Equality Report
How we perform against the NHS Equality Delivery System
outcomes – Case Studies and evidence for 2gether NHS
Foundation Trust
February 2012
Glossary of abbreviations and terms
EDS
NHS
‘Protected characteristics’
‘Disadvantaged groups’
‘Local interests’
interest group’
BME
GRIP
CQC
NIHCE/NICE
or
Equality Delivery System
National Health Service
The nine characteristics protected under the Equality Act 2010:
1. Age
2. Disability
3. Gender reassignment
4. Pregnancy/maternity
5. Marriage/civil partnership
6. Religion/belief
7. Race (or ethnicity)
8. Sex (or gender)
9. Sexual orientation
Sometimes called ‘marginalised’, ‘hard-to-reach’ or ‘seldomheard’ groups, these are people who experience inequalities in
health, healthcare and employment, but who are not
specifically protected by the Equality Act. They can include
homeless people, sex workers, people who misuse
substances, people with low socio-economic status, and
people living in rural isolation.
‘Local Patients, the public, voluntary sector organisations, members
of the community, staff and staff side (trades union)
organisations who have an interest in what we do.
Black Minority Ethnic
Gloucester Recovery in Psychosis
Quality Care Commission
National Institute for Health and Clinical Excellence
Page 2 of 83
1. Introduction
1.1
The Equality Delivery System
The Equality Delivery System (EDS) is a tool that has been developed by the NHS for use
by organisations that commission and provide NHS services. We use the EDS in
partnership with patients, the public and staff to review our equality performance and to
identify future priorities and actions.
The EDS consists of four goals:
1. Better health outcomes for all
2. Improved patient access and experience
3. Empowered, engaged and included staff
4. Inclusive leadership at all levels
The goals are underpinned by 18 outcomes. These are set out in the appendices. The aim
is to achieve equality in these outcomes across the nine characteristics protected by the
Equality Act, i.e. age, disability, gender reassignment, pregnancy/ maternity, marriage/ civil
partnership, religion/ belief, race, sex, and sexual orientation.
1.2
About this report
This document describes some of the work that we have done which we believe shows
how we achieve the EDS outcomes. We have described our ‘best practice’ and recognise
that we may not achieve this quality of service consistently or perhaps not on every
occasion, however it enables us to strive for excellence.
For each of these goals and their related outcomes, we have set out:
 Examples of how we deliver our services
 How we are doing compared to regional or national averages where possible this
information is available
 For people with protected characteristics why they may experience different outcomes
 Where appropriate information for other disadvantaged groups such as homeless
people, sex workers, drug users, people with low socio-economic status (NB
‘disadvantaged groups’ are an optional extension of the EDS).
 How people from across the ‘protected characteristics’ are involved and engaged in
decisions;
 How we have integrated equality considerations into our mainstream business
processes;
 Where we think we can improve equality in this area, and the plans we have in place
to achieve this.
1. Drawing up this report was the first stage in the EDS process.
Page 3 of 83
2. We shared examples of our ‘best practice’ case studies at engagement events on the
6th December 2011, 16th, 19th and 27th January 2012. About fifty people attended and
came from voluntary and community organisations, other public sector organisations,
were service users or carers, and for this Trust, were our members and Governors plus
staff. These people represent our ‘local interest’ groups. At these events we asked
participants to describe the barriers they or others face in accessing health care or
achieving healthy outcomes. We asked what an ‘excellent’ health service would look
like and many people described services which reflected key aspects of our ‘best
practice’ examples.
3. This report (as at February 2012) is just one stage in our processes. We are seeking
your assessment of how we are doing. You can work with us to agree ‘grades’ for each
outcome, based on the evidence in this report and your own assessment of how we are
doing. For each outcome one of four grades is possible:
 Excelling – Purple
 Achieving – Green
 Developing – Amber
 Undeveloped – Red
4. The final stage will asking you to work with us to agree a number of equality objectives
which we can embed into business planning. Objectives need to be agreed and
published by 5th April 2012.
1.3
About the NHS in Gloucestershire
Three NHS organisations provide services in Gloucestershire. All three organisations
actively supported the countywide events and individual organisations have supplemented
this with their own events. Briefly this is what they each do:
NHS Gloucestershire
NHS Gloucestershire is made up of two separate parts – the Commissioners and
Gloucestershire Care Services.
NHS Gloucestershire (Commissioners)
NHS Gloucestershire is responsible for commissioning (buying) healthcare for the
population of Gloucestershire (approximately 602,000 people). It is responsible for a
budget of £910 million to spend this year (2010/11).
NHS Gloucestershire commissions (buys) services from Gloucestershire Hospitals NHS
Foundation Trust, 2gether NHS Foundation Trust, Gloucestershire Care Services, Great
Western Ambulance Service, and voluntary sector organisations. NHS Gloucestershire
also supports local GP Practices (and Clinical Commissioning Clusters) to buy health
services to meet the needs of their local communities.
Page 4 of 83
NHS Gloucestershire Care Services
Gloucestershire Care Services provides a wide range of community health services to
people living in Gloucestershire. These include:


Community (or district) nursing
Therapy services for adults and children (such as physiotherapy, occupational therapy,
podiatry and speech & language therapy),
 8 community hospitals providing inpatient, outpatient and emergency care
 Out-of-hours services
Gloucestershire Care Services currently employs over 3,325 staff.
For more information about equality and diversity in NHS Gloucestershire contact
lucy.lea@glos.nhs.uk
Gloucestershire Hospitals NHS Foundation Trust
The Gloucestershire Hospitals NHS Foundation Trust provides acute elective care (which
means it carries out planned operations, from hip and knee replacements, to heart surgery
and cancer care) and specialist care (including emergency care, brain injury care). The
Trust serves people in Gloucestershire and beyond. The organisation runs both
Cheltenham General and Gloucestershire Royal Hospitals. The doctors and nurses also
see patients at clinics in all of the community hospitals across the county.
Gloucestershire Hospitals NHS Foundation Trust employs more than 7,500 staff and sees
in excess of 700,000 patients each year.
The organisation is a Foundation Trust. This means it has more control over its finances,
and it has a Council of Governors and a large group of Members, who are made up of
people from across Gloucestershire. Their role is to suggest ideas and to tell the Trust
what it is doing right, and how it can be improved.
For more information about equality and diversity in Gloucestershire Hospitals NHS
Foundation Trust contact mike.seeley@glos.nhs.uk
1.4
2
About our organisation
gether NHS Foundation Trust
2gether NHS Foundation Trust is the main provider of mental and social health care in
Gloucestershire and Herefordshire. We provide services for individuals experiencing
learning disabilities, mental health or substance misuse problems.
Page 5 of 83
At any one time we provide services to over 10,000 people and offer education and
support to carers, families and schools. We employ over 2000 staff across the two
counties.
As a Foundation Trust we have over 6000 members who influence our activities both
directly by contacting the Trust and through locally elected representatives who sit on the
Council of Governors.
For more information about equality and diversity in 2gether NHS Foundation Trust contact
Carol.sparks@glos.nhs.uk
Page 6 of 83
2. Our performance against EDS Outcomes
Goal 1: Better health outcomes for all
Goal 1 states: “The NHS should achieve improvements in patient health, public health and
patient safety for all, based on comprehensive evidence of needs and results”. There are
five outcomes under Goal 1.
Goal
1. Better
health
outcomes for
all
Narrative
The NHS should achieve
improvements in patient
health, public health and
patient safety for all, based
on comprehensive
evidence of needs and
results
Outcome
1.1 Services are commissioned, designed and procured to meet the
health needs of local communities, promote well-being, and reduce
health inequalities
1.2 Individual patients’ health needs are assessed, and resulting
services provided, in appropriate and effective ways
1.3 Changes across services for individual patients are discussed
with them, and transitions are made smoothly
1.4 The safety of patients is prioritised and assured. In particular,
patients are free from abuse, harassment, bullying, violence from
other patients and staff, with redress being open and fair to all
1.5 Public health, vaccination and screening programmes reach and
benefit all local communities and groups
Page 7 of 83
Outcome 1.1: Services are commissioned, designed and procured to meet the health
needs of local communities, promote well-being, and reduce health inequalities
This Trust does not commission services – lead responsibility sits with the
commissioning arm of NHS Gloucestershire. However this Trust works closely
with the commissioners to agree our services and take into account how health
inequalities can be reduced. An example of how we do this is the work of the
Intensive Health Outreach Team. This team works across services and sectors
to meet the health needs of people with a learning disability and thereby reduce
health inequalities.
What are the health inequalities faced by those with a learning disability?
There are about 11,000 adults with learning disabilities in Gloucestershire. This
Outcomes: how are we doing?
number is expected to rise by 15% by 2030, including a 59% increase in those
aged 65 years and over because people are living longer. People experience ill
health as often as or more often than the general population, but are less likely
to seek or receive appropriate healthcare and often die at a younger age.

Older adults are more likely to develop dementia, with those who have
Down’s syndrome developing dementia up to 40 years earlier than the
general population.

Epilepsy is at least 20 times more common in people with a learning
disability

Family and other carers can find it difficult if they cannot access the support
they need to help them care.
Do we know how well or not we are doing compared with national
figures?
Local figures for dementia are currently only available at GP register level.
However these figures probably under-estimate the true prevalence of
dementia which may be difficult to diagnose in the early stages. This is being
addressed locally as part of the implementation of the National Dementia
Strategy. Meanwhile it is suggested that dementia is likely to be an increasing
Goal 1
burden on the health economy in the coming years1.
8
Outcome 1.1: Services are commissioned, designed and procured to meet the health
needs of local communities, promote well-being, and reduce health inequalities
What services do we have which meet the health needs of local
communities, which promote well-being, and reduce health inequalities?
The Intensive Health Outreach Team was set up in 2009 to address the health
inequalities set out in the Department of Health’s ‘Valuing People’ paper 2001,
and Valuing people now: a new three-year strategy for people with learning
disabilities : Department of Health - Publications.
The 2001 paper sets out the higher prevalence of health needs as experienced
by those with a learning disability, their higher levels of marginalisation and
Outcomes: how are we doing?
lower levels of access to health care.
Working with the Commissioners in the county and in recognition of the poorer
health outcomes for people with a learning disability the Intensive Health
Outreach Team were seen as a way of enhancing mainstream services for this
group of people. The purpose of the team is to bridge the gap between
services, enabling more information to be available to ensure a better
diagnosis. In addition the Intensive Health Outreach Team can work with carers
to ensure they have the right skills and can better record and report symptoms
which can again be used to improve the information available for a diagnosis.
The team have no fixed working pattern. Each service user is assessed to
determine their specific requirement for support taking into account risks and
the intensity of support required. The team have developed a ‘reasonable
adjustment’ tool which can be used for example when working in partnership
with another health provider. This tool may be used where the team identify that
an individual because of their health needs requires a forty minute consultation
with their GP rather than twenty minutes and that to provide the person with
access via a back door to the Surgery would address their levels of anxiety.
Goal 1
These actions actively address health inequalities and improve health
outcomes for an individual.
9
Outcome 1.1: Services are commissioned, designed and procured to meet the health
needs of local communities, promote well-being, and reduce health inequalities
How have we worked across services and different parts of the NHS to
meet the health needs of local communities, promote well-being, and
reduce health inequalities?
The
Commissioners
set
up
a
multi
agency
group
which
representatives of Gloucestershire NHS Hospitals Trust,
included
2
gether NHS
Foundation Trust, NHS Gloucestershire and GPs. This group looked broadly at
what could be done to improve the health outcomes for people with a learning
disability, looked at what was known about the population and what was known
about their needs.
Outcomes: how are we doing?
The Intensive Health Outreach Team and the Learning Disability Hospital
Liaison Nurses are both good examples of collaborative working which reflect
the principles of the work of this group. The Learning Disability Hospital Liaison
Nurses have a strategic role to improve health outcomes at the pre-admission
stage, during a hospital admission and on discharge. They can ensure that the
‘reasonable adjustment tool’ is utilised and work collaboratively with the
Intensive Health Outreach Team.
The Intensive Health Outreach Team is able support service users in a wide
range of settings including people's own homes, assessment and treatment
units, care homes, local authority run respite centres as well as delivering care
at the general hospitals alongside mainstream primary and secondary health
services. The team has also been a valuable resource for signposting carers,
and playing an educational role to other professionals, service users and
carers. They can deliver services 24 hours per day.
The Hospitals Trust now has in place a ‘flagging’ system to indentify someone
who is known to have a learning disability. This can help with ensuring that
Goal 1
health inequalities can be addressed on admission. Working with GPs it is now
possible to track the journey of someone with a learning disability through all
NHS services to better meet health needs.
10
Outcome 1.1: Services are commissioned, designed and procured to meet the health
needs of local communities, promote well-being, and reduce health inequalities
A case study
An individual of 64 years of age with a diagnosis of Down’s syndrome, learning
disability and Dementia and was referred to the Intensive Health Outreach
Team in late 2010. This person also had many other health issues including an
under active thyroid, arthritis, epilepsy, type 2 diabetes and a pace maker.
Since the onset of Dementia there had been a loss of ability to move
independently and this person would no longer use their few known words.
All skills for self care and feeding had also been lost and this individual was
now totally reliant on carers for all activities of daily living, and also was refusing
Engagement
to leave the house.
This individual was living in a care home and had been referred to the Intensive
Health Outreach Team by the East County Learning Disability
Team which is another 2gether service.
The Intensive Health Outreach Team visited the home. The team made an
assessment to determine why this individual was so distressed. Their
observations were taken over an extended day to ensure a comprehensive
picture was obtained. They:

observed pressure areas which had previously been undetected

undertook blood glucose monitoring to provide baseline information for the
GP

considered whether medication was impacting on levels of distress

observed that ‘poor positioning’ could be improved by Occupational Therapy
input
Goal 1

observed the person’s reaction to seeing reflections in the windows of the
conservatory after dark
11
Outcome 1.1: Services are commissioned, designed and procured to meet the health
needs of local communities, promote well-being, and reduce health inequalities
The team took the following actions:

