South West Yorkshire Partnership NHS Foundation Trust welcomes and embraces the new NHS Equality Delivery System (EDS) and intends to use this tool to improve performance on Equality & Inclusion within the Trust. The EDS is designed for the NHS to deliver on the Public Sector Equality Duties 2012, Human Rights
Act 2000, NHS Constitution and Care Quality Commission standards. The EDS and Equality Act 2010 is fundamentally based on an outcomes focus approach, addressing any health inequalities and disparities faced by equality groups and puts people who use our services and communities and who will ultimately hold us accountable, at the heart of the process.
The Trust Board have signed up to the EDS, Dawn Stephenson, Director of Corporate Development has director level responsibility for Equality and Inclusion, with
Non Executive, Helen Wollaston equalities champion at board level. We have a strong governance structure for Equality and Inclusion which consists of the Strategy into Action Group (STAG), which is the Quality Academy and BDU director level group reporting into the Clinical Governance and Clinical Safety Committee supported by the BDU local Equality & Inclusion Action Groups.
On the 31 st January the Trust published equality information on its workforce and people who use our services, meeting its requirements under the Public Sector
Equality Duty. However, this information is by no means the full picture in terms of data and through the EDS, we plan to publish more equality information on an annual basis.
We have adopted the EDS four strategic goals as part of our Equality Strategy and developed employment and service delivery equality objectives, which are specific and measurable to particular equality groups and based on the equality information that has been published so far. This approach supports our requirements under the Equality Act 2010.
During March 2012 the Equality & Inclusion team facilitated Equality & Service Users Experience strategy workshops across each district, for our service users, carers and staff, who had the opportunity to have their say and influence the Equality Strategy and objectives. Overall based on the existing information, the above workshops and local authority led workshops involving local economy stakeholders the Trust has provisionally graded itself as “Developing “on the EDS grading system. To ensure the EDS process is as meaningful as possible for our service users, carers, interest groups and staff, we aim to schedule stakeholder assessment events for each Business Delivery Unit in June/July 2012 to reassess the information we have used to grade our services as “Developing”.
As this is the transitional year of the EDS and the Public Sector Equality Duties, we aim to have an on-going approach to engagement, which will mean service users, carers, staff and communities will have the opportunity to influence our plans throughout the year and beyond.
Included in this document are:
- Overarching General Duty (PSED)
- EDS goals and Strategic Equality Objectives
- Service Delivery Equality Objectives
- Employment Equality objectives
- Equality Delivery System (Dash Board Assessment as at March 2012)
- Equality & Inclusion KPIs (draft)
1

Overarching General Duty(PSED)

Eliminate prohibited conduct of discrimination, harassment and victimisation;

Advance equality of opportunity between those sharing a protected characteristic and those not;

Foster good relations with those with a protective characteristic and the wider community.
EDS goals and Strategic Equality Objectives
1. Better health outcomes for all

Strategic Equality Objective : Consult and involve service users, employees and the wider communities in prioritising actions to reduce health inequalities, exclusion and promote equality.
2. Improved patient access and experience.

Strategic Equality Objective : To provide accessible, appropriate information and communication to our employees, service users and the wider communities we serve and improve access to our buildings and facilities.
3. Empowered, engaged and well-supported staff

Strategic Equality Objective : Ensure equality of opportunity and outcomes in our recruitment, selection and appointment processes, terms and conditions of employment, workforce development and support schemes (e.g. training, career progression and promotion, flexible working arrangements).
4. Inclusive leadership at all levels

Strategic Equality Objective : Ensure talent management and leadership programmes opportunities support and develop inclusive leadership within the
Trust and the new national Equality and Diversity competencies are embedded across the Trust.
Service Delivery Equality Objectives:
1. Reduce average length of stay of women within inpatient MH services
2. Reduce self harm within British groups
3. Reduce MH admissions of BME groups within inpatient services year on year so it is broadly representative of the local population (Excluding Forensic services)
4. Reduce Average Length of Stay of BME groups within inpatient MH services
5. Reduce seclusion and restraints of BME groups within inpatient MH services
6. Increase utilization of BME groups using Talking Therapies and community services
7. Improving patient experience by all protected characteristics
Employment Equality objectives:
1. Increase the number of people with a disability employed within the Trust workforce
2. Increase the number of young people within the Trust workforce
3. Increase BME representation at all levels, with a focus on band 7 and above.
4. Reduce the incidence of bullying and harassment (NHS Staff Survey)
5. Undertake pay audit between men and women (Pay audit)
6. Improve employee engagement by protected groups (Equality Staff networks)
7. Increase uptake of equality and diversity training
2

