Equality Outcomes– Progress to date (Full)
Long term NHS outcome:
Within NHS Forth Valley, everyone has the best start in life and is able to live longer and healthier lives.
Aligned to Strategic Priority:
vision
NHS Forth Valley Integrated Health Care Strategy – in line with the Scottish Government’s 20:20
EQUALITY OUTCOME 1: LGB &T, Disabled, ethnic minority and people of various ages have a positive experience of services that
are equality informed and are sensitive to their diverse needs and potential impact of discrimination
What we set out to do
1.1 Improved staff awareness on
equality issues, patient needs &
improvement in practice.
Indicators
 Evaluation of training
completed
 1:1 Personal development
sessions conducted on an
annual basis with staff
 Concerns raised from
management team

Progress to date
We have completed a range of methods to improve staff awareness of all
Equality and Diversity, dignity and respect training relevant to individual
protected characteristics via e- learning/face to face training, discussion
workshops etc. Using E&D e-learning saw a significant increase in take up.

Over 3000 staff have completed a range of equality training over the past 2
years to enhance current service provision to our diverse communities and
are sensitive to their personal needs.

The Patient Relations Team have had No Concerns/Complaints raised by
service users in relation to discrimination.

All staff are appraised on Equality and Diversity annually as part of their
Knowledge and Skills Framework (KSF) Core Competency 6 personal
development review.
What difference has been made to date?



Significant uptake of training.
NHS Forth Valley staff are more confident and better informed on equality
and diversity matters and can engage with service users to deliver care
which is person centred.
No significant concerns from managers about staff’s behaviours in relation
to Equality and Diversity that required further input from the Equality
Manager.
Actions 2015-17
Although training is
evaluated at the time of
the session a system is
currently being
developed which will
enable us to contact
participants to identify:
 What they have
achieved in practice
with the information
gained during face
to face training
sessions
 Identify any best
practice, gaps or
further training
needs.
1.2 Campaigns delivered,
service data demonstrates
increased uptake of screening i.e.
Cervical testing of lesbian women
and men’s health and well being
programme
Indicators
 Feedback from , Forth Valley
LGBTI Steering Group, local
LGBTI community groups or
individuals if any
discrimination or difficulties in
accessing services is noted.
(To date there have been no
issues raised)
NHSFV have developed inclusive & targeted preventative healthcare messages
for LGBT services including ’Why NHS ask about sexual orientation’ and
information on screening services including smear testing.
Although we can target women accessing NHS Forth Valley generic services,
much of the work is completed by the Scottish Cervical Call/Recall System.
At present the NHS Health Scotland Lesbian and Bisexual Smear testing
information leaflet only has this information contained within it and is not a core
content of the letter itself. It is proposed that this will be added after the review.
What difference has been made to date?
Through talks with NHS Health Services Scotland they are currently reviewing
current information in patient notification/recall letters to identify if a statement
can be included about the importance of cervical smear for lesbian & bisexual
women.
It may take several years before we are fully aware of the long term outcomes or
benefits of this national and local approach.
Continue discussions
with NHS Health
Scotland and NHS
Forth Valley Health
Promotion Team
Continue to ensure
smear testing is
embedded in Health
Promotion Materials
developed for
community settings.
Conduct online
questionnaire with
LGBT Youth Scotland
during 2015/16
Provision of specific information for Lesbian and Bisexual women will extend
patient choice and awareness to have procedure completed.
Men’s Health Programme is in
place
Indicators
 Report available
 Updates for the Board on
actions and outcomes (6
monthly basis).
 Uptake of service provision
Staff will continue to work to raise the confidence and awareness of Lesbian &
Bisexual women to have this procedure completed.
The Men’s Health Programme is now an integral part of NHS Forth Valley Keep
Well.
The Keep Well health assessment has been developed to recognise gender
influences in health.
Additions to the assessment which have a strong gender element include:
1. Use of Diabetes risk score
2. Screening for Atrial Fibulation
3. Risk of blood born virus

Men continue to present with more health needs; men are much more likely
to be identified as high risk of developing cardiovascular complications.
Work progresses to
understand the gender
influences in health
amongst various
cultural and ethnic
groups.
Some of this can also
be obtained within the
Keep Well project as
identified in Outcome 3d

The men’s health weight management programme continues to provide
successful outcomes for men who attend. Following published research the
programme has influenced both national and international programmes
aimed at addressing men’s weight problems.

Outreach with gypsy travellers in Clackmannanshire is providing useful
transferable learning for other areas and a report will be provided to the
Keep Well steering group in the autumn 2015.
Specific work with a men’s health group re ‘men experiencing mental health
problems’ was carried out in Stirling.


All NHS FV Keep Well staff received training on gender influences on health.
The focus of this training was on how gender affects the health of some of
the specific ethnic groups and other health vulnerable groups that Keep Well
engages with.
What difference has been made to date?
 Equitable uptake between the genders has been maintained mainly due to
the provision of gender specific evening clinics.

Opportunities to increase uptake with men have continued through
partnership work with local authorities. The aim was to increase awareness
on men’s health issues and encourage men to attend for one to one health
assessment. This has been achieved.

The result is that over 200 male council employees working within manual
labour jobs have attended. A similar programme targeting female workers
will commence in 2015.

A weekly clinic has been established to work with homeless men.

Further to staff training, attendees now have an enhanced knowledge of how
gender effects specific ethnic groups and vulnerable groups the project
engages with. This has been evident from the positive feedback from
communities accessing this project.
1.3 Recorded data on LGB &T
and other protected
characteristics to increase
Indicators
Systems in place to allow
information to be pulled to inform
practice.
N.B This is also a Scottish
Ministers key equality theme
for 2013-17
To date we have:
 Processes in place to gather evidence and data about equality and protected
characteristics; ensuring patient confidentiality is secure.
 Patient administration system is currently under local review. As part of this
review Equality and Diversity data collection will be considered.
 Completed training with Medical Records Team June ’13 (50 people).
Guidance developed for supporting staff, letter developed to be sent to
patients.
 Age, gender is routinely recorded however ethnicity field is still not fully
completed. No action taken to date re Sexual Orientation and Religion and
Belief.

Some improvements in recording of Ethnicity we still have work to do to
enhance current data collection regarding religion & belief and Sexual
Orientation.

Information produced in a range of languages to identify why we complete
equality monitoring and just as importantly equality profiling of people. This
should encourage people to understand the benefits of disclosure and the
impact it can have on service development and person centred care.
 All community involvement events completed by Public Partnership Forum
identify profile of the population attending. This information has proved
beneficial to identify groups we may not be fully reaching out to and put
actions in place.
 Work ongoing to enhance data collection is in place to address this issue
Information Services Division Figures
(Feb ’15) Figures re ethnicity data collection
Percentage of discharge episode records (SMR01) with a valid ethnic group:
Quarters ending April 2013 - September 2014
Year
AprJulApril ’13 – Sept ‘14
Jun13
Sep14
All NHS Scotland
79.0%
81.9%
2.9% +
NHS Forth Valley
69.6%
69.3%
0.3% -
From discussion with
local communities and
from the evidence
contained within our
involvement activities
in relation to our
equality outcomes it
has demonstrated:
 peoples lack of
understanding
about the benefits
of the NHS
knowing the
identity of the
diverse
communities that
access our
services
 more importantly
how we use this
information to
inform our EQIA’s
and service
provision
LGBT specific actions
will be completed with
support and advice
from local multi
agency LGBT
Steering group, LGBT
Youth Scotland and
Stonewall
Percentage of new outpatient appointment records (SMR00) with a valid ethnic
group Quarters ending April 2013 - September 2014
Year
Apr-Jun13 JulApril ’13 – Sept ‘14
Sep14
a) Transgender Reassignment
Protocol, Transgender
Employee Protocol and
Transgender etiquette is in
place (short document setting
out guidance to staff on
delivering person centred
care to transgender people)
Indicators
 Protocol in place, guidance
and etiquette in place
 Evaluate any concerns or
complaints during 3 year life
span of publications
All NHS Scotland
67.3%
73.9%
6.6% +
NHS Forth Valley
56.5%
69.7%
13.2%+
Transgender Reassignment Protocol is in place. This has also been supported
with the development of a DRAFT Transgender Employee Protocol and
Guidance.
Transgender Etiquette is in place; Assessed by Scottish Transgender Alliance
as an example of best practice.
What difference has been made to date?
Over the past 5 years people have been supported with their transition process
using existing Transgender Reassignment Protocol; figures low
No complaints of discrimination received by our Patients Relations Team from
Transgender community. One concern was raised via intranet questionnaire
when reviewing progress on equality outcomes 2015. Although did not highlight
where or when this occurred or what form this discrimination took place.
Stonewall Scotland
has offered to provide
support in introducing
Sexual Orientation
Data collection
including information
for service users and
training for staff.