Worked with the GP and the GP undertook a review of medication

Through the GP, the team made contact with the District Nurse

A new care plan was drawn up which supported physical and mental
wellbeing

Made a referral to Occupational Therapy for a review of equipment

The team provided the care home staff with basic training to identify early
warning signs of deteriorating health and thereby reduce the
likelihood of hospital admission

A joint care plan was developed with the GP for the care home staff

Worked with care home staff to ensure that this person received the right
level of personal care to reduce incontinence which was causing distress

the team gave advice on promoting a suitable environment which included
ensuring that the person was not left in the conservatory at times when their
own or others’ reflections could be seen which because of the Dementia
caused distress.
What we have done to ensure that people with a learning disability and
particularly those with dementia have been involved and engaged in
improving services?
Gloucestershire Voices is a group of people with LD who will speak up and act
for all people living and working in the county who are struggling with different
learning disabilities.
The Big Plan is the Learning Disability strategy for Gloucestershire. It sets out
how Gloucestershire County Council and NHS Gloucestershire intend to plan
services for people with a Learning Disability, their families and carers over the
next five years (2010-15). The Big Plan is informed by the work of the LD
Goal 1
Partnership Board which is made up of clients, service users, carers and staff
from the County Council, Social Care, NHS and voluntary organisations.
12
Outcome 1.1: Services are commissioned, designed and procured to meet the health
needs of local communities, promote well-being, and reduce health inequalities
What else will we do to reduce health inequalities for older people with
dementia? When will we take action?
The Intensive Health Outreach Team have identified that there can be issues of
dehydration and poor nutrition for people with a learning disability and
particularly those of an older age, with or without dementia. These same issues
are experienced in services provided to older age adults regardless of the
sector. In addition it can be that carers may not recognise general signs of ill
health or recognise signs of dementia. Where the team take a referral, they will
offer follow up training to the carers / providers with the intention that this will
improve the wellbeing of the individual referred and others receiving care from
the same provider. It will also reduce the likelihood of hospital admission or readmission. This can have significant health benefits and demonstrates more
Improvements
effective use of resources across NHS services and the third sector.
The team will work with the 2gether Health Facilitation Team in 2012 to ensure
training provided to the third sector maximises lessons learnt.
The photograph below shows the Intensive Health Outreach Team receiving
Goal 1
recognition and the annual Chief Executive award for their work in 2010.
13
Outcome 1.1: Services are commissioned, designed and procured to meet the health
needs of local communities, promote well-being, and reduce health inequalities
What other work or evidence does the Intensive Health Outreach Team
have which might be relevant to this outcome or other outcomes?
During and after the grading event on the 7th February a number of cases were
described by the team which also relate to Outcome 1.2 and 1.3. All cases are
individuals who have a learning disability:
One individual was in the homeless shelter. District Nurses had difficulty
engaging with the man because of his intimidating behaviour. The man had
Trench Foot and was very vulnerable. The team worked with him to gain his
trust and acceptance of them by taking part in social activities and
communicating with him in a way which met his language skills. Over a period
Other evidence
of time they were able to gain his confidence and through linking with Podiatry
services and the Tissue Viability Nurse improve his care and the treatment for
his feet. District Nursing contact remains difficult because of his behaviour but
there is now contact and input from the GP for medication.
The team has very few referrals from Black or Minority Ethnic families or
individuals. However one member of the team is Muslim and was recently able
to help with a family who were concerned that their daughter’s cultural needs
were not being met through existing providers. By working with the family in
both English and the family’s mother tongue it was possible to do an initial
health screening, provide information about the service in an alternative
language and signpost the family to carer support.
The team have few service users who are or have been pregnant. However one
young female with a personality disorder was referred to the service because of
Goal 1
her poor health and drug issues. Her health was affected by acquiring sexually
transmitted diseases through unsuitable relationships. Through working with
her, the team were able to identify that her drug usage was as a consequence
and impact of a late abortion.
14
Outcome 1.1: Services are commissioned, designed and procured to meet the health
needs of local communities, promote well-being, and reduce health inequalities
She was unable to relate to young female staff or pregnant team members. The
team therefore ensured that those team members who had contact with her
were of an older age so that she would feel comfortable with them.
By ensuring the right level of contact and the right staff mix, the team are able
to ensure that the health needs of very vulnerable people can be assessed, and
by making the right links with other agencies and providers appropriate care
can be provided.
Other evidence
The team use Ri0 – the Trust’s electronic patient record and work with service
users to complete as much data as possible. Religion or belief can be difficult to
ascertain if the person’s language skills are limited and they do not live with
their family. Service users in residential settings often have carers who are
transient and background or family data may be very limited, so religion may
not be known.
The team have an operational policy which was written in 2009. It is in the
process of being updated as it no longer reflects the working practices. The
team no longer have beds as the focus of the work has moved to providng
support and care in individual’s own environments. Where hospitalisation is
required the team will support a service user into and out of local acute
hospitals so that the same care is available to them as can be accessed by
people who do not have a learning disability. This ensures that artificial barriers
Goal 1
are not introduced into care.
15
Outcome 1.1: Services are commissioned, designed and procured to meet the health
needs of local communities, promote well-being, and reduce health inequalities
What was the general feedback from engagement events that might apply
to this outcome?
Local interest group feedback
“[The NHS] needs to have a person-centred approach – we’re all individuals”.

It’s vital that each service user is seen as an individual person first and
foremost and that the diagnosis comes second – treat the individual rather
than let the process take over.

Good links with other agencies are vital to providing a good service, with a
multi disciplinary and professional approach.

There is currently a lack of collaborative working and transition between
services, which effects service users e.g. in cases of dual diagnosis,
duplications of assessments etc.

Have services which allow flexibility to provide personalised assessment,
care and place of care throughout person’s care pathway (including
discharge).
This case study was shared at all four engagement events.
Participants were impressed with the approach taken by the team and the
positive impact of their work. Participants agreed that preventing hospital
admission was in the best interests of the individual and that hospital admission
was costly. However questions were raised as to how or whether it was
possible to demonstrate that intensive input prevented hospital admission and
that this approach was ‘cost effective’. Work is being done with the
Commissioners to look at these questions although the anecdotal evidence is
that the service is cost effective.
What was the feedback from our ‘Grading’ event on the 7 th February 2012
or what additional information was provided which has contributed to the
overall grading?

This case study addressed specific issues related to disability, physical
Goal 1
health and age.
16
Outcome 1.1: Services are commissioned, designed and procured to meet the health
needs of local communities, promote well-being, and reduce health inequalities
 The case study was not gender specific and religion/ belief; race; gender
reassignment and sexual orientation were not highlighted as contributing to
the health inequalities for this individual. However additional examples were
given which indicated that the service is sufficiently flexible to ensure health
needs can be addressed in an holistic way regardless of protected
characteristic and the approach is used with all service users.
A number of cases were described by the team which also relate to Outcome
Local interest group feedback
1.2 and 1.3. All cases are individuals who have a learning disability:

One individual was in the homeless shelter. District Nurses had difficulty
engaging with the man because of his intimidating behaviour. The man had
Trench Foot and was very vulnerable. The team worked with him to gain his
trust and acceptance of them by taking part in social activities and
communicating with him in a way which met his language skills. Over a
period of time they were able to gain his confidence and through linking with
Podiatry services and the Tissue Viability Nurse improve his care and the
treatment for his feet. District Nursing contact remains difficult because of
his behaviour but there is now contact and input from the GP for medication.

The team has very few referrals from Black or Minority Ethnic families or
individuals. However one member of the team is Muslim and was recently
able to help with a family who were concerned that their daughter’s cultural
needs were not being met through existing providers. By working with the
family in both English and the family’s mother tongue it was possible to do
an initial health screening, provide information about the service in an
alternative language and signpost the family to carer support.
Goal 1

17
Outcome 1.1: Services are commissioned, designed and procured to meet the health
needs of local communities, promote well-being, and reduce health inequalities
 The team have few service users who are or have been pregnant. However
one young female with a personality disorder was referred to the service
because of her poor health and drug issues. Her health was affected by
acquiring sexually transmitted diseases through unsuitable relationships.
Through working with her, the team were able to identify that her drug usage
was as a consequence and impact of a late abortion.

By ensuring the right level of contact and the right staff mix, the team are
able to ensure that the health needs of very vulnerable people can be
assessed, and by making the right links with other agencies and providers
Local interest group feedback
appropriate care can be provided.

The team use Ri0 – the Trust’s electronic patient record and work with
service users to complete as much data as possible. Religion or belief can
be difficult to ascertain if the person’s language skills are limited and they do
not live with their family. Service users in residential settings often have
carers who are transient and background or family data may be very limited,
so religion may not be known.

The team have an operational policy which was written in 2009. It is in the
process of being updated as it no longer reflects the working practices. The
team no longer have beds as the focus of the work has moved to providing
support and care in individual’s own environments. Where hospitalisation is
required the team will support a service user into and out of local acute
hospitals so that the same care is available to them as can be accessed by
people who do not have a learning disability. This ensures that artificial
barriers are not introduced into care.

The Trust actively works with its Governors and membership to keep them
informed and involved in the delivery of services. A service experience
Goal 1
committee meets on a regular basis (see Outcomes 2.3 & 2.4) and service
user groups exist across the Trust (see Outcome 3.1).
18
Outcome 1.1: Services are commissioned, designed and procured to meet the health
needs of local communities, promote well-being, and reduce health inequalities

Whilst the original case study did not demonstrate work across all protected
characteristics,
the
additional
evidence
covered
most
protected
characteristics.

There appeared to be a lack of well-developed reporting structures to
Local interest group feedback
ensure information could be easily captured to demonstrate evidence
against the Equality Delivery System.

It was accepted that as part of the holistic approach, health inequalities are
identified and addressed on a one to one basis.

The team have a remit to work with carers, care agencies and across NHS
services. Training and support is available to all carers and this is integral to
improving well-being and reducing inequality.

