EQUALITY AND DIVERSITY STRATEGY ANNUAL REPORT OF ACTIVITY 2008 July 2008 NHS LOTHIAN Summarised annual report of progress on Equality and Diversity 2007-08 Introduction The Equality and Diversity Strategy was completed in June 2007 setting out the proposed actions required across equality strands. This work complemented and extended the work identified in Equality Schemes for Race, Disability and Gender and set out the direction of travel to achieve outcomes up to 2010 across all equality strands. Progress is reported across the five headings identified in Checking for Change, a building blocks approach to performance monitor progress against targets. This approach is not yet available across all equality strands levels but the headings provide a valid structure for reviewing progress. The purpose of the report is to provide an annual review of progress across the five headings of energising the organisation and leadership; demographics; access to services and information; human resources and training and community involvement. It will also help to inform the development of a Single Equality Scheme in 2009. Energising the Organisation The Director of Human Resources and Organisational Development (HR and OD) has delegated responsibility for the Equality and Diversity agenda. A steering group was formed, chaired by a Non-Executive Director, Teresa Douglas, to lead, monitor and review progress across equality strands. Three Lead Managers are identified across NHS Lothian working across equality strands to progress work both strategically and operationally and have support from leads in Human Resources and Organisational Development. Progress is reported back to the Healthcare Governance and Risk Management Committees, Spiritual Care and Staff Governance. Strong networks of public sector and voluntary sector organisations have been established e.g. Lothian and Borders Equality Practitioners Group, Edinburgh Equality Forums with joint partners and links with Public Partnership Forums, Patient Forums/Councils and the Lothian Minority Ethnic Health Forum. The Joint Health Improvement Plan was consulted on jointly with Edinburgh Equality Forum representatives and members of the Edinburgh Public Partnership Forums. This links well with Patient Focus and Public Involvement (PFPI) activities and provides an example of community involvement both geographic and from communities of interest within NHS developments. The implementation of NHS Knowledge and Skills Framework (KSF) will ensure that within the next eighteen months 95% of staff will have completed Equality and Diversity training, a core competence through five e-learning modules which will be extended to seven by the autumn. There is a requirement to Rapid Impact Assess (RIA/EQIA) any paper going to the Board or CHP Management groups prior to presentation. A steering group reporting to the Equality and Diversity Steering Group has been established to quality assure the process across equality strands and monitor compliance. Following initial assessment of progress, findings demonstrated that further work was required to achieve this. To complement this RIA, guidance and training have been developed. In the year 115 staff have attended the training and implementation of the revised guidance is improving the quality of impact assessments. 1 Priority areas requiring further development: The Head of Equality and Diversity post reporting to the Director of HR and OD is welcomed and will strengthen strategic and leadership functions once appointed. The revised Human Resources Strategy for the period 2008-2012 will provide additional support to ensure the NHS values and behavioural objectives are met and support the requirements of the Human Rights Act (1998). State of preparedness : GREEN Demographics NHS Lothian is contributing to national projects on data collection including the second national retro-coding project. Work on diabetes which had a 98% take up of ethnic coding provides a model of good practice and reflects the importance of data collection across equality strands. There has also been improvement in data collection in the Royal Hospital for Sick Children and Mental Health services but there are still gaps in progress. A pilot project to improve data collection in primary care is in development and is linked to a national initiative at Information Services Division. Areas requiring further development: Developing systems to increase data collection across all equality strands will be helped by the introduction of a national DVD in the autumn, developed with the support of NHS Lothian staff. Effective data collection systems will not only provide an evidence base for current use of services but will provide evidence to direct future interventions to address inequalities in health. This will be a key priority for work in 2008-11. A mandatory requirement to develop appropriate systems in Lothian and responsibility to be placed on all staff to record patient and staff data would be welcomed. State of preparedness : RED for patient profiling, AMBER for staff profiling Access to Services and Information Equity of access to information and services provided by NHS Lothian is being supported by the