Evaluate impact of
Transgender Staff
Protocol.
Further discussions
and feedback from
Local Transgender
Group and FFA Lay
Advisors
Evaluate through
development of tool
to support outcome
1.1 if awareness
training has made
any changes in
practice or staff
confidence in
working with
Transgender
people.
b) Age appropriate ‘Apps’
available for public usage.
Indicators
Mobile phone resource in place
based on feedback from service
users
NHS Forth Valley web site has been adapted to enable it to be used as an App.
This has been informed by young people and evaluated as a positive action by
them. This was reflected in the recent report completed by Central Scotland
Regional Equality Council whilst reviewing our Equality Progress to date with
community members.
What difference has been made to date?
 NHS Forth Valley service information and health promotion materials are
more accessible to people who use smart phones.

c) Information sheet available in
a range of alternative formats
for download by staff and the
public in top 8 NHS Forth
Valley community languages
informing communities how to
access Pharmacies, GP’s,
Minor Injuries and Emergency
Department.
Indicators
 Systems in place
 Evaluation by
communities
 Information available on
line.
 Copies disseminated to
communities and partner
agencies


Young people are satisfied that their comments have been listened too and
actions put in place to ensure information is provided in their preferred format
Information sheet designed based on feedback from local communities and
Fair for All in place to support communities to make best use of current
services available thereby enhancing direct patient care and preventing
inappropriate use of services.
Information translated into top 8 languages. Public Partners and 3rd sector
agencies and community groups have agreed to disseminate this information
through internal sources. Thereby, people within NHS Forth Valley will be
able to understand which services can meet their needs and generic
information on access. This will be of particular benefit to those people new
to the country and who are unaware of the various types of NHS Service
delivery.
This will support work being completed on inappropriate use of Emergency
Department rather than Minor Injuries Unit.
What difference has been made to date?
Feedback from English as a Second Language attendees was that they were
delighted with the "Know where to go" sheets. People are more confident in
accessing services.
Information may also support local communities including older people etc.
Feedback on resource has been positive during Public Participation events.
We will evaluate this
after one year to identify
if it has further
enhanced people’s
awareness of access to
services and
information to the
diverse communities.
It is difficult to
measure if there has
been a reduction of
inappropriate
attendance at clinics,
A&E by community
groups or a greater
update of NHS24
services due to
patient confidentiality
of need for
consultation. Arrange
for leaflets to be left in
A&E and Minor Injury
areas
Long term NHS outcome 2:
Aligned to Strategic Priority:
vision
EQUALITY OUTCOME 2a:
What we set out to do
2.1a
What we set out to do:
Patients and carers can readily
access services and report
positive experiences
Indicators
 Patient feedback comments,
concerns and complaints
reports which capture
feedback comments and
concerns can generate data if
complaint is in relation to a
Protected Characteristics.
 Action taken as a result of
feedback comments and
complaints is reported
annually
 Results of NHS Forth Valley
inpatient experience Survey
increase
 Results from Patient Opinion
Within NHS Forth Valley everyone has a positive experience of health care.
NHS Forth Valley Integrated Health Care Strategy - in line with the Scottish Government’s 20:20
NHS Forth Valley promotes and delivers on patient centred care and will meet best practice
standards in relation to Equality and Diversity.
Progress to date
Existing mechanisms enhanced to measure the patient experience to reflect
complaints specifically relating to protected characteristics and other support
needs.
Young Carers
Difficulties identified by young carers when accessing NHS Forth Valley Services
(see Mainstreaming Report 5.9.1).

Training DVD for staff completed. Now available ion YouTube and launched
at Person Centred Care event.
http://nhsforthvalley.com/media-item/young-carers-in-forth-valley/

NHS Forth Valley Young Carers card developed by young people to support
access to services and information.
What difference has this made to date? - Training materials has had over 600
hits on You tube.
Evaluation completed by Young Carer & Befriending Project identified:
The introduction of the young carer’s authorisation card and the increase in staff
training regarding the needs of young carers. This has enhanced young carer’s
confidence when accessing health services and speaking with staff.
It gives young carers a mechanism that identifies them as a young carer more
readily, knowing that the staff member will immediately understand. It has
allowed the young carers to have a better understanding of the cared for
person’s condition and ask questions, which reduces frustration and anxiety.
Actions 2015-17
Ongoing review to be
completed during
2015/17
NHS staff are more aware of young carers giving them reassurance that when
they do approach a professional who is supporting their family member they will
be listened to and treated as an equal partner in care.
This work needs to be ongoing, with continued opportunities for input with staff
and opportunities to working in partnership with Local Carer Centres. A
Presentation with the dental staff in December 2014 highlighted this, as many of
their services can support young carers, greater understanding of the project, to
ensure a good understanding and awareness of clients needs.
2.2a
What we set out to do:
Feedback comments, concerns
and complaints from services
users or others which reflects
where possible specific actions
taken to enhance care for people
with protected characteristics
It is proposed that these actions through partnership working will minimise the
likelihood of young carers having negative experiences within health.
Arrangements have been reviewed to encourage feedback comments, concerns
& compliments so that patents have the opportunity to improve service
development and learning within the organisation.
FFA Development Group member highlighted that they felt their BME community
members still experienced discrimination in service delivery & employment. NHS
Forth Valley offered to attend meetings with particular groups experiencing
problems. No uptake of support.
FFA Members now on distribution list for all emails regarding Public Partnership
Forums. Information to be cascaded to communities as well as open invitation to
attend events etc held to identify any changes to service provision or concerns.
Profile of population attending meetings completed.
Patients Rights - Piloting in 5 key areas the new Safeguard System’ that will
support staff to gather comments, concerns, feedback, compliments and
complaints.
The pilot sites have been testing the electronic data collection system for 2
months, about to carry out an evaluation of the pilot; this has been carried out
and will inform us of any changes that may require to be made. There is to be a
meeting with the service leads to discuss the Patients Rights and the role out of
safeguard across the organisation.
We will enhance current
measures in place to
ensure that we can
identify any feedback,
comments concerns
and complaints, which
are specifically relating
to protected
characteristics.
Work to be completed
with BME communities
to ensure they are
aware of how to raise
concerns etc
Equality and Diversity was mainstreamed into the above process.
Research also being completed to identify national and local areas of good
practice.
2.3a
What we set out to do:
NHS Forth Valley involves
consults and offers the
opportunity to inform or monitor
our actions in an equitable way
Indicators
Implementation of young
person’s group.
Action Plan to be developed by
group
Review and develop arrangements for planning, monitoring and evaluating
patient/public engagement to improve effectiveness including develop Young
person’s forum based on evidence from 2013 involvement activities.