There was evidence that although central Trust patient data reporting
systems offer limited information about protected characteristics, within
teams an holistic approach can put into practice work that may not be
captured centrally.
Goal 1
Initial / draft grading: Achieving
19
Outcome 1.2: Individual patients’ health needs are assessed, and resulting services
provided, in appropriate and effective ways
This case study looks at the health and social needs of a patient at Her
Majesty’s Prison – Gloucester. This case study also looks at homeless
people, their social exclusion, the impact this has on their health needs and
how their needs can be assessed on an individual basis. It should also be
considered alongside the case studies in Outcomes 1.1, 1.3 and 1.5.
What are the health needs of the homeless? Locally, are we doing better
or worse than the regional or national picture?
Over half of all homeless people have long-term problems with their physical
health. However, homeless people are one of the groups most excluded from
health services. It can be difficult to access mainstream services without a
Outcomes: how are we doing?
permanent address, making it possible to end up with a situation where
homeless people avoid services and the services avoid them.2
Homelessness is both a cause and effect of issues such as substance
misuse, offending and mental ill health. These factors on their own make this
group vulnerable to poor health and make tackling other problems such as
housing and unemployment difficult.3
In addition to those regarded as statutorily homeless there are many people
living in hostels and refuges, bed and breakfasts, squats, unsatisfactory
accommodation, and on the floors or sofas of friends and families, that have
not accessed the services provided by the local authority. This means that
they are often not known to services, despite meeting the legal definition of
homelessness.4
In 2010, Tewkesbury and Gloucester had higher rates of homelessness than
the county as a whole and the South West, but equal rates to England. This
Goal 1
means that in 2010 a total of 267 households in the county were homeless
and in priority need (as assessed by the local authorities).
20
Outcome 1.2: Individual patients’ health needs are assessed, and resulting services
provided, in appropriate and effective ways
Mental health problems can lead to homelessness and be made worse by
being homeless. Homeless people are also more likely than the general
population to have a history of childhood neglect or abuse.
Three quarters of single homeless people and more than four fifths of street
sleepers have a history of substance misuse. 5 Drug users are seven times
more likely to be homeless than the general population.6
Currently information on the health of homeless people in Gloucestershire is
Outcomes: how are we doing?
limited. However national data from 2010 highlighted the following health
issues.7

The average life expectancy of a street homeless person is 42 years old.

Street sleepers are 35 times more likely to attempt suicide than the
general population.

80% of people using homeless services have one or more physical health
needs.

70% of homeless people have one or more mental health needs compared
to 30% of the general population.

80% of homeless people used a GP in the last six months.

40% had been to the Emergency Department at least once and 33% had
been admitted to hospital.

a third regularly eat less than two meals a day

31% of homeless people had an inpatient stay over a six-month period
compared to 7% of the general population over a 12-month period.

77% of homeless people smoke compared to 21% of the general
population.

Goal 1
5
21
Outcome 1.2: Individual patients’ health needs are assessed, and resulting services
provided, in appropriate and effective ways
 Over 50% of homeless people use drugs and 20% drink alcohol at harmful
levels.

The average length of stay in hospital for a homeless person is 6.2 days
compared to 2.1 days for the general population. 2
Background
Mr X is 39 years old; he is originally from the north of England but has lived in
and around Gloucester for the last 10 years. He has no known contact with
his family and is very reluctant to enter into any discussion on this; he has
referred to a strict Roman Catholic upbringing but not in any detail. Many
Outcomes: how are we doing?
professionals who have had contact with him suspect that there is a history of
abuse of some kind.
He is heterosexual, has no disabilities and no history of serious illness or
injury. He is of normal intelligence but states he never finished school and has
no qualifications or work history of note.
He states he began using drugs (heroin) at the age of 27 and considers this to
be the start of his addiction problems. However he was a very heavy drinker
from his teenage years which progressed to drug use during his twenties
when
he
started
using “recreational drugs” such
as cocaine and
amphetamine. Heroin use was a natural progression for him and he also has
a very significant problem with benzodiazepines, codeine-based drugs and
continues to drink very heavily.
He has been in prison numerous times for petty offences such as affray and
drunken criminal damage but also has convictions for burglary (committed to
Goal 1
pay for drugs & alcohol).
At the time of admission, Mr. X was homeless, having been evicted from
social housing for non-payment of rent and anti-social behaviour.
22
Outcome 1.2: Individual patients’ health needs are assessed, and resulting services
provided, in appropriate and effective ways
He was not eligible for housing in any other social housing as he had a history
of similar problems. He had no GP and had been accessing healthcare via the
Homeless Healthcare Team and other support at the Vaughan Centre,
Gloucester. He has active Hepatitis C.
He was considered to have removed himself from active drug/alcohol
treatment because he stopped attending a supervised consumption clinic for
methadone and did not respond to attempted contact from his Care Coordinator.
Outcomes: how are we doing?
What have we done to ensure that services to people in prison address
their immediate?
Mr. X was referred to the Integrated Drug Treatment Team at the Prison. He
was subsequently assessed and prescribed methadone maintenance, alcohol
detoxification and diazepam stabilisation programmes. He remained under the
Integrated Drug Treatment Team who continued to monitor his response to
treatment and mental health. He stabilised physically but remained erratic in
his behaviour with unrealistic expectations of himself and the treatment he
was offered.
He was offered access to psychosocial programs & support via the Substance
Misuse Team including 1 to 1 sessions looking at drug use, relapse
prevention, harm reduction, etc which are patient led using problem solving
techniques’. However he found group situations difficult due to reduced
attention span and poor short term memory, but responded better to 1 to 1
sessions where they could be offered. It can be difficult at times to offer one to
Goal 1
one’s due to limited availability of therapeutic environments.
23
Outcome 1.2: Individual patients’ health needs are assessed, and resulting services
provided, in appropriate and effective ways
Ongoing physical health observations were undertaken by healthcare staff
and Mr. X was referred onwards regarding his Hepatitis C infection. However
this only involved monitoring of liver function and viral load as there was no
possibility at that time of Mr. X being able to access and complete the
required 48 weeks of antiviral treatment.
How do we ensure that we work across services and traditional
boundaries to meet the health needs of the homeless?
Outcomes: how are we doing?
For onward care, community agencies such as housing providers will offer
assessment before release where possible. There is a new initiative called the
“Atlas Project” locally that would be ideal for him as it involves intensive
support, housing, access to healthcare, etc in a co-ordinated system, however
places are limited.
It would be hoped that he would engage with services and work to prevent
relapse to drinking and drug use, however it would take a determined, coordinated and reliable service for him to truly engage. The issue of motivation
is enormous with patients such as this as they have often attempted to
address their problems in the past with variable results due to both their own
capacity and that of services in being able to deliver what is needed where
such complex issues are evident.
Where all plans come together effectively the ideal scenario would put Mr. X
in supported accommodation, he would not be drinking or using drugs and
should mean less likelihood of reoffending. Once stability was established,
Hepatitis C treatment should help prevent further deterioration in his health
Goal 1
with the resultant liver problems that are currently almost inevitable.
24
Outcome 1.2: Individual patients’ health needs are assessed, and resulting services
provided, in appropriate and effective ways
How have we involved and engaged the homeless in ensuring that we
can improve their health care?
Gloucestershire PCT has set up the “Improving Health Services for Homeless
People in Gloucestershire” project to fully understand the health needs in the
population, set priorities, survey service users and stakeholders, target
services
to
meet
essential
criteria
and
identify
appropriate
health
interventions, systems and service provision.
Research was completed and published in August 2011 which aimed to gain
a
detailed
insight
into
the
health
needs
of
homeless
people
in
Gloucestershire. The two key aspects of the research were to understand the
Engagement
physical and mental health problems faced by homeless people, and to
understand their experience of health care in the county. This research
focused on the collection and analysis of qualitative data through 60 in-depth
interviews with people who have experience of homelessness and a series of
interviews with representatives of key agencies/Stakeholders who worked
with or represented homeless people.
Interviewees raised issues around the following:

Lack of time to raise all relevant issues with GPs, health visitors etc when
anxious about homelessness.

GP surgery staff / GPs and dentists often make verbal judgements /
discriminatory remarks.

Many GPs do not understand the reality of homelessness and living on
benefit level incomes.

Difficulty in maintaining a healthy diet if homeless and reliant on free
Goal 1
meals.

Illegal drugs are readily available and are often used by those with
underlying mental health issues to self-medicate.
25
Outcome 1.2: Individual patients’ health needs are assessed, and resulting services
provided, in appropriate and effective ways
 Specialist services, Homeless Healthcare Team, Vaughan Centre, Trinity,
Family Haven, and Marah do not “judge”, but understand the reality of
homelessness, and people trust the staff.

Changes to drug maintenance services that take away the individual’s
feelings of control cause anxiety and negativity – e.g. go from
maintenance to clean within 12 months.
Engagement

Homelessness is an uncertain time and impacts significantly on mental
health.
This work has been presented to NHS Gloucestershire in the report
‘Improving Health Services for Homeless People in Gloucestershire –
Health Needs Assessment’
Across the Trust patient or service user groups are widely used to gain
feedback and influence how services are provided and reflect the needs of
individuals in our services. There are added dimensions and difficulties in
engaging with patients in the Prison Service because the population may be
transient or they do not wish to engage. However regular meetings are held
and staff actively respond to the feedback and support patients to attend.
What else do we need to do and when are we going to do it?
Improvements
NHS Gloucestershire will publish a Homeless Health Needs
Assessment for Gloucestershire in 2011, which will provide us with local
health information which staff in this Trust will be able to access.
The Gloucestershire Homeless Health Needs Assessment will inform what
Goal 1
health services are provided for homeless people in the future.
26
Outcome 1.2: Individual patients’ health needs are assessed, and resulting services
provided, in appropriate and effective ways
Work needs to be undertaken across statutory, voluntary and
Improvements
Community organisations to understand the extent of homelessness in the
county, particularly for those who are not considered to be statutorily
homeless.
The Integrated Drug Treatment Team continue to work proactively with
prisoners and ensure that as far as possible appropriate care is provided for
both physical and mental health.
What was the general feedback from engagement events that might
apply to this outcome?


Local interest group feedback


If a service user does not understand or accept the diagnosis they can feel
out of control, and that things are being done to them, not with them – a
holistic, person centred approach should stop this from happening.
Certain communities are hidden or forgotten when we design or deliver
services. We need to ensure that their voices are heard.
Good links with other agencies are vital to providing a good service, with a
multi disciplinary and professional approach.
Use voluntary and community groups to reach isolated people and enable
staff to spend more time tailoring care to patients.
What was the feedback from our ‘Grading’ event on the 7 th February
2012 or what additional information was provided which has contributed
to the overall grading?

This case study reflect gender, age and in the main social exclusion.

It demonstrated working across NHS services and work with the other
sectors although it was accepted that more work needs to be undertaken
across statutory, voluntary and Community organisations and this applied
to all NHS organisations

It was accepted patient data was either not collected or there was not
Goal 1
much evidence for particular groups including the Traveller / Gypsy
community, people from an Eastern European background and the trans
community.
27
Outcome 1.2: Individual patients’ health needs are assessed, and resulting services
provided, in appropriate and effective ways
 There was evidence of proving an holistic approach to care and that on a
case by case basis there was evidence to demonstrate that staff took into
account health inequalities however the patient data did not cover all
Local interest group feedback
protected characteristics.

Patient groups are set up and it was acknowledged that there are added
dimensions and difficulties in engaging with patients in the Prison Service
because the population may be transient or they do not wish to engage
and yet these groups were actively supported.

There were some plans to improve the service but these were limited.