Equality Delivery System Dash Board – March 2012
RAG: Completed In progress
EDS Implementation Steps
1. Buy-in from Boards & Governance
Structure in Place
2. Resources for EDS implementation identified
3. Engagement / Involvement:
Voluntary / Community Sectors;
Local Authorities/ LINks
4. Engagement / Involvement: Patients and Carers
5. Engagement / Involvement: NHS
Staff and Staff Side
6. Publish information; Compliance with Equality Duty (31.01.12)
7. Evidence assembled for EDS grading by *Stakeholders
8. Performance analysed and EDS grades agreed by *Stakeholders
9. Equality Objectives Set
Not started / insufficient progress
Grade: RAG Narrative & proposed actions
Board signed up & Equality & Inclusion Governance structure already established
Equality & Inclusion team, Corporate services
Stakeholder Assessments scheduled for June/July 2012
Equality & Service User & carer experience strategy workshops across the BDUs taking place March 2012
Equality & Service User & carer experience strategy workshops across the BDUs taking place March 2012
Completed and Published on Trust website
Completed and Published on Trust website, however, requesting more equality data from performance and information
Provisional grading is given as Developing based on the information gathered and published so far. However, this will be checked by the stakeholder events in the summer
Draft Equality Objectives, see below
KPIs and proposed equality objectives part of BDU performance framework 10. Integrated Equality Objectives in
Mainstream Business Planning
11. EDS Grading and Equality
Objectives Published (06.04.12)
12. EDS Implementation Plan
Equality strategy and objectives published
EDS Plan will be submitted to the SHA July 2012
3

Equality & Inclusion KPIs will underpin and deliver the Strategic Equality Objectives
Equality & Inclusion: BDU KPIs 2012/2013 (draft)
Key Performance Indicator Source (Key Drivers) Measure/possible evidence
EDS Goal 2: Improved patient access and experience
1. The BDU/service has a range of mechanisms in place for seeking the views of people who use services and their carers, and involve people in the annual planning and developing of services, in particular, engaging with seldom heard groups .
Public Involvement Duty
Equality Act 2010
Equality Delivery System
(EDS)
CQC standard
NHS Constitution
Feedback audits
National patient opinion surveys
KIOSK
Dialogue Groups
Annual Reports
CPA audit etc
2. BDU/service monitors patient experience audits by all protected characteristics and demonstrates year on year improvements
3. The BDU/service has taken action to address any issues raised as a result of service user and carer feedback and has fed back to service users/carers
4. All service users have been involved in developing their individual care plan which identifies any special needs in relation to ethnicity, language, culture, religion, gender, sexual orientation, disability, age, maternity and pregnancy etc.
Public Involvement Duty
Equality Act 2010
Human Rights Act 2000
NHS Constitution
EDS
Public Involvement Duty
Equality Act 2010
EDS
CQC standard
Public Involvement Duty
Equality Act 2010
EDS
CQC standard
Time scales
2012 -
2013
EDS
Grading/
Developing
RIO
Count me in census
National opinion surveys
EIAs
Discharge feedback survey
2012 –
2013
Under
Under developed
Feedback audits
National patient opinion surveys
KIOSK, CPA audit,
Story boards
Equality Impact
Assessments (EIAs)
Feedback audits,
National patient opinion surveys,
KIOSK, CPA audit etc.
2012 -
2013
2012 –
2013
Developing
Developing
Trend Actions
BDU’s need to undertake targeted engagement & involvement activities with seldom heard groups.
All Trust’s patient experience audits should collect and measure information from all equality groups covered by the Equality Act 10.
BDU ’s to develop story boards as evidence & monitor this by equality groups.
Ensure CPA &
Count Me In census audit collects and measure this by equality groups.
4