Public Partnership Forum (PPF) meetings currently develop an equality
report on the profile of people attending them. This information is used to
inform NHS FV of audience gaps etc. This information has been highlighted
as best practice by the local Scottish Health Council and will inform future
actions.
PFP Coordinator and PPF Elected Representatives, along with Local Office,
Scottish Health Council conducted sessions within Braes High School
September 2013 and several other schools during 2014 to identify access to
NHS services and information.
NHS Forth Valley www.nhsforthvalley.com/about-us/equality-anddiversity/protected-characteristics/age/service users have a range of
methods in which to give comments and raise concerns including the use of
Patient Opinion: www.nhsforthvalley.com/news/2014/forth-valley-patientencouraged-to-give-feedback-online
Due to the limited amount of BME communities attending local NHS
involvement events a programme of meetings and news updates are
regularly disseminated via the Fair for All Community representatives and
Police Lay Advisory Groups to inform them about the any meetings or
community changes/actions thereby ensuring that we give people the
opportunity to discuss with service leads areas of importance to
communities thereby ensuring people are not discriminated against,
advance equality of opportunity and that we foster good relations.
The quarterly PPF Community Involvement events during 2013-15 E&D specific
topics as well as ongoing issues and improvements within NHS both local and
national including: Reshaping Care for Older people; Integration of health and
social care; Update on hospital transport, Primary & secondary interface, What
you can get from your GP and Hate Crime/Incidents. An update was also given
Further to discussions
with some young
people it has been
identified that short
working groups maybe
beneficial for some
topics. However a
virtual forum or
feedback method could
be completed using
social media. This is
being considered for
2015/17
Work continues to be
completed to ensure
that our approach to
engagement reflects the
diversity of all our
communities
during February 2015 on actions to date regarding NHS Forth Valley’s (HNSFV)
Equality outcomes and mainstreaming report.
In total the breakdown of attendees April – June 2013 – January 2015 has
identified the breakdown as follows
Number of forms issued at Events – 933
Number of forms returned completed – 629
Average Age = 73
Disability
Is your activity limited: No = 361 Yes a lot = 83 Yes a little = 182
Prefer not to answer = 3
Conditions that limit activity: Long Term Illness = 240
Physical Disability = 106
Deaf = 48
Blind = 12
Mental Health = 121
Prefer not to answer = 102
Gender Female = 467
Male = 162
Race/Ethnicity
Scottish = 463
English = 97
British = 10
African/Scottish African/British African/Welsh/Irish/Other = 59
Religion, Faith or Belief
Church of Scotland = 412
Roman Catholic = 137 Other = 49
Sexual Orientation
Heterosexual = 554
Prefer not to answer = 10
Other = 65
Results from the evaluation of figures identified that few BME Communities or
people from LGBT Communities attended these meetings.
Despite information being disseminated to numerous local groups the above
reflects that there is limited involvement of people from BME Communities or
younger people. This information was fed back to Fair for All Group, which has
community representation on it. Actions will be taken over the next few months
to enhance work with younger people and to encourage BME Communities to
attend local meetings.
With The support of Fair for All Lay advisors and Central Scotland Regional
Equality Council people are informed through a range of means about meetings
being held as well as updates on actions and activities taking place.
Therefore people who share a protected characteristic will be more directly
involved in the planning and delivery of Forth Valley services.
2.4a
What we set out to do:
Improve Interpretation and
Translation services
demonstrating best use of limited
resources and improved patient 
experience
Indicators
 Enhanced use of Language
Line, reduction in Patients
Do Not Attends (DNA’s) when
interpreter Booked
 Evaluation of service,
consider provision in relation
to financial spend. Review
changes to local population
and health service needs.

What difference has been made to date? - Through our involvement activities
and in the use of patient feedback we are more confident and better informed on
Equality and Diversity matters and will continue to engage with partners and
stakeholders to effect change and improvement.
Review completed on interpreting, translation and communication support
Ongoing review to be
arrangements, for languages other than English, implement development plan
completed during
including processes for booking appropriate interpreters and recording of generic 2015/17
translated materials.
All bookings for Interpretation and Translation are now coordinated via the
Disability Service using a single NHS Forth Valley point of contact. The
Disability Service, receive all calls and allocate the appointment to the
appropriate provider as per the Service Level Agreements, this situation will
remain until tender process completed.
During 2014 a tendering process was undertaken with assistance from
procurement and financial services to provide interpretation and translation
services for languages other than English (not including BSL etc). It is expected
that the award of business will be completed by Spring 2015.
 Better hourly rate, financial savings
 Better reporting mechanisms
 Centralised day/OOH booking system
 Consistency of interpreters provided

 Data of community populations
 Increased training opportunities
 Increased community engagement opportunities
 Smoother invoicing processes
 Language Line usage where appropriate
 Telephone reminder service
 Translation materials to be shared
Having a central booking process has enabled appointments to be discussed,
time allocation considered and geographical layouts highlighted e.g. where an
interpreter already in that area could pick up an appointment rather than
allocating a second interpreter. This system is more financially efficient and
effective in ensuring patient communication needs are delivered. We have
provided staff and patients with the direct number reducing confusion and
allowing support to be provided quickly.
Evaluation report on current
interpreter usage



A design management system has been operational since Sept ’13, reviewed
continuously and improved and adaptations made where appropriate. The
system provides;
 All appointment details, live and stored data
 Demographic profiling
 Did not Attend (DNA) capture and action
 Financial spend and area breakdown
 Services being utilised
 Statistical reporting
Two community engagement/involvement events were undertaken in partnership
with the Central Scotland Regional Equality Council (CSREC) in 2013 followed
by a further three events during 2014. Having contact with our community
members we have a better understanding of their needs and expectations, we
also had the opportunity to increase community knowledge of the impact of Did
Not Attend (DNA) relating to their health. This also highlighted the financial
implications to the wider organisation relating to the management of missed
appointments.
As part of NHS Forth Valleys Community Language redesign, a monthly DNA
report produced and where appropriate patients who DNA are contacted. Some
of the DNA's are results of patient not receiving letters in their own languages,
financial difficulties getting from a – b, childcare and health difficulties. The
initiation of the telephone reminder system has reduced the DNA numbers and
assisted in the rescheduling process where appointments have been unsuitable.
Often patients do not have the resources to call directly to cancel or amend
appointments due to their limited English proficiency.
What difference has this made to date?
Findings to date: In June 2013 NHS Forth Valley had 300 patients utilising
community language interpreters, in January 2015 we now have 1256 patients
registered and using the service on a regular basis. Appointments have
increased from 250 per month to in excess of 550 across the broad spectrum of
health services.


DNA’s from people using community language services:
o 2013 – 2014 = 89 DNA’s captured
o 2014 – January 2015 there were 73 captured
o however there was an appointment rise of over 50% and an increase
of nearly 1000 new service users
NHS Forth Valley staff training “What is an Interpreter” commenced in May 2014
in partnership with CSREC and Forth Valley Language Services.
Generic session held in Sep 2014. Working on a customised programme with
speech and language services, provided increased knowledge of the need for
clear roles and expectations prior to appointments progressing. The need for
language to be child friendly, for flexibility of the appointment space, and
consistency of interpreter provision to support patient journey. For each
appointment allocated, there is now a pre discussion takes place between the
interpreter and the Speech and Language therapist and this has been a positive
outcome.
Since centralisation, feedback has been positive – staff are more confident and
better equipped to understand the booking process. They have increased
options when contacting patients directly or via the booking process. The
centralised booking system enables better client – Interpreter match, more
flexibility with interpreters, as they can be co-ordinated to other appointments
whilst on NHS sites.
Increased usage of the interpretation service, more appointments booked and
completed that the previous year. Financial accountability and governance in
place with data available to each service manager regarding overall spend,
demographics of patients including language, age, gender and area of habitat.
Data collection increased to include contact details of patients; this enables
appointment reminders to be undertaken and any cancellations to be given to
the patient, in their native language, therefore decreasing inconvenience and
avoiding confusion.
Review of Telephone Interpreting Solutions (telephone interpretation) contract
and information regarding how to access to this service has been disseminated
and actions informed by NHS FV staff has been completed.
Annual review undertaken of current cost and usage across NHS Forth Valley.
 New contract agreed and a further reduction to rate will be initiated from
January 2015, making calls 68p per minute.
 Work underway with specific services to better understand and utilise
telephone interpreting. Highlighting the need to contact patients in their own
language when allocating or cancelling appointments.
 Information provided and discussion had with those services that may be
utilising calls inappropriately, for example, calls over 30 minutes would
indicate that perhaps the need for “face to face” interpretation should have
been considered.
 Telephone contact/reminder service will continue to reduce the number of
DNA’s to services.
 Telephone Interpreting calls have increased significantly; all telephone
reminders for languages other than Polish are made this way, (Polish
Interpreter is booked for 1 hour to do those reminders- more timely and cost
efficient) other departments have adopted this system as a way of
reminding/changing appointments. We are able to evidence that this has
reduced face to face, offering a more enhanced overall service provision.
Ongoing review to be
completed during
2015/17
What difference has been made to date?
Although there is increased usage within the interpretation service, financial
accountability measures, reduction in core costs to contractors, as part of the
service level agreements implemented, have enabled this increase in usage to
be addressed and managed.
The evidence collected across 2013 and early 2014 has enabled the tender and
procurement process to be completed, again reducing the financial cost per
individual appointment and ensuring we meet service/patient needs.
A central direct contact point for interpretation booking has created better
relationships and understanding with wider services. Speaking with the same
team has increased the staff confidence to ask questions or phone for advice
regarding what provisions would be most suitable.
The Current text reminder service for Deaf service users mhas already reduced
the number of DNA’s across the organisation.
What difference has been made to date?