It was accepted from the evidence provided against other outcomes that
the Trust actively works with its Governors and membership to keep them
informed and involved in the delivery of services. A service experience
committee meets on a regular basis and service user groups exist across
the Trust.
Goal 1
Initial / draft grading: Achieving
28
Outcome 1.3: Changes across services for individual patients are discussed with
them, and transitions are made smoothly
This case study looks at the work of the Crisis Teams which work out of a
variety of locations across the county and how they have supported the
transition of care from a GP to their team and back again for a Traveller
family.
What are the difficulties that the Traveller Community experiences and
what can Crisis Teams do to ensure a smooth transition?
Most referrals to the Crisis Teams are made from GPs. Some GPs have good
links and relationships with Traveller communities or with individual Traveller
Outcomes: how are we doing?
families. A referral to the Crisis Team will usually be made at the point that the
GP has concerns about the wellbeing of an individual for example when
displaying psychotic behaviour. This can be demonstrated by lack of sleep,
behaviour that is bizarre and out of the ordinary, feelings of being unsafe,
becoming obsessed with something or someone. The Crisis Team as part of
any assessment have to think broadly about what might trigger the current
condition and that would include considerations of substance misuse. The
Crisis Team usually work with individuals and their families in their own
homes although as an alternative appointments can be made for service
users to attend a locality base.
In this case a young man was referred to the Crisis Team by the GP at the
point the GP became concerned that the individual may need hospital
admission because of his symptoms. It was not possible or acceptable to the
family for the young man to have an appointment, with the Crisis Team at the
Team’s base, and there was no question of the team visiting the family on
Goal 1
site.
Through discussion with the GP and the family it was agreed that the Team
would attend the Surgery. This reflected the needs of the family and the
family’s concerns for the care of their family member.
29
Outcome 1.3: Changes across services for individual patients are discussed with
them, and transitions are made smoothly
The Surgery was seen as a ‘place of safety’ by the family and was a reflection
of the relationship which the family had with the GP. The GP and the Crisis
Team worked collaboratively to ensure that this solution was managed
smoothly and successfully.
The Crisis Team explained what services they provided and also explained
their role. The Team were aware that if the young man’s condition were to
deteriorate there was a risk that his behaviour might result in police
intervention. Their initial task was to build a sense of confidence and
understanding with the family and respond appropriately to the different
reactions of individual family members. Of particular concern to the family was
Outcomes: how are we doing?
the anxiety that the team might in fact contact the police. However the team
were able to explain under what circumstance police involvement might occur
and under what circumstances hospital admission might be considered.
Communication and understanding between the Team and family was critical
in enabling the Team to provide an appropriate service. There was
considerable discussion about ‘consent to share’ and how this worked. It was
clear from discussions that the young man and the family wanted limited
contact with the Crisis Team. It was agreed that a core group of only two staff
would be involved in the young man’s care and that on all occasions one of
the two core staff members would be at an appointment. The gender and age
of the core staff were discussed and the team worked to preferences
indicated. As part of a routine assessment the Team ask a range of standard
questions about family background and any previous history of mental ill
health. The family were not prepared to share or discuss this information and
the Team had to work with limited information to support the young man.
Goal 1
It was agreed that a medical review would take place with the Consultant
Psychiatrist. Treatment options and medication plans were fully explained and
discussed with the young man and his family.
30
Outcome 1.3: Changes across services for individual patients are discussed with
them, and transitions are made smoothly
One consequence of the medication was that his ability to drive would be
impaired. This proved to be a difficult topic as the family’s business involved
driving and the young man needed to contribute to the family income.
Working closely with the family the team were able to bring an understanding
of how the medication worked and why driving was prohibitive. This enabled
the family to accept both the medication and the restrictions it imposed on the
whole family.
Outcomes: how are we doing?
Over a period of time, the Team gained the confidence and trust of the family
to the point that the core staff were allowed to visit the young man on site.
However the family were clear about the restrictions which accompanied this
which were based around a prescribed time to attend, no wearing of badges
or Trust identity, and a limit on the length of time of the visit. This posed
considerable problems for the team as the designated visiting time clashed
with a regular and necessary team activity. To accommodate the prescribed
time, the schedule for a number of team members had to be changed for the
duration of the care package. However it was felt that it was both necessary
and appropriate to make these adjustments for what proved to be a relatively
short period of time.
How does this compare with any regional or national data? Are we doing
better or worse? Give an example:
Our local data about how we deliver services to the Traveller community is
limited although some information is contained in the Trust’s Single Equality
Scheme. Contact between the Traveller community and mental health
services occurs infrequently. Whilst some information is available from our
Goal 1
electronic patient records much is dependant on what is recorded by the
clinician and what the patient wishes to declare.
31
Outcome 1.3: Changes across services for individual patients are discussed with
them, and transitions are made smoothly
Are Traveller communities less likely to be involved in discussions or
Outcomes: how are we doing?
experience poor transition across services?
Historically Gypsy and Traveller Communities were thought to form the
biggest single minority ethnic group in Herefordshire. There are no official
statistics of numbers for these communities in the county, but recent
estimates suggest there are between 800 and 900 individuals.
Source: Gypsy & Traveller Accommodation Assessment: Shropshire, Herefordshire,
Telford and Wrekin and Powys, Centre for Urban & Regional Studies, University of
Birmingham (July 2008)
Providing services in rural communities can be more difficult than for some
urban areas. Transition across services will rely on communication and
relationships between our services and other health providers.
Explain what we have done to work with the Traveller community to
ensure that changes are discussed and that transitions occur smoothly.
At the point that the young man’s symptoms had stabilised it was agreed with
Engagement
the family that his care would transfer back to the GP. The medication could
be managed by the GP. Visits and care from the Crisis Team cease which
enabled the family to return to a known and accepted relationship. The Team
wanted to ensure that the family knew and understood that the illness
experienced by the young man could re-occur and that if this was the case the
family could contact the Team directly. There has been no further contact with
the family since the transfer back to the GP but the Team believe that their
contact with family was genuinely appreciated.
Improvements
Goal 1
What do we still need to do to improve discussions and improve
transitions? What are we going to do and when?
The services available from mental health teams needs to be known as widely
as possible and the experiences of teams if shared can bring significant
advantages to individuals and groups.
32
Outcome 1.3: Changes across services for individual patients are discussed with
them, and transitions are made smoothly
What was the general feedback from engagement events that might
apply to this outcome?

The NHS ‘expects patients to fit in with its systems and processes’.
Frontline staff often lack the time or understanding to properly assess
individuals’ needs, including in relation to their carers and ‘significant
others’. This can disadvantage more vulnerable people and those with
complex needs, such as those with learning disabilities, older people, the
traveller community, and those who do not have English as a first
language.
Local interest group feedback

Some participants reported negative experiences where healthcare
professionals had been insensitive to or unaware of their needs including
‘unthinking actions’ (e.g. giving menus to people with visual impairments
without additional support to understand them) to NHS staff acting on
negative stereotypes associated with some communities (e.g. traveller
community).

Before accessing the service, people should know what it is and what is
does. The service should be well funded and fully flexible – available 24
hours a day, 7 days a week, in suitable locations – to ensure the service is
there when it’s really needed, is flexible to meet community needs, whilst
also providing stability.

There is still a poor general public attitude towards mental health.
Assumptions and prejudice are far reaching.

Fear of the stigma attached to using mental health services, the “labels” of
diagnosis and the lack of understanding around this e.g. not knowing what
will happen if they use a particular service, can prevent someone from
seeking help.

Some of our communities do not understand the NHS system, what is
Goal 1
available, and how to access services.
33
Outcome 1.3: Changes across services for individual patients are discussed with
them, and transitions are made smoothly
 People may not feel services are relevant to them principally related to
ethnicity and culture, and this can apply to people for whom English is not
their first language.

Staff need better awareness of individual cultures, traditions and customs
in order to better meet the needs of individuals, their carers and families

People do not understand how we use their data. They are concerned that
it will not remain confidential or anonymous. There may be limited
confidence in public authorities using data effectively to improve services.

Use voluntary and community groups to reach isolated people and enable
staff to spend more time tailoring care to patients.

Ensure staff are better informed about equality issues e.g. cultural
awareness, legislation etc
Goal 1
What was the feedback from our ‘Grading’ event on the 7 th February
2012 or what additional information was provided which has contributed
to the overall grading?

This case study was considered alongside the case studies in Outcomes
1.1, 1.2 and 1.5 which it was felt provided a wider view of transitions
across services.

Overall, age, gender, disability, sexual orientation were covered. Ethnicity
and language were not covered although there was additional evidence
suggested from Outcomes 2.1 and 2.2 which addressed these protected
characteristics. Social exclusion was extensively highlighted in a number
of the case studies.

The Trust has identified that for the services it provides, individuals or
groups with multiple protected characteristics were more likely to
experience poor transition of care and may be less involved in decisions
about their care. The case studies clearly demonstrated how an holistic
approach was taken to address the needs of individuals.
34
Local interest group feedback
Outcome 1.3: Changes across services for individual patients are discussed with
them, and transitions are made smoothly
 It was not clear from the evidence how service changes and transitions for
patients from protected groups compare with the changes and transitions
for patients as a whole.

It was accepted from the evidence provided against other outcomes that
the Trust actively works with its Governors and membership to keep them
informed and involved in the delivery of services. A service experience
committee meets on a regular basis and service user groups exist across
the Trust.

There are some good examples of how transition across services and
through mainstream services take place, but it was felt that this was not
well evidenced across all protected characteristics.
Goal 1
Initial / draft grade: Developing
35
Outcomes: how are we
doing?
Goal 1
Outcomes: how are we
doing?
Outcomes: how are we doing?
Outcome 1.4: The safety of patients is prioritised and assured. In particular, patients
are free from abuse, harassment, bullying, violence from other patients and staff,
with redress being open and fair to all
What have we done to reduce abuse, harassment, bullying and violence
towards service users specifically where this behaviour is as a result of
service users having one or more ‘protected characteristic’?
Evidence for this outcome has not yet been collated or graded
How do our patients’ experiences compare with any regional or national
data? Are we doing better or worse?
Are there any groups or communities which experience more abuse,
harassment, bullying and violence than others because of one or more
‘protected characteristic’? If yes what are we doing to address this?
36
Improvements
Engagement
Outcome 1.4: The safety of patients is prioritised and assured. In particular, patients
are free from abuse, harassment, bullying, violence from other patients and staff,
with redress being open and fair to all
What have we done to ensure that those who experience abuse,
harassment, bullying and violence because of one or more ‘protected
characteristic’ are engaged and involved in developing actions to
improve this situation? Give an example:
What work do we still need to do to improve the situation? What are we
going to do and when?
Local interest group feedback
What was the general feedback from engagement events that might
apply to this outcome?
What was the feedback from our ‘Grading’ event on the 7 th February
2012 or what additional information was provided which has contributed
to the overall grading?
Goal 1
Evidence for this outcome has not yet been collated or graded
37
Outcome 1.5: Public health, vaccination and screening programmes reach and
benefit all local communities and groups
This case study looks at the role of the Children and Young Peoples Service
as provided by 2gether NHS Foundation Trust. It shows how they work
across services to ensure that screening for mental health problems can
reach all communities and groups and enable mental ill health to be
Outcomes: how are we doing?
identified early in life.
Why is early screening and intervention important? Are children and
young people in Gloucestershire receiving better or earlier screening
than the rest of the country?
Gloucestershire is one of the healthiest counties to live in. Overall health
outcomes are better than the English national average. However it is also
known that half of lifetime mental health problems arise by the time people
are 14 years old and three quarters by their mid-twenties.8 Around 25 – 50%
of mental illness during adulthood could be prevented with effective
intervention during childhood and adolescence.9 It is crucial to put in place
programmes that improve early identification and intervention.
According to the Indices of Multiple Deprivation only 7.4% of Gloucestershire
residents live in neighbourhoods considered to be among the 20% most
Outcomes: how are we doing?
Goal 1
deprived in England.
What are the Children and Young People’s Service doing to reach out
to young people in these vulnerable groups?
The Service has staff who deliver training to other frontline care workers
across Gloucestershire to raise awareness of mental health and emotional
wellbeing. They also share information about common mental health
difficulties in children and young people and the importance of early
intervention and prevention.
Some of the training is targeted at BME communities as referrals for children
and young people from these communities are low.
38
Outcomes: how are we doing?
Outcome 1.5: Public health, vaccination and screening programmes reach and
benefit all local communities and groups
A programme is in place to support the Community Development workers to
deliver mental health training and Mental Health First Aid. They have
identified key stakeholders with whom there can be direct liaison, of
particular importance are the contacts with the Islamic School, Afro
Caribbean Association and the Chinese Association. Strong links have also
been forged with dedicated Gloucestershire County Council education staff
who work with ethnic minority groups and Travellers. The Community
Development workers have developed a range of leaflets (Bengali Chinese
Czech Gujarati Polish Urdu) to ensure communities understand their role.
What has the service done to ensure that their work is ‘joined up’
across the NHS and other providers in the county?
The Children and Young People Service has been commissioned by NHS
Gloucestershire and Gloucestershire County Council to provide frontline
training in mental health across the county to children’s services
practitioners. There is a county wide co-ordinated training plan being
developed which links with Gloucestershire County Council. There is
provision in the service specification to target vulnerable groups where
historically there is evidence that they have had difficulties accessing
services.
At a strategic level senior managers from the Children and Young People
Service are working in forums to co-ordinate training to ensure that whilst
content and delivery is consistent it can be targeted at and meet the needs
of areas of known disadvantage. These forums include the Suicide
Prevention Strategy Group and the Child Health Planning Group where the
expertise and knowledge from across care sectors can be effectively utilised.
Goal 1
Recently a multiagency campaign activity was planned to introduce the ‘5
ways to mental wellbeing’ through raising awareness and understanding with
school age children.
39
Outcome 1.5: Public health, vaccination and screening programmes reach and
benefit all local communities and groups
The campaign also aims to reduce mental health stigma through increasing
everyone’s understanding of their own health and to contribute to reducing
the stigmas associated with the use of mental health service use.
The plan was realised on World Mental Health day (10th October) with junior
school children in Stow-on-the-Wold Primary School. A session of activity
was facilitated by practitioners of the Children and Young Peoples Service
and a balloon launch activity followed to reinforce the learning points. The
Outcomes: how are we doing?
event was supported by the Community Involvement Team.
Very encouraging feedback was received from the Head Teacher of the
participating school, press coverage was achieved and a plan is now in
place to undertake a similar session on a monthly basis in different schools
across Herefordshire and Gloucestershire. There has been much interest
expressed and offers of support from partner organisations.
Successful launch events and market place information stalls were held at
‘City Works’ in Gloucester for children’s service’s practitioners and health
colleagues in partner agencies in July and September 2011. Over 60
attendees attended each event.
2
gether’s Children and Young people’s Service is actively working with
Rethink to develop a ‘siblings’ programme for children and young people.
The service were also chosen by Young Minds to develop/trial training for
practitioners across the agencies about the emotional and mental health
Goal 1
needs of care givers, funded by Comic Relief.
40
Outcome 1.5: Public health, vaccination and screening programmes reach and
benefit all local communities and groups
Are there any groups of children and young people who are
particularly vulnerable?
The 'Fair Society Healthy Lives' (The Marmot Review) 10 (see ‘Executive
Summary’ and ‘Indicators’) and highlighted the challenges faced by people
who start out life in difficult circumstances and the importance of early
intervention, specifically in children’s lives because of the tendency for
disadvantage to become multiplied as they go through life. Cycles of
deprivation frequently repeat from generation to generation. Individuals can
find it difficult to break these cycles without appropriate encouragement and
support at key times in their lives. Some examples of groups (in no particular
Outcomes: how are we doing?
order) where children and young people in those groups will be particularly
vulnerable:
1. Those experiencing mental ill health
2. Travellers
3. People with disabilities
4. People with brain injuries
5. Children in care
6. Children in single parent households
7. Carers in general and especially young carers
8. People who cannot speak or understand spoken/written English well
9. People for whom speech and/or hearing is not their principle means of
communication
10. People in poverty
11. People with a Learning Difficulty
12. People who are visually impaired
13. People who need, but are not receiving health, or social care services
14. Black and minority ethnic communities
Goal 1
15. People suffering from a life limiting illness
16. People whose lives are affected by the complex repercussions of
disability, long-term illness, or social care needs, who encounter different
services that do not ‘join up’
17. Asylum seekers and refugees
41
Outcome 1.5: Public health, vaccination and screening programmes reach and
benefit all local communities and groups
How are the Children and Young Peoples Service ensuring that those
who are vulnerable are engaged in reaching and benefitting all local
communities and groups?
There are a number of children and young people from BME communities
Engagement
who are members of the CYPS Children and Young People’s Board. This
Board carries out a number of tasks including site visits and assessments of
clinic locations to ensure they are child and young person friendly. They
have also written and performed a play about mental health which they are
performing in schools and to the public to reduce the stigma around mental
health problems and encourage improved access to services. Primary
mental health Workers are working with a number of practitioners from
community
groups
and
offering
advice
guidance
consultation
and
Improvements
supervision.
What can the service do to reduce exclusion and when will this
happen?
Community Development Workers and Children and Young Peoples
practitioners have devised feedback sheets to be used when visiting BME
groups. This is to ensure that their needs are understood and that services
Local interest group feedback
Goal 1
are configured and delivered in acceptable ways.
What was the general feedback from engagement events that might
apply to this outcome?
 Fear of the stigma attached to using mental health services, the “labels”
of diagnosis and the lack of understanding around this e.g. not knowing
what will happen if they use a particular service, can prevent someone
from seeking help.