EDS Goal 1: Better health outcomes for all
5. The BDU/service has been subjected to a full and robust EIA and has subsequently developed equality objectives and action plans. Furthermore the service can demonstrate better outcomes through the EIA process year on year.
Equality Act 2010
EDS
CQC standard
6. Service has good community data on equalities and uses this data to benchmark and set targets.
Equality Act 2010
EDS
7. The BDU/service provides and monitors the quality of accessible information and communication.
Equality Act 2010
Human Rights Act 2000
EDS
8. The BDU/service has assessed the accessibility of its premises for people with physical, learning, sensory disabilities etc.
9. Ethnic profile and also other protected characteristics detained under Mental Health
Act in the service are consistent with local population profile.
CQC standard
Equality Act 2010
Human Rights Act 2000
EDS
Equality Act 2010
Human Rights Act 2000
DRE
CQC standard evidence
EIAs & Action Plans
EIAs
Count me in Census
JSNA
PEAT assessments
EIAs
PEAT assessments
EIAs
RIO
Count me in census
EIAs
Benchmarking reports
Time scales
2012 -
2013
2012 -
2013
EDS
Grading
Developing
Under developed
Achieving
2012 –
2013
Developing
2012 Developing
Trend Actions
Good progress made by services, however, new EIAs need undertaking due to the recent significant changes to services.
2001 Census out of date, national projection data patchy. Begin to use
2011 census later in the year. Develop a corporate equality data template & publish this on Trust website
Develop Corporate interpreting and translation policy with clear governance structures.
Equality & Inclusion
Action groups to look at Estates and
Facilities audit on disability access
BDU to begin using patient data systematically and use postcodes to help understand high admissions.
5

10. BDU/service monitors and scrutinizes access issues by protected characteristics and appropriate action plans are developed to address any disparities.
11. BDU/service monitors and scrutinizes health outcomes by protected characteristics and appropriate action plans are developed to address any disparities.
12. Inpatient services meet national standards in relation to single sex accommodation, including access to women only day rooms and service users have access to appropriate facilities for prayer/worship.
EDS Goal 3: Empowered, engaged and well-supported staff
13. Diversity profile of the workforce at all levels within the Trust is broadly representative of the population served.
Equality Act 2010
Human Rights Act 2000
NHS Constitution
EDS
Quality Accounts
Equality Act 2010
Human Rights Act 2000
NHS Constitution
EDS
Quality Accounts
Equality Act 2010
Human Rights Act 2000
NHS Constitution
EDS
Quality Accounts
RIO
Count me in census
National opinion surveys
EIAs
RIO
Count me in census
System one
DTMS
National opinion surveys
EIAs
Count me in census
National opinion surveys
EIAs
Source (Key Drivers) evidence
Equality Act 2010
Investors in People
EDS
Publishing workforce data including the publishing of workforce report and objectives
2012 -
2013
2012 -
2013
2012 -
2013
Time scales
2012/2
013
Under
Developed
Under D
Under ped
Developed
Developing
Ensure RIO, System
One, & count me in census collects, monitors and measures access by equality groups.
(also action 2, 4, 9).
Ensure RIO, System
One, & count me in census collects, monitors and measures health outcomes by equality groups.
(See also action 2,
4, 9, 10).
Produce corporate transgender policy and training to reflect legal changes within equality act.
Link in with the work by EMSA group.
EDS
Grading
Developing
Trend Actions
HR & OD strategy setting out clear direction and support on how this would be achieved.
(Positive action schemes, shadowing, mentoring, leadership programmes and promote volunteering)
6

14. Arrangements are in place to support people with disability and long term conditions to obtain and retain employment, including evidence of reasonable adjustments.
Equality Act 2010
Investors in People
EDS
CQC standard
15. BDU/service has systems in place for employee engagement such as employee staff networks so the workforce is involved before priorities are set.
Equality Act 2010
Investors in People
EDS
CQC standard
16. BDU/service can demonstrate that all staff are up to date with their mandatory training on
Equality & Diversity.
Equality Act 2010
Investors in People
EDS
CQC standard
17. Workforce data such as applicants, short listing, appointment, promotions, flexible working, exit interviews, disciplinary, grievances, bullying/harassment, pay bands, training are monitored and published by all protected characteristics including the evidence base and analysis within workforce report and subsequent key priorities have been set.
Equality Act 2010
Investors in People
EDS
CQC standard
Workforce data report
Disability staff survey
NHS Staff survey
Exemplar employer framework
2012/
2013
Developing
Staff surveys
Employee engagement events
NHS staff survey
Local partnership forum
Staff surveys
NHS staff survey
2012 -
2013
2012 -
2013
Publishing workforce data including the publishing of analysis report and objectives
2012
Under developed
Developing
Achieving
HR to facilitate the review and interpretation of the results of Disability
Staff survey, NHS staff survey and health & wellbeing survey facilitating the production of action plans.
HR strategy/ framework to address this to meet compliance under the equality act.
(Staff networks are seen as good practice).
Corporate training arrangements are in place for E&D training, need to review frequency
Workforce data on diversity published, analyzed and objectives developed in accessible format by
January 2012.
7