What we set out to do
Translated materials in other
languages/health which are
related are available


Continuing the text reminder system for all health appointments has reduced
the number of DNA’s and enabled appointments to be rescheduled where
appropriate
Meetings arranged with particular patients who have shown regular non
attendance to assist them to understand the health implications and also to
explain the best use of our financial resources.
Disability Service has also been able to share information, with the patients
consent, to services on with the patient has not attended. This has resulted
in some areas making an alternative site or different clinic day an option,
therefore enabling the appointment to take place successfully.
In 2013 there was no central point for the collection of translated materials.
At that time the Disability Service has created a database to hold details of
what was available across the organisation.
As part of the tender, we will provide leaflets in translated forms in a more
proactive way and hold a data base of the materials to reduce duplication.
Ongoing review to be
completed during
2015/17
Indicators
Range of materials available


The work considered creating letters in native languages to investigate
consistent “Do Not Attend” service users. After discussion it was agreed to
utilise language line to contact the patient and review the reasons for non
attendance. The finding supported the tender and procurement process and
our Access and Capacity Team have a better understanding of the causes
for failures in attendance.
With the management system, all translation requests are logged on to it.
Patient Identifiable requests are held separately to ensure data protection.
General leaflets, letters and booklets are logged to ensure no duplication of
work - should another request come in for the same work.
What difference has been made to date?
This is beneficial regarding the translation of documents with the Disability
Service holding a central list of documents/publications, which have been
translated and in what specific language this will be available in.
They also provide indicative cost for translation to services prior to any work
being completed, discussing options, for example only having a specific section
of the document translated or booking an interpreter and going over the leaflet
with the client to ensure a better understanding than the printed information
alone.
Review arrangements regarding
translated materials in other
languages, which are
organisationally provided to
communities. e.g. community
briefs or newsletters
Community Language materials are available but have been independently
funded including ‘Know where to turn to when you are ill”
This has made significant difference to people knowing where to and how to
access services.
 Although work continues to meet requests, there is no central budget to
produce generic materials which are not directly linked to a particular
service.
 In 2013/14 Disability Service met the financial cost for translated generic
materials, all other materials are charged back to the requesting service.
Some areas choose not to have information translated due to cost or copy
write issues/delays.
There continues to be no
identified budget
provided for
organisational
community leaflets,
briefs etc. Disability
Service has arranged for
some information to be
cascaded to
Action
Language Line available in
Pharmacies to enhance direct
patient support re minor ailments,
patients to take ownership for
own care and reduce wait and
attendance at GPs

Indicator
% of pharmacies with Language
Line in place
What difference has been made to date?
Identified during our tender and procurement review, some pharmacies
highlighted they did not have the facilities to accommodate calls in private or a
telephone access in the public area. Discussion had also taken place regards
dual handset telephones and the rental costs involved.
Evaluate use of language line by
pharmacy services
Action
Review interpretation, translation
and communication support
arrangements for hard of hearing,
Deaf and Deafblind people are
currently provided as part of a
contractual agreement leading
from the 2011 Tendering and 
Procurement exercise.

Review of current provision within Pharmacies completed re access to
telephone interpreters, translations etc. This work was incorporated with-in
the Interpretation and Translation re-design.
Letter, flow chart and language line pack sent to all pharmacies at the
beginning of July 2014. Targeted work also completed in relation to the
Commonwealth Games and the possible increase of visitors to the area
utilising the services of either face to face or telephone interpreting.
Renewal or re-tender of BSL contract as current agreement was due to come to
an end Feb 2015, however after discussion and some service amendments
provision of British Sign Language, Lip Speaker, Deafblind Guide
Communication and Notetaker will be extended and remain with the current
contractor until December 2015.
We have completed:
Audit of service provision completed December 2013 and November 2014. This
included both service user and NHS staff feedback.
 Small focus groups were undertaken to support service review in December
2013 and again in 2014 alongside a BSL formatted questionnaire.
 The outcome from the 2014 audit informed the new tender and procurement
process.
What difference has been made to date?
The audit information and changes to the local population have required some
amendments to service provision, these have been made.
Increased requirement for Deaf Blind Guide Communication services has been
identified and will be considered during the 2015 Tender and Procurement
process.
communities by utilising
community member links
Ongoing review to be
completed during
2015/17
Ongoing review to be
completed during
2015/17
Action
Reduce costs of patients Do Not
Attends further to interpreter
being booked
As a central booking point where, patients can make direct appointments or
have information / letters adapted quickly and efficiently.
What we did
The current text reminder service for Deaf service users has already reduced the
number of DNA’s across the organisation.
What difference has been made to date?
Continuing the text reminder system for all health appointments has reduced the
number of DNA’s and enabled appointments to be rescheduled where
appropriate.
This service will
continue to be provided
and monitored and
details provided to the
appropriate services
Meetings have been arranged with particular patients who have shown regular
non attendance to assist them to understand the health implications and also to
explain the best use of our financial resources.
Review current Interpreter and
translation flow charts for British
Sign Language and community
languages
Indicator
Report available of actions taken
Enhanced confidence in staff in
arranging an interpreter
The Disability Service has also been able to share information, with the patient’s
consent, to services on why the patient has not attended. This has resulted in
some areas making an alternative site or different clinic day an option, therefore
enabling the appointment to take place successfully.
 New flow chart disseminated to services across NHS Forth Valley with
guidance on how to access interpretation services, translation and
accessible format documents. August 2013 (ongoing).
 Reminder of flow chart sent to Acute service leads January 2014.
 Payslip message sent in May 2014 in regards Interpreter and Translation –
“How to work with Interpreter” training commenced “A Day in the life of an
Interpreter article has been developed and is currently in draft format
awaiting approval and publishing for staff news.
 Information on access to Interpreters is now included on A_Z internet
directory. (May 2014)
 As part of the ongoing work regards the wider Interpretation and Translation
provision (Minority Language), updated flow charts will be distributed as part
of the 2015 tender outcomes.
 Staff informed at Induction training, e-learning, midwifery training, Healthcare
assistant training: on how to access interpreter services.
 Information also available for all staff to download from intranet site.
Ongoing review to be
completed during
2015/17
What difference has been made to date?
 The flow charts have been widely distributed across NHS Forth Valley and to
our contracted services. All new services requesting interpretation for the
first time are provided with the chart and other materials, pocket cards etc, to
support the use of the service.
 The one point of contact has improved the booking process for staff, with
confirmation of the booking provided during the call.
 Reduction in double booking, if contact by another staff member or
administrator from that service; we can confirm appointment details are
already entered.
 Staff more confident in accessing appropriate usage of Interpreter Services.
2.5a
 NHSFV Disability Service supported by e-Health and the Health Records
Robust systems in place to
Teams initiated the requirement of access and communication needs being
identify particular needs incl
recorded on the front page of SCI referral process.
community language and sensory  Where details are provided in the electronic GP referral (SCI gateway)
impairment prior to appointment
specific “access and communication requirement” box Health Records staff
being sent out from NHS FV both
record patients special needs in their system and support transfer of relevant
acute and primary care.
data
 Health Records staff can request alternative formats including documents
Indicators
and appointment letters as and when required by contacting the Disability
 Reduce DNA’s of disabled
Service.
people or BME Communities
 Put in place agreed systems to send appointment details to patients in their
 Total DNA's for NHSFV
preferred formats.
currently at 7.5%
 Text messaging currently being explored for BME Communities as part of
 Reports from TOPAS OP
tendering process.
Appt Booking system (HEAT
Target)
What we did
 DNA’s of people with a
 Training and information sharing meetings carried out across GP teams and
disability currently 6% reduce
at Practice Manager Meetings. These were successful in gaining the practice
to 2% by 2017
point of view and encouraging completion of the “Access and
 Reduced numbers of DNA’s,
Communication” box.
increase to number of
 Ongoing communication with GP Practices. Incidences continue to occur in
appointments rescheduled
regards access information not captured in the box (at referral point) or if it
rather than cancelled
is, then it is not easily transferrable / recorded in secondary care.
 Where information box is completed Disability Service are alerted by
Ongoing review to be
completed during
2015/17



