet
Participation
Standard
Associate
Nurse Director,
Strategic
Development
To be
determined
when Standard
developed in
2010-11
To be
determined
when Standard
developed in
2010-11
June 2012
None
(a) Work with
Local Authority
Education
Equality leads
Audit provision
of education
services for
Data available
through local
education
June 2013
Involvement
event 14
December 2009
20
access to
appropriate
education while
receiving longerterm health care
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
Departments to
children
departments
identify children
receiving long
needing services.
term care in
Ensure families
home and
are informed of
hospital
availability of
settings
services
21
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
5. The right to enjoy a comfortable standard of living, with independence and security
For example, being able to:
 enjoy an adequate and secure standard of living including nutrition, clothing, housing, warmth,
 have personal mobility, and access to transport and public places
 live with independence, dignity and self-respect and having the support to allow this to happen
 have choice and control over where and how you live
Human Rights reference: Article 5 – the Right to Liberty & Security
Outcome
Actions to achieve
this
5.1 It is easier for
people to access
and use transport
to and from health
services
Department or
person
responsible
How progress
is to be
measured
Baseline
Timescale
Link to
involvement
(a) Revise the Car Facilities
Parking Strategy to Department
make improved
provision of
parking spaces for
disabled car users
– see action 3.3(d)
See action
3.3(d)
See action
3.3(d)
See action
3.3(d)
See action
3.3(d)
(b) Joint work with
Scottish
Ambulance
Service and other
patient transport
partners to
improve services
for disabled
people, older
people, people
from poor socioeconomic
To be
developed
No current
baseline
June 2013
Involvement
event 14
December 2009
Equality leads
Facilities
Department
Transport
Group
22
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
backgrounds
5.2 Wheelchairs
are more available
and more
appropriate for
those who need
them to access
NHS services
(c) Ensure that
access to
transport where
this is an issue is
considered in
discharge and
community care
plans
Acute Division
and CHPs
Impact
assessment of
discharge
planning
processes
Not yet carried
out as of March
2010
June 2011
Involvement
event 14
December 2009
(a) Revise
wheelchair
provision across
NHS Lothian sites,
for visitors to
premises
Facilities
Department
Number and
range of
wheelchairs on
each site
To be
determined
June 2012
Disability
Equality
Steering Group
10 July 2009.
(b) Implement
national and local
modernisation plan
2008-11 for
provision of
wheelchairs to
individuals,
including use of
needs assessment
Smart Centre
Range of
To be
indicators, to be determined
determined
June 2011
None
(c) Revise
signposting across
NHS Lothian sites
Facilities
Department
Signage is
monitored
through PEAT
audits.
June 2013
Involvement
events 5
August and 14
December 2009
Involvement
event 5 August
2009
Awaiting data
Access audit
reports
Feedback from
23
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
patients, carers,
family members
and community
representatives
5.3 NHS Lothian
supports disabled
people who wish to
direct their own
care
(a) Implement
NHS Lothian pilot
delivering health
care services via a
self directed care
model from 2009 –
2012.
Project
Manager – Self
Directed Care
5.4 Disabled
children moving
into adult services
receive appropriate
services and
support and are
treated with dignity
and respect
through their
transition.
(a) Improve
transition of
disabled children
to adult services
University
Hospital
Division
Equality &
Diversity
Implementation Group
Strategic
Programme
Manager Disabilities
Steering Group
– supported by
Scottish
Government
will directly
monitor impact
and outcomes.