Patient Information Framework to ensure provision of information in different formats to facilitate public understanding. Much work continues to be achieved in this area. This links to work on the Patient Experience and Involving People strategy and ensures that patients from communities of interest have access to feedback mechanisms including comments, suggestions and complaints. The Minority Ethnic Health Inclusion Service continues to bridge ethnic minority communities in to services in primary care and mental health. Uptake of interpreting services is increasing annually and this work is supported by the review of the Interpreting service and development of the Interpreting and Translation Service (ITS) policy and guidance currently in draft and going out for consultation. All NHS Lothian procurement requires evidence of compliance with Equality and Diversity legislation as third parties and this is also being evidenced in revised Service Level Agreements. Where contracts are developed nationally NHS National Services Scotland is working on increasing compliance with requirements for evidence to support practice. NHS Lothian works to meet the legislative requirements of the Equality Schemes and these are reported separately and annually. 2 Areas requiring further development Improvements in data collection and analysis across equality strands will contribute to work on improving the patient experience of health care. Gaps in information need to be considered in terms of what needs to be provided nationally and what is required locally in terms of efficiencies. Further work on improving access to advocacy services across equality strands will be developed in the Lothian Advocacy Plan which is currently in the consultation stage. State of preparedness: AMBER / GREEN Human Resources NHS Lothian has a range of family friendly policies and will shortly be in a position to monitor the uptake of these policies across the equality strands. Considerable progress is being made in awareness training on equality and diversity issues through the development of e-learning modules and in the Management in Practice development modules. The roll out of KSF core competencies will make a significant impact on the competence of staff in this area and will link training requirements to personal development plans. A project is currently being established to provide mentoring opportunities to minority ethnic staff to increase opportunities for Black and Minority Ethnic staff at all levels of the organisation. This work builds on the introduction of Confidential Contacts as part of our Dignity at Work Policy who can support all staff who may have experienced discrimination or harassment. Areas requiring further development A fixed-term appointment within the Human Resource team has been made to assist in improving the recording of staff data across equality strands and will monitor this to provide information on and for the workforce. Similarly work will be developed in implementing the Equal Pay Policy as part of the revised Human Resources strategy. More specialised training is required to increase the capacity of the training department, front-line staff and team managers to improve the patient experience where enhanced knowledge is required. A bid for additional funding for this is to be submitted. State of preparedness: AMBER / GREEN Community Development Community groups and representatives are increasingly involved in NHS Lothian initiatives supported by the Involving People and Improving Patients Experience Framework and community engagement standards. These have enabled diverse groups to be involved in strategy development and service reviews as well as membership of forums and consultations. Opportunities are well established for joint work with other local partner agencies on shared issues. Best practice is shared with partners in the Lothian and Borders Equality Practitioners Group and NHS Health Scotland’s Equalities and Planning Directorate’s Lead Network. Examples also exist of good practice in local areas between voluntary sector and public sector partners and members of local communities. Areas requiring further development Building closer links with Joint Equality Forums, Public Partnership Forums and Patients Forums/Councils will enable increased involvement and reflect the views of our diverse population. A current example is the joint consultation on the Joint Health Improvement Plan in Edinburgh’s CHP. State of preparedness: GREEN 3 Conclusion Steady progress is being maintained across all areas of practice complemented by the uptake of training on equality and diversity issues linked to induction training, NHS Knowledge and Skills Framework (KSF) competencies and the implementation of Rapid Impact Assessment / Equality Impact Assessment (RIA/EQIA). Further practical skills training, rather than awareness training, for key groups and trainers is essential to increase the capacity of the organisation to improve the patients’ experience. A key priority is to improve systems for data recording and analysis across patient and staff information to provide a baseline to measure progress against and identify inequalities in health outcomes and employment