Certain communities are hidden or forgotten when we design or deliver
services e.g. deaf people, carers, young people and people with learning
disabilities. We need to ensure that their voices are heard.

There is a lack of support in general from the other services that would
help with early intervention. This may be linked to the perception of
outside agencies that there is a “one-way relationship” with the Trust.
42
Outcome 1.5: Public health, vaccination and screening programmes reach and
benefit all local communities and groups
 Make access to advocacy a high priority. There needs to be a strategic
approach to this to encourage vulnerable groups to access advocacy
What was the feedback from our ‘Grading’ event on the 7 th February
2012 or what additional information was provided which has
contributed to the overall grading?

This Trust does not undertake public health, vaccination or screening
programmes. This responsibility lies with NHS Gloucestershire. However
there was evidence of teams raising awareness of mental health issues.
Local interest group feedback
The Community Development Workers are instrumental in improving
understanding of mental health amongst community groups. Specific
work has begun with children and via schools in the county.

From questioning there was evidence that staff had access to a Religious
and Cultural Guide (see Outcome 4.2) to help them understand the
impact that culture and religion can have on an individual or community
response mental ill health. This has been widely promoted in the Trust. In
addition, staff have access to equality and diversity training which can be
focused on particular clinical service needs over and above generic
equality and diversity training that is available to all staff. The Religious
and Cultural Guide is available on the Trust’s staff intranet and the Trust
web site as an example of good practice.

The Trust has the lead for social inclusion in the county and a social
inclusion strategy was developed and agreed in 2010/11

Case studies from Outcomes 1.1, 1.2 and 1.3 were also considered
relevant to this Outcome as these demonstrated efforts to take action to
educate groups and communities, other voluntary and statutory
Goal 1
organisations, and carers.
43
Outcome 1.5: Public health, vaccination and screening programmes reach and
benefit all local communities and groups
 It was accepted from the evidence provided against other outcomes that
the Trust actively works with its Governors and membership to keep
them informed and involved in the delivery of services. A service
experience committee meets on a regular basis and service user groups
exist across the Trust.

Key disadvantaged groups were identified and there was evidence that
work was targeted.

Leaflets are available in a number of different languages. Additional
evidence has been provided from Outcome 2.3 that the Trust has a
Translation Policy, staff are encouraged to offer their services as a
translator and British Sign Language and makaton can be provided.
Goal 1
Initial / draft grading: Achieving
44
Goal 2: Improved patient access and experience
Goal 2 states: “The NHS should improve accessibility and information, and deliver
the right services that are targeted, useful, useable and used in order to improve
patient experience”. There are four outcomes under Goal 2.
Goal
2. Improved
patient
access and
experience
Narrative
The NHS should improve
accessibility
and
information, and deliver the
right services that are
targeted, useful, useable
and used in order to
improve patient experience
Outcome
2.1 Patients, carers and communities can readily access services,
and should not be denied access on unreasonable grounds
Goal 2
2.2 Patients are informed and supported to be as involved as they
wish to be in their diagnoses and decisions about their care, and to
exercise choice about treatments and places of treatment
2.3 Patients and carers report positive experiences of their treatment
and care outcomes and of being listened to and respected and of
how their privacy and dignity is prioritised
2.4 Patients’ and carers’ complaints about services, and subsequent
claims for redress, should be handled respectfully and efficiently
45
Outcome 2.1: Patients, carers and communities can readily access services, and
should not be denied access on unreasonable grounds
This case study looks at difficulties that older people from a black or minority
ethnic background face with the onset of dementia and the work that the
Community Development Workers have been doing to increase awareness,
access and links between different service providers.
What difficulties do older people from a black or minority ethnic
background face in accessing dementia information or services?
Age and Ethnicity - National Context
Over the last two decades the number of elderly people (65+) from BME
population groups in the United Kingdom has increased from 3% in the 1991
Goal 2
Outcomes: how are we doing?
census to 8.2% in the 2001 census. This amounts to more than 530,000 BME
elders. By 2051 it is estimated that there will be 7.4 million BME older people
aged 50+, living in England & Wales, with 3.8 million 65+ (Manthorpe, 2011).
Table 1: Age and Ethnicity - Local Context
Ethnic Group
Number
White : Irish
1800
White : Other White
2200
Mixed : White & Black Caribbean
100
Mixed : White & Asian
100
Mixed : Other mixed
100
Asian or Asian British: Indian
700
Asian or Asian British : Pakistani
200
Asian or Asian British : Bangladeshi
100
Asian or Asian British : Other Asian
100
Black or Black British : Black Caribbean
600
Black or Black British : Black African
100
Chinese or other Ethnic Group : Chinese
300
Chinese or other Ethnic Group : Other
200
The estimated resident population by ethnic group aged 60+ (females) and 65+ (males) in
mid 2009 is 6700 (MAIDeN).
The majority live in Gloucester, Cheltenham and Stroud
46
Outcome 2.1: Patients, carers and communities can readily access services, and
should not be denied access on unreasonable grounds
Dementia is one of the most common disorders in old age. It is a syndrome
which may be caused by a number of illnesses where there is progressive
decline in multiples areas of function, including decline in memory, reasoning,
communication skills and the ability to carry out daily activities. There may be
impairment of emotional control, social behaviour and motivation, but no
clouding of consciousness.
Prevalence (the number of cases at any time) and incidence (the number of
Outcomes: how are we doing?
new cases per year) rise rapidly with age, approximately 6% of the population
over 65, rising to 30% over 90 years of age may be affected.
The impact of dementia is already hugely challenging to our society, with
800,000 people in the UK currently living with this condition. The number of
people with dementia is expected to double to 1.4 million in the next 30 years.
Currently the estimated number of people with dementia in minority ethnic
groups is around 15,000 in England. However, future projections of dementia
among BME elders will rise sharply as first generation migrants from the
1950s and 1970s move into the age risk for dementia.
Dementia in BME elders is not necessarily recognised and research has
shown that in general BME elders are at far more risk of misdiagnosis and
delayed treatment. The Alzheimer’s Society publication Dementia UK
(2007:36-37) has identified that 6.1% of all people with dementia from BME
groups are living with early onset, compared with only 2.2% of the population
Goal 2
as a whole. This indicates implications for policy, commissioning and care.
47
Outcome 2.1: Patients, carers and communities can readily access services, and
should not be denied access on unreasonable grounds
What have the Community Development Workers done to remove
barriers to dementia services?
Anecdotal evidence collected through direct contact with different BME
communities in the county indicated that a number of barriers exist for specific
groups to access NHS services. Barriers identified were:

lack of awareness of services for non-English speaking communities
specifically for the elderly (and increasingly so because of an ageing
population)

lack of knowledge about services available

lack of understanding of illnesses experienced by older people

specific lack of knowledge of dementia
Outcomes: how are we doing?
A number of events were held where translators and interpreters were
present. Translators were known to the community and based in the local
community which built confidence with attendees and also reduced the risk of
information being inaccurately translated. Nuances of community language
could be used to better and more accurately translate health terminology. A
range of leaflets (Bengali Chinese Czech Gujarati Polish Urdu) have been
produced by the Community Development Workers to improve understanding
of their role.
Dementia information sessions have been held for Asian Ladies and the
Chinese community. Both events were well attended with 40 plus people.
Feedback has been very positive and participants agreed that they had a
better understanding that dementia is NOT a normal part of ageing. Most
importantly people went away with the message that if they or family
members are concerned about their memory, they can see their GP or ring
the Managing Memory Service for support and help. It was understood that
whilst dementia cannot be cured, early intervention with medication can help
Goal 2
in slowing down the illness. A number of carers signed up the Positive Caring
Programme after the sessions which is hopefully a reflection of the success of
the awareness raising. The format for these events was informal as it was
noted that formal settings and methods can themselves be a barrier to both
engagement and understanding.
48
Outcome 2.1: Patients, carers and communities can readily access services, and
should not be denied access on unreasonable grounds
How have we worked with other providers and different parts of the NHS
to improve access to dementia services?
The events included representatives of the Alzheimer’s Society which was
useful as part of drawing a distinction between Dementia and normal signs of
ageing.
A key part of raising awareness was also to explain the difference between
depression, normal ageing and dementia. During facilitated discussions,
groups and individuals were signposted to the ‘Let’s Talk Service’ as run by
mental health services if depression might be an issue. Alternatively or as well
as this, individuals and groups were signposted to the Community
Outcomes: how are we doing?
Development Worker Team to ensure that any specific resources needed to
support access such as appropriate interpreters could be provided. This was
to ensure that known barriers were addressed at the outset.
These events also enabled service users and carers to access assessments
of needs and benefits, and which in some cases enabled adaptations to be
appropriately provided via Social Services. These were additional and
unplanned benefits for attendees.