health/medical records then all necessary steps are taken to support the
patient pathway.
On occasions when a person prefers to use a family member rather than the
provision of a guide communicator or interpreter. Work continues to identify
the reasoning for this preference and support staff to manage in these
situations; staff are advised to document the patient’s choice in the
appropriate records and signed by the staff member.
Disability Service receives email from Referral to Treatment Team with any
Access or Communication requests. These requests are progressed as
required e.g. interpreter booked, Braille documents provided, Deafblind
Guide Communication.
Ongoing difficulties establishing financial accountability i.e. communicating
when the matter is related to interpreting only and not when perhaps it is
related to social work or police.
What difference has been made to date?
The Disability Service continues to provide translated or alternative format letters
when requested by Health Records Teams.
2.6a (changed from 2.5a)
What we set out to do:
Systems in place to ensure gypsy
travellers are equally informed
about NHS FV services
Indicator
Patient experience survey with
gypsy travellers
2.7a
What we set out to do:
We support the right of
individuals and groups to hold
religious and non-religious beliefs
without experiencing
discrimination
Having support in place to meet the specific needs of this client group has
helped to break down barriers, and led to effective signposting and partnership
working with wider service providers.
Final report Spring 2015
will reflect outcomes
achieved
What difference has this made to date?
Report currently under development.
Action:
 Where appropriate identify patients Religion and Belief (R&B) in patient’s
records.
 Support patients where possible to complete personal observance.
Unfortunately there has been no further development regarding patient’s
records. We are still waiting to hear if we are either going to be part of the
Despite considerable
work by the Spiritual
Care Team the
evaluation on equality
progress report
identified that some
community members
Spiritual Care Service available
to all people who hold religious
and non-religious beliefs.
Indicator
Evaluate feedback, comments
and concerns and report within
Spiritual Care Annual Report
2014
Patient Reported Outcome
measure for Spiritual Care.
2.8 a
What we set out to do:
Forth Valley sexual health needs
assessment will look at
describing the local BME
population’s needs. Engagement
will then be targeted to local
people of BME communities, to
ensure accurate information on
local sexual health and Blood
Borne Virus (BBV) service
provision and its accessibility.
Gaps in service provision may
national pilot or whether we are going to design our own and progress that way.
There is to be a short life working group of clinical staff who will be involved in a
few work streams of documentation so this will definitely stay as a work in
progress.
What we did
 Support in place with a variety of dedicated staff and honorary chaplains.
 Evaluation to be completed regarding patient profile to ensure appropriate
recording is in place. This will support Person Centred Care (PCC).
 Evaluation completed as part of reviewing Equality Progress report 2015.
 Discussions ongoing to ensure that Religion and Belief and Spiritual Care is
recorded incl. Prefer not to answer on 100% of patient’s notes.
were under the
impression that the
Spiritual Care Centre
was mainly for Christian
Worship.
This information will be
used to inform actions
for 2015/17
What difference did we make to date?
 Religion and Belief reflected within Care of the Deceased Policy March 2014
and identification of religion, belief/none identified within Mortuary Care to
enable Mortuary Staff and Funeral Directors to be aware of people’s specific
needs. Completed.
 Reviews will be completed on an Annual Basis via the Spiritual Care
Committee (completed).
 Annual Report of activities and actions available on request from Spiritual
Care Service.
Actions
Ongoing review to be
completed during
 Engagement as identified within ‘what we set out to do’.
 Deliver a one page leaflet (available in different languages on request) on 2015/17
sexual health services which will include;
 Access to specific sexual health services and the services provided by
primary care and pharmacy.
 Where to access BBV testing, condoms, contraception, Information on the
cervical screening program.
 Plans to attend 'English as a foreign language' classes to discuss use of
services and following on from this will develop the leaflet.
What difference have we made to date?
Black and Minority Ethnic (BME) population - Work has been undertaken raising
also be identified.
This will allow this target group to
make informed choice about their
health, and the delivery of patient
centred care.
This will help reduce barriers to
access and prevent inappropriate
access to other services for
example, the emergency
department.
Indicators
 Numbers attending sexual
health clinic from BME
communities – ethnicity
monitored
 Service user feedback
Community engagement
evidence and feedbackConfidence in the service and
the client’s ability to manage
their health.
awareness of sexual health and Hepatitis C within the local mosques in Forth
Valley. A DVD has been produced for Urdu speaking women which also aims to
raise awareness of both sexual health and BBVs.
EQUALITY OUTCOME 2b: All healthcare developments, polices and plans are informed by information on profile/protected
characteristics of patients in the community.
What we set out to do
2.1b
What we set out to do:
SMR returns are completed.
Indicators


SMR returns increase by 10%
each year 2013 -17
EQIA’s are informed by data
results
2.2b
Evidence available on other
protected characteristics
including disability, sexual
orientation & religion and belief
Indicators
Reports available idenifying
breakdown 2015-17
Progress to date
Respective managers take responsibility for fields on protected characteristics
being completed.
What we did:
See point 1.3 and mainstreaming report section 2.3 Service user Monitoring and
Recording
 Significant work completed re the breakdown of statistics per department
thereby identifying gaps in recording.
 Meeting with General Managers on 14th March ’14, a review of data collection
and usage to be completed during April ’14-October ’14 in 4 areas (report
available Feb 15 from ISD) Information Services Division.
 Findings from above to be used to inform future work to evaluate all service
areas re EQIA process with direct patient care.
 Discussions continue in relation to the information collected by staff on initial
contact with patients, transfer of information through existing IT systems,
difficulties in transfer of information between systems. An issue however
remains to be the lack of information from GP’s when referring patients to
NHS Forth Valley Acute services.
 Equality Impact Assessment tool has been updated with links to national and
local data. This ensures that staff have to promote equalities, ensuring that
people have equality of opportunities as well as reduce inequalities of health
outcomes.
We have developed patient information leaflets in a range of languages to inform
people about the benefits of identifying their protected characteristics not only in
service delivery but in enhancing patient care.
 Develop effective processes to gather evidence and data about equality profile
of people using NHSFV services thereby enhancing patient care.
What difference have we made to date?
 Revision completed by Medical Records Team on current patient information
leaflet. Revised publication stored on line in top 8 languages.
 The Disability Service updated the demographics in relation to communication
Actions 2015-17
Continued actions
require to be taken to
enable the
organisation to identify
the ethnicity of people
accessing our services
Ongoing review to be
completed during
2015/17
2.3b
National and local evidence
available within EQIA on-line tool
to support staff to complete
EQIA’s.
Indicators
EQIA framework is developed,
shared and adopted across
NHSFV and annual reports are
available on EQIA completed
(barrier) requirements. I.e. Language Interpreter, Deaf blind, Lip speaker etc.
Once completed (Oct 2014) this information will be forwarded to medical
records and we have agreement this information will be updated in to Topas.
 Greater understanding and figures of people currently using Community
Language and BSL service usage.
 Framework completed by Practice Development Team regarding patient
profile data collection should support this area of work. Information also being
disseminated through a programme of presentations to lead staff about the
importance of profiling and the benefits to patient care and service delivery.
Improve and review the performance of NHS Forth Valley committees and
services in completing EQIA’s.
What we have done to date
 Revised EQIA Screening document produced. Pilot in Women and Children’s
Services with positive result. Made available on-line in August 2013.
 Audit completed on E&D, which reflected need for staff to enhance skills in
completing EQIA’s and services to take responsibility for completing them.
Staff offered support and advice on a needs led basis.
 Biannual Report on EQIA completed on E&D EQIA web page.
 All NHS Forth Valley Board reports to be evaluated to identify if Equality
considerations have been taken.
 2011 Census data available to support understanding of local/national
protected characteristics demographic profile.
 DRAFT Health and Social Care EQIA Tool currently under development based
on NHS Lothian Model. It is envisaged that this resource will be available as
offspring 2015. To launch same a master-class training session will be held
which will also include a practical exercise to commence this joint EQIA
programme on existing pieces of work. Date to be arranged.
What difference have we made to date?
 All polices are EQIA’d prior to final approval. All staff involved in the process
are fully aware of how to undertake same.
 Biannual Board Equality Report completed and available on web page.
 All Board papers have Equality Assessment on same indicating position
statement.
Ongoing review to be
completed during
2015/17

What we set out to do:
Census data available for staff
completing EQIA’s
Indicator
Information in place
demonstrating local and national
breakdown.
Link to Scottish Government data
base also in place
Staff have the skills in place to complete an EQIA and have access to support
re same.
Census report developed and placed on public site. NHS Forth Valley specific
report developed and placed on intranet site for staff to support EQIA’s etc.
What we have done to date
Action completed.
What difference have we made to date?
100% staffs are fully aware of how to access this publication via the intranet site.
This information will inform EQIA’s is being completed, although specific service
equalities data will still be used to inform actions.
Ongoing review to be
completed during
2015/17
EQUALITY OUTCOME 2c
NHS Forth Valley is equitable in the way it employs and supports its workforce.
What we set out to do
2.1c
What we set out to do:
Impact assessments completed
on recruitment pathway and
actions addressed.
Recruitment panel staff have
completed Equality and Diversity
training either face to face or
online
Indicators
 HR Policies EQIA’d and
outcomes
 % staff trained on panels
 % of disclose of staff
increases following full
implementation of E-eESS
system
Progress to date
Work ongoing to:
 Review arrangements for people from protected characteristics to
apply for vacancies within NHSFV including staff bank.
 Develop targeted training on E&D for staff who sit on recruitment
panels.
 Establish a programme to improve workforce monitoring across all
protected characteristics.
What we have done to date
NHSFV Associate Director of HR-Governance/Operational Human
Resources and Recruitment Manager have been involved in national
programme of work to review the Recruitment Pathway in line with best
practice.
National standard operating procedures have been received and are
being aligned with eESS system nationally. This work has also been
aligned with the requirements of the EESS/IREC implementation.
EESS/IREC development continues at national and local level. NHSFV
is working to be in a state of readiness for its implementation during
2014.
Recruitment training review will be undertaken when national systems
are finalised and new eESS system in place.
What difference have we made to date?
68% of respondents in the 2014 Staff Survey thought that NHS Forth
Valley acts fairly and offers equality of opportunity with regard to career
progression/promotion. This is an increase of 6% since the last staff
survey.
Actions 2015-17
A programme of Recruitment
Training for all managers is
scheduled on a quarterly basis
during 2015.
eEEs has been delayed due to
national pilot in 3 Board. This is
due to finish in March 2015, and
roll-out will commence thereafter.
What we set out to do:
Statement published with
verifiable staff and partnership
involvement.
Report available which
demonstrates any pay gap and
gender imbalance
Indicator
 Statement in place