experience. This is essential to support current developments to improve the patient experience and ensure equality in employment. The strategy would be complemented by a Single Equality Scheme drawing together the general and specific duties related to race, gender and disability with the additional duties anticipated under the Equalities Bill. Areas of inequality not covered by the six equality strands are being addressed in impact assessments. This helps to ensure that all population groups are considered in terms of positive and negative impacts on equality in all aspects of NHS Lothian’s performance. Further work is needed in identifying SMART outcomes which reflect national performance targets including HEAT, and Single Outcome Agreements. The areas requiring further development as outlined and the need to focus work on achieving the national performance measures are key milestones towards ensuring equity of access to health and employment. This will help to set the agenda for 2008-11 to improve the health and well being of our diverse population in Lothian. NHS Lothian as a service provider, contractor and employer has a civic duty to tackle discrimination and harassment, promote equality of opportunity and good relations in Lothian. Through all areas of its direct and partnership working it is aiming to become an exemplar employer and service provider. A Traffic Light system has been used to assess NHS Lothian’s preparedness to address equality and diversity issues. RED signifies priority issue to be addressed, AMBER that work is in progress but has some way to go and GREEN that work is either in progress or ready to start. 4 12.1 Energising the Organisation In this section NHS Lothian has described the actions needed to change organisational culture and make it more conducive to realising equality and diversity outcomes. OBJECTIVE KEY ACTIONS TO ACHIEVE OBJECTIVE As a Board, seek to lead the equality and diversity agenda both within NHS Lothian and in the wider community Position NHS Lothian as a leader and influencer of good practice in relation to equality and diversity. NHS managers at all levels within the organisation need to promote equality and diversity in their day to day work within their area of responsibility. TIME SCALE PROGRESS Ongoing Steering group established with agreed action plan. Actively seek out, at all levels of the organisation, opportunities to develop partnerships with a broad range of other organisations and groups who share our aim to outlaw discrimination. Ongoing All Executive Directors and Senior Managers receive training on equality and diversity. 2007 Delivery and progress against the equality and diversity agenda incorporated into all senior managers’ individual performance objectives. 2008-9 Strong networks of public and voluntary sector e.g. joint work through Lothian and Borders Equality Practitioners Group, local joint equality networks and Public Partnership Forums, Patient Forums/Councils with evidence of involvement. All Exec and Non-Exec Directors completed training. Equality and Diversity KSF core competencies for all staff focuses on developing a culture which supports and promotes equality and values diversity in NHS L. Progress on Checking for Change available for Race Equality. Performance needs to be measured against agreed actions through the Checking for Change performance indicators. 5 NAMED PERSON Director of HR and OD Ongoing To ensure that all services, new and revised policies and functions take account of the six equality and diversity strands and the needs of marginalised communities. All new or revised Board, Community Health (Care) Partnerships (CH(C)P) and Divisional policies are assessed for relevance and if required are Equality Impact Assessed (EQIA) prior to agreement. Establish a structured approach to address the equality and diversity agenda, ensuring all activity is co-ordinated at a senior level. Ensure each strand of the diversity agenda has a Director lead and lead managers to lead, monitor and report on progress with all strands of diversity. Ensure continued relevant community involvement in developing plans and services through Equality and Diversity and Patient Focus Public Involvement leads. Develop and implement a costed action plan to support priorities as required. Implement Checking for Change to monitor each of the equality and diversity strands, to ensure progress is being made in integrating the agenda into our service delivery. Functions and policies deemed priorities will be reviewed and updated during the period and be monitored after six months for unanticipated adverse impacts. Strategic Programme Managers and Lead Equality Managers Director of HR and OD 2007-8 (ongoing 12 months (ongoing) 12 months 12 months (ongoing) Review all objectives to improve performance and link with HEAT, SCS and Better Health, Better Care, PAF. 12 months Establish an equality scheme for each of the strands as required by legislation or an annual action plan, detailing specific actions to be undertaken. Produce quarterly update reports for the Equality and Diversity Steering Group and other local equality and health forums as required. Report annually on progress to the NHS Lothian Board, other equality and health forums and statutory bodies. Build an evidence base to demonstrate change in service provision and employment. Monitor performance across the equality and diversity 2007 6 Equality Impact Assessment steering group will quality assure RIAs/EQIAs and report annually. 