A presentation about memory assessment services and information and
education services provided by Managing Memory 2gether was given to
members of the Forest Health Forum at their monthly evening meeting in
Bream, Forest of Dean.

Representatives from local statutory and non statutory health and social
care organisations and members of the public attend the forum meetings.

The Alzheimer’s Society in Gloucestershire has launched a new service
Goal 2
Good 2 Go for younger people with dementia. The 2gether Trust had an
information stand at the event and was represented by members of
Managing Memory 2gether Team which included the lead nurse for
younger people with dementia.
49
Outcomes: how are
we doing?
Outcome 2.1: Patients, carers and communities can readily access services, and
should not be denied access on unreasonable grounds

The Managing Memory 2gether service has developed a poster to raise
awareness of services available for people with dementia and carers in the
Cirencester Area and a general ‘business card’ and leaflet advertising the
service

Posters have been sent to all GP surgeries and other organisations in the
area. This will be followed up with talks to GP surgeries.
What have the Community Development Workers done to ensure that
older people from a black or minority ethnic group could be involved in
making dementia services more accessible?
Key to engagement was finding an appropriate engagement model. Work was
undertaken within communities and working with partners such as
Gloucestershire
County
Council
Social
Services,
the
Community
Development Support Team, the ‘Managing Memory Services Team’ at
2
gether; and the Dementia Awareness Group which is accountable through
Engagement
the County Dementia Board to the Primary Care Trust Commissioners.
It was determined that engagement needed to be specific and directly meet
the needs of individual groups or communities. In the main engagement was
‘personal’ i.e. on a one to one basis. It was targeted with information
cascaded through existing groups and community networks which avoided
resources were maximised and not duplicated. The needs of specific groups
were met e.g. Black Elders Club and venues were organised in the heart of
communities. The African Caribbean Community was also specific about the
nature of the event they wanted. Sessions were larger or smaller depending
on preference, and bespoke based on for example age or gender as in the
Improvements
Goal 2
case of the Asian Women’s Club.
What else do we need to do to improve access for this group of people
and when will we do it?
Feedback from these events was being collating during November 2011 and
will be used to inform the format of future events. This work highlighted the
need for health, social care and local authority organisations and their
frontline services to BME communities to be better integrated:
50
Outcome 2.1: Patients, carers and communities can readily access services, and
should not be denied access on unreasonable grounds

Improve and be smarter about communication

Share practice

Agree joint actions

Ensure regular networking

Continue with awareness raising of mental health and services to
communities

Provide mental health information to those under 16 years of age
These needs extend beyond the specific needs of older people from BME
communities and will be fed into other work undertaken by the Community
Development Workers, the Children and Young People’s Service amongst
others.
Improvements
Initial steps to address collaborative working across health, social care and
local authority organisations led to the formation of a joint working party which
includes membership from:

the 2gether Community Development Worker Team

Community Health Trainers

Gloucestershire County Council’s Adult & Social Care Directorate
Community Development Support Team

Cheltenham Borough Council

Gloucester City Council’s Benefit’s take-up team.
The Forum’s membership of organisations is not restrictive and Carers
Gloucestershire has expressed an interest in participating in the future.
Further work will be undertaken with Carina Sharpley of Gloucestershire
County Council to arrange an information session for Chinese carers in
Goal 2
conjunction with the Managing Memory Services.
The next step is to engage with the Polish Community. To meet their needs, a
Polish community event is planned for the 27th November.
51
Outcome 2.1: Patients, carers and communities can readily access services, and
should not be denied access on unreasonable grounds
This will be supported by Community Agents (Gloucestershire County
Council) the Community Development Workers (2gether NHS Foundation
Trust) and the Primary Care Trust.
This event is being funded by Cross
Roads (third sector care provider). The purpose of this event is to give
information on carers’ needs (specifically to those who care for individuals
with mental ill health). This work will link directly with work being undertaken
by the 2gether Carers Team and is consistent with BME Carers Action plan
Improvements
developed by Carers Gloucestershire to develop a network with specific
outcomes for BME carers.
A session for the African Caribbean community is planned for the end of
January 2012.
Work has also commenced with Delphine Butler, Gypsy and Travellers
Community support worker from Gloucestershire County Council, signposting
her to Managing Memory services and Benefits at City Council to enable her
to support her service users.’
Community Development Workers are collaborating with statutory, 3 rd sector
and independent services in Gloucestershire to produce a directory of
Local interest group feedback
Goal 2
services for people with dementia.
What was the general feedback from engagement events that might
apply to this outcome?

People may not feel services are relevant to them principally related to
ethnicity and culture, and this can apply to people for whom English is not
their first language.

Staff need better awareness of individual cultures, traditions and customs
in order to better meet the needs of individuals, their carers and families

Good links with other agencies are vital to providing a good service, with a
multi disciplinary and professional approach.
52
Outcome 2.1: Patients, carers and communities can readily access services, and
should not be denied access on unreasonable grounds

All information should be readily available and easily accessible to all, in
the most appropriate format e.g. pictorial, easy read forms

Some of our communities do not understand the NHS system, what is
available, and how to access services.

Language barriers exist for minority groups, especially where there is no
translator/interpreter available, leading to a delay in diagnosis and
treatment.
Goal 2
What was the feedback from our ‘Grading’ event on the 7 th February
2012 or what additional information was provided which has contributed
to the overall grading?

From questioning it was evident that the Trust has a Carers Charter (see
Outcome 2.3). This is available in standard format and ‘easy access’.

There was nothing specific about religious beliefs and the impact that this
may have on how service users, carers and communities may access
services. However from other outcomes it is evident that that staff had
access to a Religious and Cultural Guide (see Outcome 4.2) to help them
understand the impact that culture and religion can have on an individual
or community response mental ill health. This has been widely promoted in
the Trust. This has been developed by the Community Development
Workers. It is hoped that this will break down some of the barriers which
exist and enable individuals and communities to better access services.
However across the case studies there was evidence to demonstrate
access to services regardless of age, disability, religious belief, ethnicity,
gender, sexual orientation, plus clear cases related to social exclusion.
The Trust has the lead for social inclusion in the county and a social
inclusion strategy exists. There is a draft action plan for 2012/13

There was evidence about access to services at a national level based on
protected characteristics but no evidence to demonstrate how service
users and communities with protected characteristics compare at a local
level. It is acknowledged that patient data exists but not for all protected
characteristics.
53
Outcome 2.1: Patients, carers and communities can readily access services, and
should not be denied access on unreasonable grounds

A range of leaflets (Bengali Chinese Czech Gujarati Polish Urdu) has been
developed to reflect the local communities and the Trust has responded
specifically to feedback from service users and carers in developing
different formats for information about services.
Local interest group feedback

It was accepted from the evidence provided against other outcomes that
the Trust actively works with its Governors and membership to keep them
informed and involved in the delivery of services. A service experience
committee meets on a regular basis and service user groups exist across
the Trust.

There was evidence from the case studies and data under Goal 1 that the
Trust and individual services do take account of key disadvantaged groups
and in the main these were groups who had more than one protected
characteristic and therefore potentially faced multiple barriers or
disadvantages.

The Trust has plans to improve access and remove barriers and the
Community Development Workers along with the Community Involvement
Goal 2
Team are instrumental in this work.
54
Outcome 2.2: Patients are informed and supported to be as involved as they wish to
be in their diagnoses and decisions about their care, and to exercise choice about
treatments and places of treatment
This case study looks at the support that the Children and Young People’s
Service provides and how they work with the individual to ensure that choice
can be exercised.
What have the Children and Young Peoples Service done to ensure that
an individual can be involved in choices about their care?
A young person with low mood who was seriously self-harming was referred
to the Children & Young People’s Service. During the course of the
Outcomes: how are we doing?
assessment and treatment, the young person disclosed that they were gay
but hadn’t been able to tell family and friends. This was profoundly affecting
their mental health as they were unable to share thoughts or feelings and
were frightened of the consequences of coming out.
The clinician involved was able to help the young person talk through their
situation and discuss how to proceed. This enabled the young person to
share information with their family including their sexual orientation. There
were huge improvements in mood and overall emotional wellbeing. The
young person is now more accepting of themselves, has the support of their
family and has started a new relationship.
The young person was signposted to range of support groups that might be
useful. Having considered the situation the young person did not want to
contact local support groups but was empowered to acknowledge their
hopes and fears, and manage their feelings and relationships. This example
Goal 2
is not uncommon as a referral to the Children and Young people’s Service .
55
Outcomes: how are we
doing?
Outcome 2.2: Patients are informed and supported to be as involved as they wish to
be in their diagnoses and decisions about their care, and to exercise choice about
treatments and places of treatment
How does the Children and Young Peoples Service work across
services and different providers?
The Children and Young People’s Service has a very successful Parenting
Team which works intensively with Children’s Centre’s, Health Visitors and
School Nurses as well as participate in delivering outcomes identified at
multi agency groups. Services are also accessed by Paediatricians, GPs and
the full range of health practitioners working with children and young people.
How well are we doing in Gloucestershire?
Gloucestershire has achieved national recognition for the work done by the
Parenting Team. Outcomes are recorded as part of the programme and are
Outcomes: how are we doing?
comparable with similar services.
What are the Children and Young Peoples Service doing to ensure that
vulnerable children and young people can be informed and included in
making decisions about their care?
Young people who are not heterosexual or who may question their sexuality
often struggle with disclosing they might be gay or find it difficult to find
people with whom they can discuss these very personal and private issues.
This can severely affect their mental health and can lead to self harm or
even suicide. Clinical staff are able to give the young person the time and
space to explore the issues and work out what is most important for them.
Clinical staff will be aware of the discrimination and homophobia which is
present in society and the fears that often accompany coming out especially
Goal 2
to friends and family.
56
Outcome 2.2: Patients are informed and supported to be as involved as they wish to
be in their diagnoses and decisions about their care, and to exercise choice about
treatments and places of treatment
Whilst the issue of sexual orientation can have a huge impact on emotional
and mental wellbeing the service recognises that additional barriers to
accessing support may arise through language and cultural barriers.
Evidence demonstrated that parents and carers from the Polish and Asian
Outcomes: how are we doing?
communities were under represented in the referrals because of these
additional barriers.
The Children and Young People’s Service has a very successful Parenting
Team which delivers parenting programmes across the county according to
NIHCE guidelines, as well as to parents and carers from vulnerable groups.
To facilitate access to the Children and Young People’s Service, Parenting
Group Facilitators have been identified and trained to deliver the
programmes for the Polish and Asian communities. Facilitators are drawn
from these communities so that others will have confidence in them. As part
of developing these programmes key documents are translated for easier
access. The service now runs dedicated groups in Polish twice per year and
to Asian groups twice a year with the potential for more to be delivered if
funds/time allows. The venues used are easily accessed within localities for
example at local halls and Children’s Centres.
Engagement
How have the Children and Young Peoples’ Service engaged and
involved its service users?
The Children and Young Peoples’ Service has a dedicated participation
worker, a Children & Young People’s Board and access to advocacy and
support. Services are designed with children and young people involved to
Goal 2
ensure they are accessible and comfortable to use.
57
Outcome 2.2: Patients are informed and supported to be as involved as they wish to
be in their diagnoses and decisions about their care, and to exercise choice about
treatments and places of treatment
Recently the Children & Young People’s Board took part in Children’s Take
Over Day within the Trust. One of the events for the day was a play written
and performed publically by children and young people which was
Engagement
profoundly moving and insightful. Those involved gave interviews to Radio
Gloucestershire.
Parents and carers who have participated in the Parenting Programmes
provide session by session feedback. Some have gone on to become
facilitators in their own language to share the knowledge gained with peers.
This has enabled other parents and carers to access programmes as there
is an understanding of cultural norms and a common language
What else do we need to do to ensure that children and young people
from a BME background or those with issues related to sexual
orientation can be involved and supported with their care, and can
exercise choice about their treatments?
More work needs to be done to combat the stigma attached to attending
mental health services. The Children & Young People’s Board suggested the
Improvements
removal of the word ‘mental’ from the service title (formerly known as Child
and Adolescent Mental Health Service) in order to make the service more
socially acceptable.
We also recognise the need to support colleagues who are actively
combating discrimination against different sexual orientations in the care of
young people.
If appropriate and within the funding envelope, further work to address the
needs of BME communities in this way will be developed as it has proved to
Goal 2
be successful especially in delivering improved outcomes for families.
58
Outcome 2.2: Patients are informed and supported to be as involved as they wish to
be in their diagnoses and decisions about their care, and to exercise choice about
treatments and places of treatment
What was the general feedback from engagement events that might
apply to this outcome?