We have:
 Prepared and published an NHSFV equal pay statement.
 Report to be made available on annual basis which evidences pay
bands, job families as well as occupational segregation.
This is complete and will be
reviewed during 2017.
What we have done to date
 Statement and Report available.
 This is an annual requirement and is undertaken locally and
submitted also to SGHD.
What difference have we made to date?
Narrow % pay gap and
gender imbalance
N.B This is also a Scottish
Ministers Key equality theme
for 2013-17
What we set out to do:
LGBT staff network/dates in
place with partner organisations
from police and fire brigade.
Indicator
‘Blue Light LGBT Staff Network’
in place.
Evaluate actions completed 2015
to enhance current staff
awareness and support as well
as improve access to services.
Completed
With support from Stonewall and LGBT Youth Scotland facilitate and
establish robust staff led network to inform HR policies and service
delivery where appropriate.
What we have done to date
 System in place and advertising completed. Uptake poor. To be
reviewed following national workforce survey. National survey
results are being further analysed by the NHSFV Staff Survey
Steering Group. These are also mapped with other staff experience
outputs.
 The focus of the survey is on the 5 elements of Staff Governance,
including being treated fairly and consistently, with dignity and
respect, in an environment where diversity is valued. Issues in
relation to LGBT have not been identified through the survey, but all
opportunities will be taken to support the work of the Network in
partnership with local stakeholders
Review this action in 2015/17
further to implementation of staff
transgender policy and LGBT
Training packages
What difference have we made to date?
Although commitment to the establishment of a network was supported
by NHSFV there was little uptake regarding same
NHS Forth Valley has been awarded its LGBT Youth Scotland
Foundation Award
2.4c
What we set out to do:
Dignity at Work policy embedded
within organisation
Action:
 Revise and launch dignity at work policy with clear organisational
values
 Develop information and training package to support implementation
Indicator
Staff aware of Dignity and
Respect at work policy and have
completed awareness sessions
What we have done to date
This policy was approved on 18 March 2014 and launched summer
2014. This was after extensive development, consultation and review.
Partnership feedback from RCN is that this is an impressive piece of
work.
The focus is now on implementation which will include:
 Awareness raising through staff brief and other messages.
 Development of a manager’s toolkit.
 Refreshed staff training.
 Links with the launch of NHSFV’s Values across the organisation.
Transgender Hate Incident
protocol will support ongoing
work in relation to ensuring
Dignity at Work is maintained.
What difference have we made to date?
During 2013 -15 7 cases have been supported by Dignity at Work
Advisers.
2.5c
What we set out to do:
NHS Forth Valley supports a
culture of openness and support
for mental ill health and promotes
positive mental health and
wellbeing for staff and reduces
the stigma of mental ill health
Direct support delivered by Occupational Health and HR services and
via Management team
 Analysis and monitoring of sickness absence rates.
 Refresh and reinvigorate ‘See Me ‘, Scotland’s national campaign
to end the stigma and discrimination of mental health with a focus
on LGBT issues.
 Mental Health First Aid training available for staff in Learning and
Development Training programme.
Work will continue during
2015/16 to achieve the 4%
Attendance standard.
The Senior HR Group chaired by
the HR Director focuses on close
scrutiny of all reports and case
management. It has developed
Indicator
 Achieve the Healthy Working
Lives Award
 Review impact of ‘stress
awareness training’
 Evaluate impact on staff
attending ‘Mental Health First
Aid Training’
What we have done to date
 This support is readily available and the Employee Psychology
service is also provided for complex cases.
 Monthly monitoring and analysis of sickness absence data in
relation to stress, anxiety and depression is in place.
See Me: - Where we are now: Planning group meeting quarterly, aims
and objectives of group agreed, Leadership of the group and reporting
structure in place. Links made with the national see me...campaign and
other local activity e.g. Healthy Working Lives. Information about 'See
Me'...and related issues now available on Risk Management web
pages. NHSFV induction programme now includes references to the
see me....anti-stigma campaign.
Positive and active involvement from Stonewall Scotland ‘No
Bystanders’ campaign, which focuses on bullying and harassment
experienced by equality groups. Its impact on responding to hate
incidences and its effect on Health and Well-being. NHS Forth Valley
are leading on this project as part of ‘see me’ and are actively involving
partner agencies both from public bodies and the 3rd sector. Launched
in October 2014.
What difference have we made to date?
There were 7 Bullying and Harassment cases in 2013 and 7 in 2014.
Actions put in place to meet identified needs and concerns.
a 2014/15 mid-year Attendance
Management Action Plan.
These actions include the Winter
campaign for Attendance and
Wellbeing; a new Attendance
Audit programme where the
management of short term
absence will be prioritised; a
new protocol for Case
Conferences and a refresh of the
Early Return to Work Process.
The Action Plan will be
monitored monthly through the
HR Director’s group with
quarterly updates to the Area
Partnership Forum and Staff
Governance Committee.
Long term NHS outcome 3:
Aligned to Strategic Priority:
EQUALITY OUTCOME 3: a
What we set out to do
3.1a
What we set out to do:

NHS Forth Valley staff and
contractors are
knowledgeable and confident
in reporting hate incidents.

Evaluation of Multi Agency
Hate Response Strategy
(MAHRS) Strategy 2010-13
(completed in 2013)
Indicators
 Reports of hate incidents
provided on an annual basis
 Quarterly Analysis of Hate
Incidents and Action Plan
 Revision of MAHRS Strategy
by December 2013
 Evaluation of training
completed as well as
identification of reporting of
incidents in NHSFV 2013-15.
 Evaluation of training
delivered to schools
Within NHS Forth Valley, people are able to live well in the community.
NHS Forth Valley Integrated Health Care Strategy - in line with the Scottish Government’s 20:20
vision as well as National Priorities in relation to Hate Crime and Gender Based Violence
People in Forth Valley are confident that diversity is respected; discrimination challenged and
actively encouraged to report hate incidents motivated by malice or ill will based on racism,
religious bigotry, homophobia, transphobia and disability related discrimination
Progress to date
We have:
 Published hate incident awareness materials and information on how
to report Hate Incidents in Central Scotland to staff, contractors and to
local communities.
 Collate NHSFV and partner agency reports on a quarterly basis
 Work with local equality groups and systems in place for staff to
encourage reporting of hate incidents
 Works in partnership with pubic and voluntary sector services to
monitor and tackle hate incidents.
 Develop social media strategy for NHS Forth Valley.
 Annual Report from MAHRS
What we have done to date
 Established and maintained structures within NHS Forth Valley and
across partnerships to promote positive relations and effectively deal
with harassment and hate crimes
 Draft Hate incident protocol developed. To be approved
 Stop Hate in Central Scotland film available on NHS Forth Valley
website, commended by the Equality and Human Rights Commission
as good practice. Posters distributed widely throughout NHS FV and
on TV's at FVRH. Promotional materials targeted at black history
month October 2013 and LGBT history month event February 2014
 Staff attending face-to-face NHSFV corporate induction programme
are informed about hate incident reporting.
Actions 2015-17
Ensure that outcomes are
positive, preventative and
measurable helps to achieve
better results for staff and
service users. This will be
identified within further
actions during 2015-17
More robust processes to be
put in place to ensure
incidences are recorded and
staff continue to be supported
re same.