12 months (ongoing) 3 – 5 years Ongoing Ongoing Executive Director appointed with overall lead and Head of Equality And Diversity post funded from mid 2008. Systems in place and evidence of outcomes reported through Clinical Governance and Risk Management Committees and Staff Governance. Priority for Steering group, with work to be progressed to identify SMART outcomes Completed -E and D strategy and all Schemes have action plans. Quarterly progress reporting agreed May 2008 Annual reports will have been completed by June 2008 (see demographics 3.2) awaiting national agreement on data collection across of all strands. Checking for strands through Checking for Change. Monitor patient experience in the appropriateness of communications. Propose moving to a multi equality scheme and joint action plan. 7 R Walters/S Sinclair/Jim Robinson Change will be developed in partnership with the Equalities and Planning Directorate, NHS Health Scotland. Audit complaints and patient surveys. 12.2 Demographics In this section NHS Lothian has described the actions needed to progress equality and diversity monitoring. OBJECTIVE KEY ACTIONS TO ACHIEVE OBJECTIVE NAMED PERSON Establish baseline data of the service user Director of population for each strand of diversity. Clinical Information Monitor and report changes in population and service user profile. Use data to identify gaps in uptake of services in priority health areas and for equality and diversity monitoring to ensure health needs are integrated into the Monitor uptake of health services across strands, planning of local services. identify gaps and recommend appropriate action and outcomes Develop patient profiling work across all strands of diversity. TIME SCALE PROGRESS 12 months – 3 years Propose make mandatory requirement to collect data across equality strands*. Need to improve access to data on local profiles Need to implement improved systems for data gathering across strands as priority Roll out in progress but not yet in all areas. Ongoing 12 months – 3 years Roll out the new electronic patient record system (Trakhealth) across NHS Lothian. 12 months – 3 years Undertake further development work with Trakhealth to allow information on all strands of diversity to be easily accessed and crossreferenced in order to audit the uptake of services by diversity groups. 3 – 5 years * Progress dependent on mandatory requirement 12 months – 3 years Training DVD developed with other NHS Boards and Equality and Planning Directorate. Supporting training manual in development. Ensure data in health records and referrals is inputted into Trakhealth fields Provide training and development opportunities for all relevant staff to support this work. 8 12.3 Access and Service Delivery In this section NHS Lothian has outlined activity that will be undertaken to mainstream equality and diversity and improve patient experience and confidence. OBJECTIVE KEY ACTIONS TO ACHIEVE OBJECTIVE To provide equity of public access to information and services provided by NHS Lothian. Finalise NHS Lothian Communications Strategy and implementation plan. Implement inclusive communication requirements in all relevant policies across NHS Lothian. Provide guidance to establish standards for the provision of information, posters and sign-posting to health facilities. Continue to work with NHS Health Scotland to develop a national programme of health information materials. Signpost staff and service users to accessible evidence based resources. Ensure the provision of appropriate leaflets and information in a range of formats. Identify gaps in provision and develop materials at a Lothian level where necessary. Develop an implementation plan for the harmonising of our existing patient information systems. 9 NAMED PERSON Director of Public Health and Health Policy, Director of Nursing, Director of Communic ations TIME SCALE PROGRESS Mar 09 and ongoing Strategy out for consultation Mar 08 Considered as part of EQIA. NHS L promotes information and uses images which reflect the diversity of the local population. Work in progress on Inclusive Communication and Information Framework through new Directorate partnership. Hospital leaflets, information on complaints, advocacy and carer information all nearing completion. In progress, evaluation of SMILE. Extended hours for GP practices are currently being considered to increase accessibility. To ensure all NHS Lothian facilities reflect and meet the needs of the diversity in the local population. All NHS Lothian Patient Focus, Public Involvement (PFPI) activity meets the needs of our diverse population Ensure that all facilities meet the obligations under legislation in relation to equality and diversity including race, disability and gender, wider Fair for All strands and other disadvantaged groups Ensure all patient feedback mechanisms are accessible to all and promoted throughout our diverse communities. Implement and monitor the Involvement of Patients and Improving the Patients’ Experience Framework activity including feedback, complaints, engagement processes, advocacy and volunteering to ensure diverse representation. Ensure information from our PFPI mechanisms influence the planning, design and delivery of health promotion and healthcare. Ensure issues relating to diversity and equality are addressed in all quality improvement programmes and in the clinical governance agenda. 