The service provided should be non-judgemental and welcoming, to calm
any fears that people may have about using mental health services, with
more emphasis on prevention/early intervention.

Fear of the stigma attached to using mental health services, the “labels”
of diagnosis and the lack of understanding around this e.g. not knowing
what will happen if they use a particular service, can prevent someone
from seeking help.
Staff may avoid asking questions for fear of appearing ignorant, but if
questions aren’t asked, vital information may be missed. Issues are
sometimes avoided, rather than practice changing to deal with
differences.
Local interest group feedback


Certain communities are hidden or forgotten when we design or deliver
services e.g. deaf people, carers, young people and people with learning
disabilities. We need to ensure that their voices are heard.

Good links with other agencies are vital to providing a good service, with
a multi disciplinary and professional approach.

Make access to advocacy a high priority. There needs to be a strategic
approach to this to encourage vulnerable groups to access advocacy.
What was the feedback from our ‘Grading’ event on the 7 th February
2012 or what additional information was provided which has
contributed to the overall grading?
This particular case study looked at age and in particular sexual orientation
in young people. Evidence from other case studies for Outcomes 1.1, 1.2,
1.3, 1.5 and 2.1 provided evidence about involving service users and carers
in choices about care related to disability, gender, ethnicity and social
exclusion. No evidence was provided about the trans community and there
Goal 2
was some information related to religion.
59
Outcome 2.2: Patients are informed and supported to be as involved as they wish to
be in their diagnoses and decisions about their care, and to exercise choice about
treatments and places of treatment
 There was only a small amount of evidence to demonstrate how
information to service users and carers helps them to be involved in their
care when compared with service users /patients / carers as a whole.
 A range of leaflets (Bengali Chinese Czech Gujarati Polish Urdu) are
available and the Community Development Workers have provided a
Religious and Cultural Guide for staff to enable staff to better inform and
Local interest group feedback
support service users and carers about their diagnoses and treatment.
 There was evidence that there were under represented groups within
specific services and that this was likely to be associated with language
barriers and cultural perspectives.
 Actions are being taken to address these disadvantages and ensure
service users can be better informed about the care that is available.
Leaflets for carers are available and the Trust has a Carers Charter. It is
recognised that more work needs to be done within certain communities.
 There was no evidence to demonstrate how translation services can be
accessed including access to British Sign Language, however this has
now been updated following the grading of Outcome 2.3. The Trust does
have a Translation Policy and staff are supported to act as translators via
the Trust’s Staff bank. There are formal processes in place to access
external translation services including British Sign Language and
makaton.
Goal 2
Initial / draft grading: Developing
60
Outcome 2.3: Patients and carers report positive experiences of their treatment and
care outcomes and of being listened to and respected and of how their privacy and
dignity is prioritised
What positive experiences have patients and carers reported about:
a) their treatment and care outcomes?
b) being listened to and treated with respect?
c) how their privacy and dignity has been prioritised?
Table 2: Range of compliments received by 2gether in Quarter 2 (Service
Experience Report)
Outcomes: how are we doing?
Service
TOTAL
Learning Disabilities
TOTAL
13
Children & Young People
TOTAL
1
Older Peoples
TOTAL
94
Working Age Adults
TOTAL
320
Herefordshire
TOTAL
70
Total number of recorded compliments from
service users / cares / other agencies
501
It should be noted that it has not been possible to produce these figures based
on the ‘reasons’ for the positive experience as stated in this outcome. Positive
experiences are very varied and examples of statements are:
 I would like to thank you and your team for your very prompt and
sensible advice … your helpful letter gave me everything that I
needed.
 I have received outstanding and dedicated care from the GRIP
team….they have helped me keep my daughter at home…and even get
back to work. This is a wonderful service and the level of care
received is second to none.

Goal 2
Corporate
Numbers
3
I really can’t begin to tell you how grateful I am to you….you will never
know how you changed my life…I know you saved me from ending it.
The Trust also runs an annual awards scheme which is open to service users
and carers to nominate individuals or teams for the quality of care they have
provided. Each year the Trust receives many nominations with compliments.
61
Outcome 2.3: Patients and carers report positive experiences of their treatment and
care outcomes and of being listened to and respected and of how their privacy and
dignity is prioritised
How do the positive experiences of our service users and carers differ
from any regional or national data? Are we doing better or worse?
Enabling people to experience NHS services that meet their needs continues
to be a key national strategic goal. To support this vision, the Government
published No Health without Mental Health (a cross-government mental health
outcomes strategy for people of all ages) in February 2011. One of the six
overarching objectives relates directly to service experience and states that
services must ensure that people have a positive experience of care.
The national context reinforces the critical importance of paying close attention
Outcomes: how are we doing?
to what patients and carers say about the services provided by 2gether NHS
Foundation Trust. The Trust should respond appropriately to their comments,
concerns and complaints and be proactive about the development of inclusive,
quality services.
Understanding the perspectives of service users and carers is a core value of
our organisation. A high level of importance is placed on gathering feedback
about how our services are experienced which enables us to be a learning
organisation by addressing any areas for improvement, providing evidence of
service experience outcome and to strive for the achievement of best practice.
The Care Quality Commission National Patient Survey results published in
August 2011 indicate that the experience of 2gether NHS Foundation Trust
services in Gloucestershire between January and April 2011 was ‘about the
same’ as in other mental health NHS Trusts in England.
The Director for Social Inclusion has reviewed the Trust’s local processes for
Goal 2
gathering service satisfaction information. This revealed that there are many
ways of gathering local satisfaction information. For example we can collect
information via computer surveys, service specific questionnaires, and hotelstyle feedback cards.
62
Outcome 2.3: Patients and carers report positive experiences of their treatment and
care outcomes and of being listened to and respected and of how their privacy and
dignity is prioritised
However this means that the information is requested in ways that do not
necessarily allow for correlation across services and that the resulting
information does not necessarily reach a central source for analysing the
information for the organisation. In order to offer strategic and efficient ideas
about developing such local surveys a Task and Finish group is recommended
Outcomes: how are we doing?
to review the work gathered and make recommendations about a way forward.
The Trust has developed a Carers Charter which sets out what carers can
expect from the Trust.
Are there any groups or communities of service users or carers who are
less likely to report positive experiences, less likely to be listened to or
respected, and less likely to have their privacy and dignity is prioritised?
If yes what will we do to address this?
The Care Quality Commission in collaboration with the National Mental Health
Development Unit published a census report in April 20114. This report holds
important broad information regarding the ethnicity and gender of in-patients in
NHS and independent mental and learning disabilities services in England and
Wales. It highlights how people’s service experience still differs depending on
their ethnicity and gender. In addition, people with a learning disability often
Goal 2
have difficulty in getting their experiences heard and understood.
63
Outcome 2.3: Patients and carers report positive experiences of their treatment and
care outcomes and of being listened to and respected and of how their privacy and
dignity is prioritised
What we have done to ensure that people who are less likely to be
listened to, respected or have their privacy and dignity prioritised
because of one or more ‘protected characteristic’ have been involved and
engaged in making changes which will improve their experiences?
The Learning Disabilities Service routinely invite a group of people who have
learning disabilities to review new 2gether initiatives (for example leaflets and
other publications) to ensure that they are accessible to people who finding
reading challenging. The group have met on several occasions and are
providing a valuable resource to influence the development of equitable and
accessible resources. This group called the ‘4 Me About Me Group’, won an
award at the 2011 annual awards event that recognises and celebrates
Engagement
outstanding achievements. Two service user group members attended the
event and were presented with their certificate of achievement.
Inclusion work has been underway to involve service users, carers and
communities in understanding the Trust’s new model of service delivery called
“Fair Horizons”. A reference group event was held on 1 st March 2011 and
service users, carers and people from a variety of communities attended. The
event yielded much positive engagement, helpful questioning and contributed
ideas to further the development plans. A second event was held on the 14th
June 2011.
Participants have requested more information on how dual diagnosis will be
managed and more information about the Trust’s response to supporting
people from the wide variety of ethnic backgrounds that are a feature of our
communities. All engagement events are captured in the Trust’s full equality
Goal 2
impact assessment for Fair Horizons.
64
Outcome 2.3: Patients and carers report positive experiences of their treatment and
care outcomes and of being listened to and respected and of how their privacy and
dignity is prioritised
A small group of people with dementia and carers have been meeting every
few months since February 2010. The group was formed primarily to support
Engagement
the development of the Managing Memory Service. The insights shared and
ideas generated through this work have contributed to:

a new session for the Managing Memory programme for people with
dementia and their carers called ‘Living Well with Dementia’

a ‘business card’ and leaflet advertising Managing Memory 2gether

feedback postcards for those assessed by the Memory Assessment Service

focus groups of carers, community partner organisations, service users and
2
gether staff have developed a Carers Charter.
What else do we need to do to improve the experiences of patients,
service users and carers? What are we going to do and when?
Systems have been successfully put in place to generate compliment reporting
Improvements
from Trust services in Herefordshire.
More work is needed to develop a robust system of teamwork across the Trust
to ensure that learning is achieved routinely from service experience feedback.
The Service Experience department have been working with colleagues in
Herefordshire to build an understanding of our service experience systems.
Connections with Herefordshire’s Multiagency Public Experience Committee
and Herefordshire Local Involvement Network (LINk) and Herefordshire’s
Goal 2
Mental Health Network have developed and meetings are attended routinely.
65
Local interest group feedback
Outcome 2.3: Patients and carers report positive experiences of their treatment and
care outcomes and of being listened to and respected and of how their privacy and
dignity is prioritised
What was the general feedback from engagement events that might apply
to this outcome?

All information should be readily available and easily accessible to all, in the
most appropriate format e.g. pictorial, easy read forms

Service users should be consulted about every aspect of their care and
treatment in a sensitive manner.

If a service user does not understand or accept the diagnosis they can feel
out of control, and that things are being done to them, not with them – a
holistic, person centred approach should stop this from happening.