Being
June 2013
established in
partnership with
Lothian Local
Authorities
Involvement
event 5 August
2009
Measures to be
determined
during 2010-11
No current
baseline
DES
Consultation
response
November 2009
June 2013
Involvement
event 14
December 2009
24
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
6. The right to engage in productive and valued activities
For example, being able to:
 undertake paid work
 care for others including parenting to an expected standard
 have rest, leisure and respite, including holidays
 choose a balance between paid work, care and leisure on an equal basis with others
 work in just and favourable conditions, including health and safety, fair treatment during pregnancy and maternity, and fair
remuneration
 not be forced to work in a particular occupation or without pay
 not be prevented from working in a particular occupation without good reason
Human Rights references: Article 4 – Prohibition on Slavery and Forced Labour
Article 8 – the Right for Respect for Private and Family Life
Outcome
Actions to achieve
this
Department or
person
responsible
How progress
is to be
measured
Baseline
Timescale
Link to
involvement
6.1 Employees of
NHS Lothian feel
more confident
about disclosing
diversity
information to their
employer
(a) Implement
Dignity at Work
section of NHS
Lothian Human
Resources
Strategy, including
use of external
support services
where this is
relevant, e.g.
LCiL’s Your Call
service for
disabled staff
Director of
Human
Resources &
Organisational
Development
Range of
indicators
including staff
satisfaction
levels from staff
survey, exit
interviews,
grievance &
disciplinary
monitoring.
Peer support
networks
established for
disabled and
155 staff or
0.5% of NHS
Lothian
workforce have
disclosed a
disability (Sept
2009). 48% of
workforce has
responded to
ethnicity
monitoring
question. No
peer support
networks
November
2012
Staff workshop
20 October
2009
25
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
LGBT staff.
currently exist.
6.2 NHS Lothian
employs and trains
a more diverse
range of people
(b) Promote and
implement staff
survey
Director of
Human
Resources &
Organisational
Development
Rate of return,
broken down by
division/
department.
Detailed
breakdown
possible across
many
measures.
26% overall
January 2011
response in
2008, with
significant
variation across
divisions
None
(c) Support
ongoing work to
develop capacity
of trade unions to
assist and advise
diverse range of
staff
Head of Equality
& Diversity
To be
discussed
To be
discussed
To be
discussed
Staff workshop
20 October
2009
(a) Implement
recruitment &
selection section
of NHS Lothian
Human Resources
Strategy, including
promotion of
health care
careers to underrepresented
groups in Lothian
Director of
Human
Resources &
Organisational
Development
Wide range of
recruitment and
selection data
available,
including data
on disability
and impairment
type obtained
during
recruitment
process.
155 staff or
0.5% of NHS
Lothian
workforce have
disclosed a
disability.
November
2011
Disability
Equality
Steering Group
10 July, 9
September
2009.
Staff side
535 staff or
4.85% of those
who gave
ethnicity
information are
of a non-white
ethnic origin.
Involvement
event 5 August
2009
79% of the
NHS Lothian
workforce (or
26
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
23,041 staff)
are female
(September
2009).
(b) Implement
Healthcare
Academy, work
placement
sections of NHS
Lothian Human
Resources
Strategy.
Director of
Human
Resources &
Organisational
Development
(c) Implement
Lothian Learning
Plan
Associate
Director of
Training &
Workforce
Development
Wide range of
data obtained
during training
and placement
allocation,
including data
on disability
and impairment
type
85 graduates of November
Healthcare
2011
Academy
during 2009-10.
Awaiting data
on work
placements
Disability
Equality
Steering Group
10 July, 9
September
2009.
Some course
participant data
obtained.
Actions in
Lothian
Learning Plan
to improve data
collection
No current
baseline
Disability
Equality
Steering Group
10 July, 13
August, 9
September
2009.
June 2013
Involvement
event 5 August
2009
Learning
Disability
workshop 22
July 2009.
Involvement
events 5
August & 14
December
2009
Staff workshop
20 October
2009
27
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
(d) Improve levels Associate
Number of staff 155 staff or
June 2011
of staff diversity
Director of Pay
disclosing a
0.5% of NHS
monitoring,
& Workforce
diversity
Lothian
including through
Modernisation
characteristic.
workforce have
Occupational
Number of staff disclosed a
Associate
Health Service
assessed and
disability.