10 March 09 Director of Nursing RES, DES and GES in place underpinned by the Equality and Diversity action plans which will be harmonised by Dec 09. March 09 and Monitored through PFPI. ongoing Scottish Patient Experience Programme to be implemented. Involving People Framework is in progress and nearing completion as are the volunteering, advocacy and carers information strategies. The Quality Improvement Teams established across NHS Lothian provide a systematic approach to quality improvement. Better Health, Better Care Action Plan will provide a further focus on measurable outcomes and will be enhanced by improvements in data collection across equality strands. The Patients Bill of Rights will provide future direction. Ensure that public and staff have access to interpreters and translated information Establish clear unified system for provision of ITS (Interpreting and Translation Service) support. Ensure public and staff are aware of the need for and availability of ITS Establish a system for monitoring, across all the relevant strands of diversity, existing use and unmet need for interpreting and translation for health and healthcare issues. Work to the national code of good practice, information and training on working with an interpreter and in providing translated information currently in development. Increased awareness of the equality and diversity agenda amongst all service providers including those contracted to provide services to NHS Lothian All procurement and service contracts with NHS Lothian to include within the agreement the requirement to provide evidence of non discriminatory practices within employment and service provision. Monitor all existing contracts to ensure compliance with the relevant legislation associated with equality and diversity and ensure appropriate feedback is received on a regular basis. 11 March 09 Director of Strategic Planning, Head of Procurement NHS Lothian Policy and Procedure for Interpreting and Translation – Annual review meeting the needs of people with limited English proficiency is out for consultation. Regular reporting from ITS service is in place - meetings held between ITS and 12 months NHS Lothian regarding the service level agreement, monitoring processes and quality control. Information and training on working with interpreters is in development 12 months – NHS Lothian Service 3 years Level Agreement (SLA) for non-clinical services require evidence of compliance with antiOngoing discriminatory legislation to be submitted prior to sign off. Section 10 of the SLA focuses on nondiscrimination and states that the Board will request evidence and information on equality groups. The mapping of SLAs is occurring within NHS L and will compliment the current work in local authorities. 12 12.4 Human Resources In this section NHS Lothian has described activity designed to improve workforce representation from the different diversity groups and increase knowledge of the issues among the staff of NHS Lothian. OBJECTIVE Fulfil the Employment Duties set out in equality and diversity legislation. KEY ACTIONS TO ACHIEVE OBJECTIVE Prepare Human Resources components of Equality Schemes as required. Review employment policies, procedures and practices for compliance with legislation. Audit operational implementation of NHS Lothian policies to ensure general compliance. Support employment and improve representation of employees from diverse groups such as disabled people, ethnic minority groups and the older generation. NAMED PERSON Director of HR and OD TIME SCALE 2007 12 months 12 months (ongoing) 13 PROGRESS The Human Resources components of the Equality Schemes and the Equal Pay Statement have been prepared as required. Employment policies are reviewed on an ongoing basis by the HR Policy Group and Lothian Partnership Forum The Equal Opportunities and Race Equality Policies have been in place since 2006 and are linked with the Dignity at Work policy which established a network of confidential contacts to support staff who feel they are subject to bullying, harassment or discrimination. Grievance, disciplinary issues and Dignity at Work investigations are monitored monthly by HR Employee Relations Managers and reported quarterly in Workforce reports. Incidents related to 2008-11 To have an appropriately trained and skilled workforce in equality and diversity issues. Develop and implement training programmes for Executive and Managerial staff and those involved in service planning in equalities awareness, impact assessment and mainstreaming equality and diversity issues. Ensure induction training includes equality and diversity issues, covering all six equality strands. Review mandatory and other training programmes for frontline staff to ensure they include equalities awareness and appropriate workplace behaviours. Monitor attendance at equality and diversity training sessions and take any necessary action to maximise uptake. Link training requirements to Personal Development Plans. Work with communities of interest to monitor quality of training. 