Summary of reported incidences supplied by Police Scotland (Forth
Division) attached at end of section 3.1. These figures are given in
relation to incidences reported. Some cover more than one aspect of
protected characteristics.
Hate incident awareness delivered to 3 public involvement sessions
during 2013/14 in partnership with Police Scotland
Evaluation of MAHRS Strategy undertaken by Quality Manager in 2013
on behalf of MAHRS Stop Hate Group to ensure fit for purpose.
Board approved new Social Media Policies for Business and Personal
use in 2013. 100% staff were informed about system in place
What difference have we made to date?
100% of staff attending face-to-face NHSFV corporate induction
programme are informed about hate incident reporting.
Hate incident protocol developed ensuring that NHSFV staff are
empowered victims of hate crime/incidents
The quality of training has ensured that staff are confident about care
pathways in place to respond to any hate incident
All staff are more confident and are aware of the accountability and
responsibility within services to offer adequate support to victims of
hate crime/incidents as identified by employees or service users
Through the delivery of Equality & Diversity and hate incident training
over 1000 secondary school pupils and 120 staff are more confident in
and better informed on Equality and Diversity matters and can engage
with their peers and school support to effect change and improvement
to their health and well being.
Further to involvement with young people, NHS Forth Valley developed
a mobile phone resource with Police Scotland in relation to reporting
hate incidences
NHS Forth Valley staff are more confident in accessing pathways,
mechanisms, including policies, procedures and contacts for reporting
discrimination and harassment
Long term outcomes are that “Individuals and communities who are
affected by, and victims of, hate crime feel safe and secure”
Reported incidences in Forth Valley for 2013 = 437 (9)
Reported incidences in Forth Valley for 2014 = 438 (14)
 NHS Forth Valley figures in brackets
Outcome 3 b. In collaboration with partner agencies, NHS Forth Valley will improve the early identification of women and men
experiencing Gender Based Violence (GBV) within local health services; particular focus on A&E, Mental Health, Substance Abuse,
Community Care, Sexual Health and Women and Children’s Services
What we set out to do
3.1b What we set out to do:
NHS FV GBV Steering Group to
develop a 4-year GBV action
plan.
Indicators
 Evaluation of reported
incidents of GBV annually
from 2013 – 17
 Annual report available.
Systems in place to address
needs
 E-learning package in place.
Uptake of training 2013-14 to
form baseline
 50 % staff who completed
routine enquiry training have
completed refresher training
By March 2016 (Changed
from 2014)
 Action Plan in place to inform
progress
 Monitoring reports available
on biannual basis to evaluate
effectiveness of service and
identify breakdown of users to
inform future direction of work
in Forth Valley area.
Progress to date
Action:
Continue to implement action plan developed from Chief Executive
Letter (CEL-41) on GBV for 2013 -17; with a focus on; Community
Health Visiting, Emergency Department, Mental Health Services,
Substance Misuse Service, Sexual Health, Women and Children
Services
Actions 2015-17
Ongoing review to be completed
during 2015/17 as part of NHS
Forth Valley GBV Action Plan
What we have done to date
 3500 cases reported to the Police Scotland Forth Division in 2013 14. NHSFV GBV Strategy currently not in place, although an action
plan has been developed
 Train the Trainers Course on Gender Based Violence Work
completed with partners in Local Authority to identify common goals.
 GBV Training in place either face to face or online.
 Dedicated support completed during festive period with A&E staff:
Women's Aid Falkirk based from 7pm – 2am from 25th Dec - 4th
Jan to support cases of GBV: 2 cases identified during this period.
Police identified during similar period that 151 cases of Domestic
Abuse were reported. Approx 16.5% included physical Assault.
 Further 3 year action plan submitted to Director of Public Health for
approval.
 Patient Pathway available within Services areas
 Increased data collection within key areas
 Female Genital Mutilation (FGM) protocol in place within Women
and Children’s Services
 Specific information has been designed to support staff confidence
in responding to abuse
Enhance work completed with
Dental Practices to support early
identification and support to
people accessing these
services.
Data collection systems to be
review during 2015.
Enhanced awareness and direct
referral system within GP
Practices to women’s aid is
currently under discussion
Key action
NHS input into Multi Agency
Risk Assessment Conferences
to be progressed

Patient specific information has been developed to increase their
awareness of identifying abuse as well as support available. This
has also included specific materials for people with a learning
disability designed in partnership with them.
What differences have we made to date?
Progress has been made towards the reduction in violence against
women by 2017 through a strategic and co-ordinated approach by
agencies and women’s organisations.
What we set out to do:
Service monitoring data
demonstrates implementation
Staff are more confident in completing routine enquiry and have clear
pathways to refer patients where appropriate.
Continuation of GBV Routine enquiry within NHSFV
What we have done to date
 Routine enquiry is completed within maternity services. There
were 3251 deliveries in Forth Valley during 2014.

o
49 referrals to the Pre-birth Planning Service with current or
historical abuse as one of the reasons for low level vulnerability,
requiring additional support.
o
39 Midwife referrals to Social Work with current or historical
abuse as one of the reasons for requesting Child Protection
assessment
o
76 calls from Police Domestic Abuse Unit to update incidents
where female involved has identified as being pregnant
Direct referral can be made via secure email address from A&E to
Women’s Aid, discussions ongoing about opening this up to GP’s
and Dental staff
Ongoing review to be completed
during 2015/17 as part of NHS
Forth Valley GBV Action Plan
Mental Health and Substance Abuse staff have developed Functional
Analysis of the Care Environment (FACE) clinical care and data
recording system to incorporate GBV Routine enquiry questions as well
as CAADA Dash Risk Assessment.


CADDA DASH stands for Co-ordinated Action Against Domestic
Abuse (CADDA)
Domestic Abuse, Stalking and Honour Based Violence (DASH)
Sexual Health Team
 102 attended where last sex was reported as non-consensual
 140 others reported previous sexual assault: 50 in previous year; 90
more than 1 year ago
 Of the 242 above, 25%were men (33% of these were men having
sex with men) Community Nursing: MiDiS System for Health Visitors
etc has now started to develop reports re GBV recording. Sept 2012
– Feb 2014 there were 83 cases identified. This reporting
methodology will be structured during 2014/15.
Emergency Department: No update regarding recording
What we set out to do:
E-learning package in place for
staff to complete regarding
Gender Based Violence.
Refresher training on GBV in
place.
Action:
 NHSFV GBV Steering Group to identify key areas to target in
relation to completing e-learning package.
 Further develop refresher training for staff as identified within CEL
41 (2008) in relation to GBV.
 Programme of GBV Training to be developed following meeting with
trainers in September 2014.
What we have done to date
 Package completed and launched along with trafficking e-learning
resource. From Sept ‘14. Figures to be collated on a 6 monthly
basis of people completing it. 100% of staff on learn pro have
access to it.
Ongoing review to be completed
during 2015/17 as part of NHS
Forth Valley GBV Action Plan





Training delivered in Partnership with Women’s Aid to Child Smile
Team in June 2013. Approx 20 staff attended.
Range of GBV training to be developed 2014/15. This has initially
started with refresher training for midwifery staff completed on a
monthly basis.
GBV Awareness is included within Child Protection Training.
Monthly training started Jan '14 for Maternity staff. Health Visitors
have been receiving updates within existing training.
Training for trainers course commencing June 2014 with members
of local Women’s Aid attending the training with a view to delivering
NHS package during 2014/15.
What differences have we made to date?
160 staff completed e-learning GBV package Jan 2014 – March 2015.
12 staff completed GBV Training for trainer’s course June 2014.
Trainers included third sector providers. Positive evaluation from
training completed.
All staff attending the Women & Children’s Clinical Unit; Continual
Professional Development Midwives Study Day are more confident in
completing routine enquiry and have resources to undertake same
What we set out to do:
Deliver on actions identified by
NHS Health Scotland GBV
Steering Group.
Drop in facility for GBV available
on a monthly basis at Forth
Valley Royal Hospital Women’s
Aid to evaluate amount of usage
incl age, disability, gender, sexual
Evidence has shown that staff are more confident in identifying and
responding to Gender Based Violence and are aware of where to get
additional support internally and externally.
Action:
 Use information from National Steering Group to inform NHSFV
GBV Action Plan.
 Launch and publicise Drop in facility at FVRH.
What we have done to date
 NHSFV Group notified of national priorities.
 Drop in facility available at NHSFV but low uptake, so
postponed. To be reviewed again Summer 2015.
Ongoing review to be completed
during 2015/17 as part of NHS
Forth Valley GBV Action Plan
and Violence Against Women
Strategy (no indicators published
as yet from national programme)
orientation and ethnicity of
service users.