Director of
supported
by
Occupational
535 staff or
Health Services Occupational
4.85% of those
Health Service. who gave
Staff workshop
20 October
2009
ethnicity
information are
of a non-white
ethnic origin.
79% of the
NHS Lothian
workforce (or
23,041 staff)
are female.
Men are
concentrated in
the lowest and
highest grades
(September
2009).
(e) Improve
support for
disabled student
nurses, midwives
and Associated
Health
Professionals
while they undergo
training
Associate
Director of
Occupational
Health Services
Edinburgh
Napier
University
Student Support
Edinburgh
Napier
University
monitoring of
disabled
students
Awaiting data
June 2012
Consultation
response 6
May 2010
28
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
placements with
Services
NHS Lothian
6.3 Employees of
NHS Lothian
report less
harassment on the
grounds of age,
disability, gender,
race, religion,
sexual orientation,
and socioeconomic
background, and
are happier and
more fulfilled in
their employment
(a) Implement
Dignity at Work
section of NHS
Lothian Human
Resources
Strategy – see
action 6.1(a). To
include Human
Rights awareness
and awareness of
cognitive
impairments such
as dyslexia
See action
6.1(a)
See action
6.1(a)
See action
6.1(a)
See action
6.1(a)
Staff workshop
20 October
2009
(b) Review
application of
capability
procedure and
redeployment
policy to improve
advice & support
for line managers
of disabled staff
Director of
Human
Resources &
Organisational
Development
Number of
disabled staff
undergoing
capability
proceedings
and
redeployment
To be
determined
during 2010
June 2012
Staff workshop
20 October
2009
(c) Raise
awareness of
equality & Human
Rights issues
among HR
departments
including
Occupational
Health Service,
Employee
Head of Equality
& Diversity
Training and
briefing
sessions
undertaken.
Evaluation of
these.
No current
baseline
June 2013
Staff workshop
20 October
2009
Equality &
Human Rights
Steering Group
18 February
2010
Consultation
response 11
March 2010
29
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
Relations.
6.4 A diverse
range of people
are more visible in
senior and
management roles
within NHS Lothian
(d) Review DATIX
incident recording
through Quality
Improvement
Teams
QITs
Range of
indicators
including race,
sexual
incidents. See
also 3.7(c)
above
Awaiting
baselines. See
also 3.7(c)
above
June 2012
See 3.7(c)
above
(e) Implement
lesbian, gay,
bisexual and
transgender
recommendations
from Stonewall
Workplace
Equality Index
plans
Associate
Director of Pay
& Workforce
Modernisation
Annual
Workplace
Equality Index
reporting
NHS Lothian
placed at 272
out of 330
employers in
the UK Index in
2009 (76
points)
June 2013
None
(a) Implement
Diversity Delivers
for Board
members (Office
for the
Commissioner for
Public
Appointments in
Scotland strategy,
2009)
Head of Equality
& Diversity
Diversity
monitoring of
Board
members
No current
baseline
June 2013
Disability
Equality
Steering Group
10 July 2009
(b) Continue Black
& Minority Ethnic
Mentoring
Scheme, develop
to include staff
with other
Associate
Director of
Training &
Workforce
Development
Detailed
participant
data, for both
mentors and
mentees
25 participants
in total
(including
mentors) as of
May 2010.
Evaluation of
June 2011
None
Equality Leads
30
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
characteristics
Year 1 very
positive.
6.5 Employees of
funded and
contracted
services receive
fair pay and have
non-discriminatory
terms and
conditions of
employment
(a) Revise
standard contract
and Service Level
Agreement to
include reference
to these. Carry out
audit of key
contractors and
funded services.