14 12 months 12 months ongoing discrimination or harassment are identified through this channel. The HR strategy and action plan is being revised to take account of changes in legislation and practice. Executive and Non Executive Directors have received training in equality and diversity issues and their responsibilities as Board members. Awareness training is currently provided at corporate induction through 5 e-learning modules: Equality and Diversity overview, learning disabilities, Disability Equality, Sexual Orientation/Lesbian Gay, Bisexual and Transgender (LGBT) issues and age discrimination. The new 18month mandatory training programme includes the elearning modules. This is currently applicable to clinical staff. Equality and Diversity awareness workshops are provided year round. Training for Equality and Diversity and Equal Opportunities is part of the Management in Monitor the profile of the NHS Lothian workforce in line with legislative requirements and consider any action required to address inequalities and promote equality. Continue to participate in the SWISS (Scottish Workforce Information System) Equality project and encourage staff to complete the Equality Questionnaire so as to improve the diversity database of staff. Explore different ways of capturing this information including an intranet based site. Produce and publish regular analyses of the workforce in terms of age, disability, ethnicity and gender. Add other equality strands as relevant information becomes available. Utilise the rollout of the standardised HR information system to implement robust reporting on relevant aspects of recruitment, development and retention of staff. Identify any areas of apparent inequality and recommend appropriate action. Ongoing 12 months – 3 years Mar 09 ongoing 15 Practice modular training programme. Rapid Impact Assessment is run monthly. Attendance at Training can be monitored through the Empower HR system. £5,287 completed core induction training on equalities in the year. Quarterly Workforce Reports now include data required under the Race Equality Scheme. Items raised by the Commission for Race Equality in 2007 have been addressed. Workforce profiles required under the Disability and Gender Equality Schemes are currently in development. A project officer has been appointed for a six-month period to support the improvement of workforce monitoring and to increase staff disclosure of equality and diversity information. The NHS Scotland SWISS project has a national database holding information on the whole NHS workforce. NHS Lothian provides data for this and has access to local reports. 12.5 Community Development In this section NHS Lothian has outlined the activities required in relation to consulting with communities and capacity building activity. OBJECTIVE KEY ACTIONS TO ACHIEVE OBJECTIVE Community groups and individuals are able to express views and needs across all the diversity areas. Identify and use the existing representative forums, and where necessary establish and support additional forums to ensure the views of our diverse community are listened to. Establish a range of mechanisms for individuals to present their views on issues related to diversity. Work with our local partner agencies to share best practice on equality and diversity issues and learn with other organisations. Build on the work to date with our partner agencies for addressing the equality and diversity agenda. Involvement of our diverse groups in the planning processes. NHS Lothian planning mechanisms to be reviewed to ensure inclusion from all the relevant diversity groups. Ensure people from the diversity groups are engaged in the Patient Focus, Public Involvement activity. Provide support to engage people in development of strategies and policies in partnership with local authorities, Lothian and Borders Police and the voluntary sector. Involve representatives from equalities groups in scrutinising plans. NAMED PERSON Division and CHP General Managers and Equality Leads TIME SCALE Ongoing 12 months – 3 years Ongoing Ensure continued representation on the Lothian and Borders Equality Practitioners Group. 16 Ongoing 12 months – 3 years PROGRESS Wide range of opportunities available e.g. Lothian Minority Ethnic Health Forum, joint strand specific Forums with public sector partners, Public Involvement Workers, Public Partnership Forums, patient forums. Individual consultations aim to involve wide range of users across strands. Lothian and Borders Equality Practitioners group meets quarterly to share good practice and has recently formalised a link with Scottish Government’s Equality Unit. Representatives from joint equality forums participate in health issues and representatives of voluntary sector agencies. Examples include the Physical Disabilities and Complex Needs strategy and the strategy for Long Term Conditions.