Drop in facility now also being offered at Slamannan Health
Centre.
Posters disseminated to all GP's and Pharmacies within NHS
Forth Valley during 16 days of action.
What differences have we made to date?
All staff that support people experiencing abuse are informed on
national and local priorities.
What we set out to do:
Infrastructure in place to provide
effective advice and support at
the point of contact with front line
staff
What we set out to do:
Multi Agency Risk Assessment
Conference to be established to
support high risk GBV cases
within NHSFV.
Indicators
MARAC reports available 2014 +
with summary of actions taken
In partnership with Public Bodies and local voluntary groups review
current information available and patient pathways within NHS Forth
Valley in relation to GBV.
What we have done to date
 Patient pathways in place at A&E, Women and Children Services,
Substance Misuse and Health Visiting only. Currently under
development within Mental Health Services.
 Guidance on local contacts and support redeveloped November
2014 with partner agencies and is available on line.
 Discussions regarding direct notification to GP’s (with patients
permission) following an incident happening involving the police.
Infrastructure and support required under discussion. ON HOLD
What difference have we made to date?
Detailed care pathways have been developed to provide advice and
support at point of contact.
We require to further develop joint working arrangement with partner
organisations to establish MARAC system within Forth Valley/Fife.
What we have done to date
 Report developed reflecting infrastructure required to deliver
MARAC within exiting NHS priorities.
 MARAC system in place within the Forth Valley area as from
August 2013. NHS Forth Valley as yet does not attend these
meetings.
Ongoing review to be completed
during 2015/17 as part of NHS
Forth Valley GBV Action Plan
and outcomes.

To be discussed further in April 2014 with Director of Public
Health who is the Executive Lead for GBV in NHSFV
(completed).
What difference have we made to date?
This has not been achieved during proposed timescales; currently
under review.
Discussions are ongoing regarding NHS Forth Valley Infrastructure
required to inform this process.
Equality Outcome 3 c
NHSFV Employees (women and men) affected by GBV, including those with protected characteristics, are
confident that they will receive support in the workplace and improved safety, health and well-being.
What we set out to do
3.1c
What we set out to do:
NHS Forth Valley Gender Based
Violence Staff Policy in place
Managers are trained on
implementation of policy
Communication Strategy in place
to inform staff about
implementation of GBV Policy
and resources re support and
advice
Indicators
 Evaluate uptake of policy
 % of staff completing training.
Identify gaps in services not
completing training.
 Evidence that task has been
completed
Progress to date
Action:
 Establish and implement NHSFV GBV staff Policy
 Face to face and e-learning training available
What we have done to date
 Policy implemented and is now available for all staff to either inform
them of their practice or as a support tool for people experiencing
GBV

National GBV Managers training being developed. NHS Forth Valley
GBV operational Leads on this working group to inform
development and content. Resource should be available later this
year. Date to be confirmed.
What difference have we made to date?
Through a range of methods of communication all staff are aware of
GBV policy and are confident in how to access same. All staff can gain
access and support from Hr, Occupational Health and GBV Manager.
This has been achieved on several occasions.
Reasonable adjustments in place to support people continue to work
safely; this has been implemented including review of workplace, email
address change and access to staff counselling.
As staff counselling is confidential we can only identify how many
people have accessed same – information is divided between work and
non work related. In the non work related it then cites personal problem
Actions 2015-17
Continue to monitor impact of
policy and supportive actions.
– so we have no way of knowing what this is about and could not say
for certain what it pertains to. All staff have equity of access to
counselling services if requested, or can self refer.
Outcome 3d Through’ Keep Well’ health promotion project NHS Forth Valley in partnership with other agencies will increase
opportunities for health improvement and disease prevention in deprived and vulnerable populations
What we set out to do
Progress to date
Actions 2015-17
What we set out to do:
Actions: Deliver an on-going implementation plan, and consider how to Project review to be completed
Delivery of a programme of
mainstream longer term.
2015
activity, the main output being the
What we have done to date
delivery of person-centred,
holistic, health assessments of at Annual Report April 2014 available. Summary indicates that:
least 45 minutes in duration, with  The Keep well Forth Valley programme currently delivers about
follow up aimed at bringing about
3000 health assessments per year. (Equivalent to 2.3% of the
change which will reduce risk and
population aged 40-65).
improve people’s lives in general.  85% of those undergoing a health assessment are experiencing
deprivation.
This is targeted at people
 The health assessment is greatly appreciated by the clients. It
experiencing deprivation, and/ or
invariably identifies opportunity for improvement, and often leads to
being defined as within a
health gains in a variety of ways. This can be described as ‘covulnerable group (experiencing
production through a human therapeutic encounter’.
homelessness, having substance  The focus is deprivation and vulnerable groups as per the guidance
use issues, being within a
for the programme nationally, enhanced by a local focus on men’s
minority ethnic group, being in
health and employability.
contact with the criminal justice
 The programme in Forth Valley has been developed to build
system, being a carer etc.).
capacity and enhance reach through core CHP service planning
supported by (rather than delivered through) GP practices.
In addition Keep well is and will
 There is continued commitment to Keep Well Forth Valley from NHS
continue to be delivered with
Forth Valley as a key component of primary anticipatory care work.
consideration of gender sensitive
Ring fenced funding should be maintained to enable ongoing
health improvement to meet the
capacity building and extend reach.
differential needs of men and
 We have introduced a 3 month follow up this year, which indicates
women and employability needs.
significant behaviour change associated with goal setting.
The service also has a focus on
employability
Indicators
The Keep well database records
all information relevant to the
above, and provides a means for
measurement against objectives
and outcomes

Key themes emerging from this report are - ethos and approach,
complexity (recognising and accommodating it), empathy and
compassion, innovation and application of a new, unique approach,
the importance of giving time; and underpinning it all an approach
based on values and principles.
Progress identified September 2014
 Programme remains on target over the past six months for numbers
of assessments and anticipated outcomes based on last year’s
annual report.
 Specific work targeting lower paid workers has been commenced
 Further developments have resulted in regular provision of service
within the villages of Fallin, Plean and Westquarter - areas
recognised as experiencing deprivation.
 A weekly clinic is now established within Falkirk’s mental health
association resource centre and the Salvation Army soup kitchen.
 Keep Well has started providing a health drop in service for the
travelling community in Clackmannanshire.
 Programme is building its reach and partnership capacity through
specific task groups of single outcome delivery plans a) Stirling
through the tackling poverty and inequalities group. b)
Clackmannanshire is being explored through the new adult subgroup
and Falkirk will be informed from learning in Stirling and
Clackmannanshire.
 Reach and capacity is being built through core NHS services and a
report has been completed with recommendations for joint work with
community dieticians, learning disabilities and OT's working in
integrated mental health services.
 Recommendations will be prioritised and included in the steering
group action plan.
What difference have we made by March 2015?
Summary of Outcomes achieved to date:
 Keep well has been successful in identifying people at high risk of
developing cardiovascular disease (1 in 10 people having an
ASSIGN score of 20 or above).
 Significant health gains are reported by those who attend, including
earlier detection of disease, e.g. our data show that on 3 month
follow up of 660 people 123 people with high blood pressure were
identified, 43 with Chronic Heart Disease and 18 with diabetes (plus
smaller numbers of other conditions including: Chronic Obstructive
Pulmonary Disease, depression, breast lumps including cancer,
lupus, fibromyalgia, thyroid disease, diverticulitis, chronic pain,
gastro-intestinal conditions, Irritable Bowel Syndrome ,hernia etc.)
 Health behaviour changes were also identified in the 660 people
followed up at a 3 month review. This included 24 who had quit
smoking, 28 who had reduced their alcohol intake, 26 reported an
increase in their mental wellbeing, 121 had lost weight and 2 that
had been helped to gain employment.
 Although it is difficult to quantify the health gain to our population
precisely, Keep well does seem to represent a significant
intervention. In addition this early identification and management
represents a more cost-effective use of resources (though again
difficult to quantify). If Keep well were not in place, the longer term
costs to the NHS would be considerably greater.
 At a community level Keep well contributes significantly to capacity
building for health improvement in regeneration areas and with
vulnerable groups by a joined up agency approach e.g. walks, fruit
barrow, galas, other community events, drop-ins, smoke free
homes, resource development, volunteering, access to information
i.e. welfare reform.






Health is jointly managed (clients/patients are supported by services
that are better integrated and co-ordinated).
Joint ownership of the health inequalities agenda can be
demonstrated.
Individuals can access person centred services that meet their
needs.
Increasing numbers of care service staff are providing holistic
person centred care.
Sustained behaviour change is being evidenced.
Increased participation in employability activity.