Contracting and
procurement
teams
Audit of key
contractors and
funded
organisations
Baseline to be
determined by
audit
June 2012
Involvement
event 14
December
2009
31
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
7. The right to enjoy individual, family and social life
For example, being able to:
 develop as a person
 formulate and pursue goals and objectives for yourself
 develop and maintain self-respect, self-esteem and self-confidence
 have a private life, including protection of personal data
 access emotional support
 form intimate relationships, friendships and a family
 be free in matters of reproduction
 enjoy special support during pregnancy and maternity, and during childhood and the transition to adulthood
Human Rights references: Article 8 – the Right for Respect for Private and Family Life
Article 12 – the Right to Marry and Found a Family
Outcome
Actions to achieve
this
Department or
person
responsible
How progress
is to be
measured
Baseline
Timescale
Link to
involvement
7.1 People in long
term care are
more able to
manage the
services they
receive
(a) Implement the
NHS Lothian Long
Term Conditions
framework.
CHP reports
through Quality
Improvement
Teams
Range of
monitoring
processes in
the Framework
To be
determined
June 2012
Involvement
event 5 August
2009
7.2 Counselling
and emotional
support for people
receiving health
services is
developed to
ensure that
(a) Implement priority
action of Lothian
Advocacy Plan to
extend availability of
advocacy to people
with Physical and
Complex Disabilities
Lothian
Independent
Advocacy
Steering Group
There is
currently no
independent
advocacy
specifically
available to
people with
June 2011
Midlothian
workshop 15
June 2009
Monitoring of
units,
outcomes and
expenditure of
Edinburgh Joint advocacy
provision as
Review of
part of
Advocacy
Involvement
event 5 August
2009
32
patients are not
discriminated
against on the
grounds of age,
disability, gender,
race, religion,
sexual orientation
or socio-economic
background.
7.3 Fewer adults
receive health
care in mixed-sex
wards
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
services
Edinburgh
physical and
review of
complex
advocacy
disability
services
across Lothian.
Equality
monitoring of
service users
as part of the
contract
review.
(b) Deliver and
monitor Deaf
Counselling Service
Strategic
Development
Group, Mental
Health
Monitoring of
units,
outcomes and
expenditure
(c) Link Black &
Minority Ethnic
people in to relevant
community supports
in the BME and wider
communities
MEHIS
(a) Research extent
of mixed-gender
wards on NHS
Lothian sites
Nurse Director
To be
determined
during 2010
Dec 2010
Disability
equality
involvement
event 5 August
2009
Monitoring of
Awaiting data
service outputs
June 2011
None
Number of
mixed sex
wards
June 2011
Equality &
Human Rights
workshop 13
October 2009
No baseline
available as of
March 2010
Involvement
event 14
December
2009
7.4 Same-sex
couples and
parents from
(a) Implement
awareness training
for staff in maternity
See action
3.1(a) above
See action
3.1(a) above
See action
3.1(a) above
See action
3.1(a) above
Equality &
Human Rights
workshop 13
33
different cultures
have more
positive patient
experiences from
maternity services
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
and related services,
as set out in equality
training framework
October 2009
Involvement
event 14
December
2009
34
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
8. The right to participate in decision-making, have a voice and influence
For example, being able to:
 participate in decision-making, including in one’s own care, health or employment
 participate in the formulation of government and NHS policy, locally and nationally
 participate in non-governmental organisations concerned with public and political life
 assemble peacefully with others
 participate in the local community
 form and join civil organisations and solidarity groups, including trade unions
Human Rights reference: Article 10 – the Right to Freedom of Expression
Article 11 – Freedom of Assembly and Association
Outcome
Actions to achieve
this
Department or
person
responsible
How progress
is to be
measured
Baseline
Timescale
Link to
involvement
8.1 People are
more involved in
decision making
about health
services and
policies, regardless
of age, disability,
gender, race,
religion, sexual
orientation or
socio-economic
background.
See actions 4.1(a)
and 4.1(b)
See actions
4.1(a) and
4.1(b)
See actions
4.1(a) and
4.1(b)
See actions
4.1(a) and
4.1(b)
See actions
4.1(a) and
4.1(b)
Involvement
event 14
December 2009
Learning
disability user
group 17
February 2010
(a) Involve
representatives
with a learning
disability on the
Learning Disability
Partnership Board
Lothian
Learning
Disability
Partnership
Board
Monitoring
membership of
Partnership
Board
Awaiting data
June 2010
Disability
Equality
Steering Group
meeting 10 July
2009
Involvement
event 5 August
2009
35
8.2 People find it
easier to
participate in
decision making
about their own
health or care
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
(a) Develop and
See action
See action
See action
See action
implement existing 3.1(a)
3.1(a)
3.1(a)
3.1(a)
training framework
for all NHS Lothian
staff
Disability
Equality
Steering Group
10 July 2009
Learning
disability
workshop 22
July 2009 &
user group 17
February 2010
Involvement
events 5
August & 14
December 2009
(b) Implement
National Patient
Experience
programme and
improvement plans
arising from this
Nurse Director
Associate
Nurse Director,
Strategic
Development
Chief Nurses
To be
determined
when
programme
finalised
To be
determined
when
programme
finalised
To be
determined
when
programme
finalised
Disability
Equality
Steering Group
10 July 2009
Learning
disability
workshop 22
July 2009
Involvement
events 5
August & 14
December 2009
36
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
9. The right of being and expressing yourself, being heard, and having self-respect
For example, being able to:
 have freedom of conscience, belief and religion
 have freedom of cultural identity
 have freedom of expression (so long as it doesn’t cause significant harm to others)
 communicate, including using ICT, and use your own language
 engage in cultural practices, in community with other members of your chosen group or groups (so long as it doesn’t cause
harm to others)
 live without fear of humiliation, harassment, or identity-based abuse
 be confident that you will be treated with dignity and respect
Human Rights references: Article 5 – the Right to Liberty and Security
Article 9 – Freedom of Conscience, Thought and Religion
Article 10 – the Right to Freedom of Expression
Article 11 – Freedom of Assembly and Association
Outcome
Actions to achieve
this
Department or
person
responsible
How progress
is to be
measured
Baseline
Timescale
Link to
involvement
9.1 NHS Lothian
staff report less
harassment and
bullying in the
workplace
(a) Implement
Dignity at Work
section of NHS
Lothian Human
Resources
Strategy – see
action 6.1(a)
See action
6.1(a)
See action
6.1(a)
See action
6.1(a)
See action
6.1(a)
See action
6.1(a)
9.2 NHS Lothian
receives fewer
complaints from
patients about staff
(a) Develop and
implement training
framework for all
NHS Lothian staff
See action
3.1(a)
See action
3.1(a)
See action
3.1(a)
See action
3.1(a)
37
discrimination
9.3 People who
have impairments
affecting their
communication,
have literacy
difficulties or who
do not speak
English as a first
language find it
easier to
communicate with
NHS staff
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
(b) Modernise
Nurse Director
Wide range of
Awaiting data,
June 2013
complaints
indicators
expected by
process to improve
include
April 2010.
accessibility and
numbers of
introduce
complaints in
monitoring
different
categories, plus
incomplete
monitoring of
complainant
and outcome.
Involvement
event 14
December 2009
(a) Develop and
implement training
framework for all
NHS Lothian staff,
to include effective
communication
including working
with interpreters
See action
3.1(a)
See action
3.1(a)
See action
3.1(a)
See action
3.1(a)
Involvement
event 14
December 2009
(b) Revise
Independent
Advocacy Strategy
Deputy
Director,
Strategic
Planning
Wide range of
monitoring built
into Strategy
Awaiting data
June 2011
Midlothian
workshop 15
June 2009
Involvement
event 5 August
2009
Lothian Minority
Ethnic Health
Forum 10
December 2009
(c) Promote
Interpreting,
Translation &
Communication
Equality leads
Service leads
Wide range of
data gathered:
see action
3.4(a)
See action
3.4(a)
See action
3.4(a)
Equality &
Human Rights
Workshop 13
October 2009
38
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
Support Procedure
widely across NHS
Lothian services
9.4 People are
able to follow their
religious & faith
practices on NHS
Lothian sites
9.5 Patients,
carers, family
members and
other people who
visit or use NHS
services report
Involvement
event 14
December 2009
(d) Speech &
Language Therapy
staff to give advice
on creating
inclusive
communication
environments
Head of
Speech &
Language
Therapy
Better
Communication
Better Care
pilot outcomes
Awaiting data
June 2013
(a) Support EQIA
of next revision of
Spiritual Care
Operational
Strategy, and
include
development of
diversity
monitoring in
strategy
Head of
Spiritual Care
Completion of
EQIA
Not yet
completed
(March 2010)
December 2010 Involvement
event 14
December 2009
(b) Develop and
See action
implement training 3.1(a)
framework for NHS
Lothian spiritual
care staff and
others delivering
spiritual care
See action
3.1(a)
See action
3.1(a)
See action
3.1(a)
None
(a) Promote
positive attitudes
to age, disability,
gender, race,
religion, sexual
orientation and
See actions
3.1(a) and
3.2(a)
See actions
3.1(a) and
3.2(a)
See actions
3.1(a) and
3.2(a)
Involvement
events 5
August & 14
December 2009
See actions
3.1(a) and
3.2(a)
62% of
Transgender
people in a
None
Research:
Transgender
39
less harassment
on the grounds of
an equality
characteristic, from
staff and from
other people.
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
transgender
Scotland-wide
equality through
study in 2007
the NHS
had suffered
Communications
harassment
Strategy and staff
and/or abuse
training
because of their
Trans status
Experiences in
Scotland
(Scottish
Transgender
Alliance, March
2008)
40
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
10. The right of knowing you will be protected and treated fairly by the law
For example, being able to:
 know you will be treated with equality and non-discrimination before the law
 be secure that the law will protect you from intolerant behaviour
 have the right to a fair trial
 access information and advocacy as necessary
 own property and financial products including insurance, social security, and pensions in your own right
 know your privacy will be respected and personal data protected
Human Rights references: Article 6 – the Right to a Fair Trial
Article 8 – the Right to Respect for Private and Family Life
Article 1 of the First Protocol – Protection of Property
Outcome
Actions to achieve
this
Department or
person
responsible
How progress is Baseline
to be measured
Timescale
Link to
involvement
10.1 People find it
easier to pursue
complaints against
NHS Lothian,
regardless of age,
disability, gender,
race, religion,
sexual orientation
or socio-economic
background
(a) Implement plan
to modernise
complaints
processes – see
also action 9.2(b)
Nurse Director
Diversity
monitoring of
complainants to
be collected
more
consistently.
Labelling of
complaints as
linked to
diversity
characteristics
to be
developed. See
action 9.2(b)
June 2013
Disability
Equality
Steering Group
9 September
2009
Awaiting data
Learning
disability
workshop, 22
July 2009
Involvement
event 5 August
2009
41
NHS Lothian Equality & Human Rights Scheme 2010-13 Action Plan
10.2 Boys and girls (a) Review Link
Equality Lead
Surveys of
Survey
June 2011
as children and
Worker
for UHD
children and
currently in
young people find
programme
young people
progress
Patient Focus
it easier to access
Public
services and
Involvement
information
leads
Involvement
event 14
December 2009
10.3 Patients, their
carers and families
are more aware of
their rights and
responsibilities
(a) Greater
presence of
Citizens Advice
Bureau services
on main hospital
sites
Associate
Nurse Director
(Strategic
Development)
Number of
enquiries dealt
with by CAB
advisers at
Patient
Information
Centres
Awaiting
baseline for
2009/10
June 2012
Involvement
event 14
December 2009
10.4 Carers are
more aware of
services and
entitlements open
to them
(a) Implement
Associate
Carer’s Information Nurse Director,
Strategy
Strategic
Development
Monitoring
processes built
into the
Strategy
See Strategy
June 2012
None
42