We should also be responsive and understanding to carers needs, applying
the holistic approach to them just as much as the person that they care for.
What was the feedback from our ‘Grading’ event on the 7 th February 2012
or what additional information was provided which has contributed to the
overall grading?
Information is available via the Community Development Workers in respect of
their work and this is fed into the service experience report which would cover
ethnicity, religion and age. Outcome 1.5 also provides information about how a
young person was supported and was listened to in respect of accessing non
statutory services in connection with their sexual orientation.
Questions were asked about addressing the needs of service users with
sensory impairment. It was not known whether our inpatient facilities have
hearing loops although equipment can be hired locally.
The Trust has a Carers Charter which is available in standard and easy access
format.
Goal 2
The Trust is compliant with single sex accommodation and a declaration to this
effect is on the Trust web site click here.
66
Goal 2
Local interest group feedback
Outcome 2.3: Patients and carers report positive experiences of their treatment and
care outcomes and of being listened to and respected and of how their privacy and
dignity is prioritised
The Care Quality Commission National Patient Survey 2011 for people who
use community mental health services shows that for this Trust, service users
views on:
 the responsiveness of Health and Social Care Workers
 whether their views on medication were taken into account
 the usefulness of talking therapies
 their understanding of their care plan
 their views of their care co-ordinator
 the care review process
 and crisis care
were all in the intermediate level of Trust responses when compared across 65
NHS Trusts in England. Some responses were very close to the top 20% (best)
patient responses.
The national Count Me In Census which compares inpatient data across the
country has been officially ‘retired’ however inpatient data can be extracted
from the patient data base Ri0. Nationally young black men are be more likely
to be detained under the Mental Health Act and have higher than average
representation in inpatient facilities.
The Trust considers that people with multiple protected characteristics are less
likely to report positive experiences and less likely to have their privacy an
dignity prioritised. In 2010 this was identified as pregnant and young mothers in
in-patient wards who based on their gender, mental health and family status
had no appropriate facilities which respected their family life. Through the work
of one nurse, a family room was opened. This nurse won an award at the
Trust’s 2010 awards ceremony for her work and acknowledgement of the
needs of this group of service.
The Trust recognises the particular disadvantages of young men in prison who
have drug and / or alcohol misuse and are homeless. The multiple
disadvantages are actively managed by the Prison nurses to ensure there is
joined up working across NHS and non-statutory services to enable continued
physical care and mental health care to be provided (see Outcome 1.2).
Regular sessions take place with prisoners to raise issues related to their care
and enable these to be addressed.
67
Goal 2
Local interest group feedback
Outcome 2.3: Patients and carers report positive experiences of their treatment and
care outcomes and of being listened to and respected and of how their privacy and
dignity is prioritised
The Trust has a new policy on Translation (2011) which enables staff to use
their language skills via the Staff Bank as well as formal process to access
external translation services. British Sign Language and makaton are also
referenced and available.
The Trust’s new website enables Google Translate to be used translate the
text on the web pages.
The Trust continues to develop leaflets in a range of languages.
The Community Development Workers have produced A Religious and
Cultural Guide which is available on the Trust’s intranet and Trust web site.
This provides guidance to staff which enables them to respect the needs of
service users and carers based on their religious or cultural norms and thereby
offer dignity and positive experiences.
68
Outcome 2.4: Patients’ and carers’ complaints about services, and subsequent
claims for redress, should be handled respectfully and efficiently
What have we done to improve how we handle patient and carer
complaints? Give an example:
A new, more personalised approach was taken to acknowledging expressions
of dissatisfaction with our services by offering a swift conversation with a
member of the service experience team. This approach has also been
requested by carers who have been keen to explain their concern in greater
depth prior to an investigation being launched (point raised by Carers
Goal 2
Outcomes: how are we doing?
Gloucester through the Service Experience Feedback report for Quarter 2)
The time taken to acknowledge a complaint improved in the quarter July to
September 2011. 98% of complaints were acknowledged within the 3 day target
compared with only 88% in the previous quarter.
Table 3: Time to Acknowledge Complaints - October 2010 to September 2011
69
Outcome 2.4: Patients’ and carers’ complaints about services, and subsequent
claims for redress, should be handled respectfully and efficiently
What have we done to ensure that complaints which span more than one
service or NHS Trust are handled respectfully and efficiently?
The Trust draws its information from a variety of sources including:

Patient Advice and Liaison Service report (Gloucestershire)

Compliments, Comments and Concerns Information

Narrative reports made by members of the Service Experience
Outcomes: how are we doing?
Committee

Feedback from community groups that are seldom heard

Gloucestershire LINk information

Feedback from Carers Gloucestershire

Ad hoc meetings with stakeholders (eg Gloucestershire Young Farmers)

Public Experience meeting in Herefordshire

Herefordshire Public Involvement Team

Herefordshire LINk

Herefordshire Carers Support
Through a review of all data available it is possible to respond to concerns
which are raised which span more than one NHS service provider and to
demonstrate where effective action has been taken. Where the Trust is asked
to note specific concerns related to onward referral it is possible through a
review of clinical notes that to demonstrate that for example referral to Cancer
Care specialists has been made when clinical indicators (noted in NICE
Guidelines) are evident on medical assessment. Table 4 shows the range of
complaints received by the Trust and where those complaints relate to services
Goal 2
across more than one service or Trust.
70
Outcome 2.4: Patients’ and carers’ complaints about services, and subsequent
claims for redress, should be handled respectfully and efficiently
Goal 2
Outcomes: how are we doing?
Outcomes: how are we doing?
Table 4 – Complaints by Type – October 2010 to September 2011
Are there any groups or communities which are more likely to experience
a poor or inefficient response because of one or more ‘protected
characteristic’?
At the moment the Trust does not capture complaints and experiences by
‘protected characteristic’. However the opportunity to do so and learn
considerably more through this information is being considered as part of the
review of data for 2012 – 13. The Trust recognises that better data will help
improve responses to people in the future and use the learning experiences to
improve how we deliver our services to those who may otherwise experience
poor outcomes, barriers to access and poor responses when complaints and
issues are raised.
71
Outcome 2.4: Patients’ and carers’ complaints about services, and subsequent
claims for redress, should be handled respectfully and efficiently
What we have done to ensure that those who are more likely to
experience a poor or inefficient response because of one or more
‘protected characteristic’ have been engaged and involved in changing
and improving the response they can expect?
Progress is being made in implementing recommendations to involve service
Engagement
users and carers in this medical professional training in the Trust. The Director
of Medical Education is leading an initiative to:

Recruit a pool of service users and carers who wish to participate

Set up support for them and systems for payment

Arrange for service user and care representatives to attend induction for
junior doctors

Invite representatives to attend the Medical Education Board on a regular
basis

Invite participation in other medical training sessions

Explore the possibility of developing a library of recorded interviews with
service users and carers for use in training sessions.
What work do we still need to do to improve the response that we give?
What are we going to do and when? Give examples:
The Trust is committed to ensuring that the experience of services is in line with
its core values. The following actions are examples of ways in which we will
Improvements
progress:

General practice development training, for example, that undertaken to
share the Carers Charter, where invite carers will be invited to take part in
the delivery of training. This will enable staff to hear first hand in a collegial
activity the narrative experience from people who use service.

Induction Training undertaken by the Service Experience Team will make
reference to the expectation of a high standard of customer care approach
Goal 2
expected of all staff in 2gether.

The Service Experience Team will develop a specific training package to be
delivered with Team and Clinical managers who wish to enhance the
customer service approaches in their teams.
72
Outcome 2.4: Patients’ and carers’ complaints about services, and subsequent
claims for redress, should be handled respectfully and efficiently
Improvements

Teams are expected to display anonymous compliments in public areas of
their service to encourage positive feedback for best service experience
practice. A list of compliments will feature routinely in our weekly staff
newsletter.

Where a complaint about staff attitude is investigated and upheld the
relevant HR policy will be enacted. If appropriate specific customer care
training will be offered to the staff member.
What was the general feedback from engagement events that might apply
to this outcome?


Local interest group feedback

People do not understand how we use their data. They are concerned that it
will not remain confidential or anonymous. There may be limited confidence
in public authorities using data effectively to improve services.
People do not know how to complain, or they are worried they will be treated
differently if they do raise a complaint.
The NHS ‘expects patients to fit in with its systems and processes’. Frontline
staff often lack the time or understanding to properly assess individuals’
needs, including in relation to their carers and ‘significant others’. This can
disadvantage more vulnerable people and those with complex needs, such
as those with learning disabilities, older people, the traveller community, and
those who do not have English as a first language.

GP’s are not listening to patient needs but this may be due to lack of
information available.

Ensure service user involvement at every level – recruitment, training, care
plans recovery, treatment etc.

Good links with other agencies are vital to providing a good service, with a
multi disciplinary and professional approach.
Services should regularly review how they are meeting outcomes and
promote a continuous cycle of feedback and evaluation with service users.

Goal 2
What was the feedback from our ‘Grading’ event on the 7 th February 2012
or what additional information was provided which has contributed to the
overall grading?
This Outcome is yet to be graded.
73
Appendix A
Equality Delivery System - Goals and Outcomes
Goal
Narrative
Outcome
1. Better health
outcomes for
all
The NHS should achieve
improvements
in
patient
health, public health and
patient safety for all, based on
comprehensive evidence of
needs and results
1.1 Services are commissioned, designed and procured to meet the health
needs of local communities, promote well-being, and reduce health
inequalities
1.2 Individual patients’ health needs are assessed, and resulting services
provided, in appropriate and effective ways
2.
Improved
patient access
and
experience
The NHS should improve
accessibility and information,
and deliver the right services
that are targeted, useful,
useable and used in order to
improve patient experience
3. Empowered,
engaged and
well-supported
staff
The NHS should Increase the
diversity and quality of the
working lives of the paid and
non-paid workforce, supporting
all staff to better respond to
patients’ and communities’
needs
4.
Inclusive
leadership at
all levels
NHS organisations should
ensure
that
equality
is
everyone’s
business,
and
everyone is expected to take
an active part, supported by
the work of specialist equality
leaders and champions
1.3 Changes across services for individual patients are discussed with them,
and transitions are made smoothly
1.4 The safety of patients is prioritised and assured. In particular, patients
are free from abuse, harassment, bullying, violence from other patients and
staff, with redress being open and fair to all
1.5 Public health, vaccination and screening programmes reach and benefit
all local communities and groups
2.1 Patients, carers and communities can readily access services, and
should not be denied access on unreasonable grounds
2.2 Patients are informed and supported to be as involved as they wish to
be in their diagnoses and decisions about their care, and to exercise choice
about treatments and places of treatment
2.3 Patients and carers report positive experiences of their treatment and
care outcomes and of being listened to and respected and of how their
privacy and dignity is prioritised
2.4 Patients’ and carers’ complaints about services, and subsequent claims
for redress, should be handled respectfully and efficiently
3.1 Recruitment and selection processes are fair, inclusive and transparent
so that the workforce becomes as diverse as it can be within all occupations
and grades
3.2 Levels of pay and related terms and conditions are fairly determined for
all posts, with staff doing equal work and work rated as of equal value being
entitled to equal pay
3.3 Through support, training, personal development and performance
appraisal, staff are confident and competent to do their work, so that
services are commissioned or provided appropriately
3.4 Staff are free from abuse, harassment, bullying, violence from both
patients and their relatives and colleagues, with redress being open and fair
to all
3.5 Flexible working options are made available to all staff, consistent with
the needs of the service, and the way that people lead their lives. (Flexible
working may be a reasonable adjustment for disabled members of staff or
carers.)
3.6 The workforce is supported to remain healthy, with a focus on
addressing major health and lifestyle issues that affect individual staff and
the wider population
4.1 Boards and senior leaders conduct and plan their business so that
equality is advanced, and good relations fostered, within their organisations
and beyond
4.2 Middle managers and other line managers support and motivate their
staff to work in culturally competent ways within a work environment free
from discrimination
4.3 The organisation uses the “Competency Framework for Equality and
Diversity Leadership” to recruit, develop and support strategic leaders to
advance equality outcomes
74
3. Appendix B: Patient Data
Introduction to Patient Data
For the purposes of introducing the Equality Delivery System (EDS) in 2012 – 2013, the Trust
has identified data which it hopes will indicate how our services are delivered in line with the
Equality Act 2010 and the outcomes from the EDS.
Why look at our patient data?
Our starting point has been to consider how our patient profile compares with the profile of the
county. The county figures have been taken from the Office of National Statistics estimates as
at June 2010. The purpose of making this comparison is to identify whether or not there might
be barriers to groups or communities accessing our services.
We know from the national data that some people as a consequence of specific
characteristics such as age, gender, ethnicity, sexual orientation, religion or belief, disability,
through gender reassignment, or through pregnancy / maternity may experience barriers to
accessing NHS services or have poorer health. These specific characteristics are defined as
‘protected characteristics’ in the Equality Act 2010 and are aspects we need to consider when
delivering services.
Using electronic data capture systems
Patient profile data has been extracted from our electronic patient record system called Ri0.
Not all our patient data is held on this system and some of our services use other electronic
patient records systems. Our Improving Access to Psychological Therapies Services (known
as IAPT) uses a specific patient record system called IAPTUS. Data for our patients in the
Prison Service is also held separately. Over time we hope to be able to extract consistent
data from all our patient systems to better understand the profile of our patients. However for
the purposes of this first report data has been extracted only from Ri0.
75
The generic patient record system Ri0 was introduced into the Trust during 2010. Over a
period of months it was rolled out to all services excluding those named above.
How accurate is our data?
Ri0 can hold a vast set of information and is being populated by staff as new referrals are
made and historic data has also been transferred where possible. This has been a huge task
and although every effort has been made to ensure both historic data and new data is as
comprehensive as possible there is a continual process of checking and updating data. Staff
are still adapting how they capture information and how they explain to patients the need to
capture this information. In some cases this means that our data remains limited in some
respects but will improve year on year.
What can we report on for 2012 – 2013?
For the purposes of this report, six extracts are included:

A comparison of Trust caseload information by age, gender and ethnicity with local and
national population statistics

Using three specific services which have been included in case studies describing
outcomes against the Equality Delivery System, a comparison of their caseloads by age,
gender and ethnicity with overall Trust caseload, and local and national population
statistics.
Local and national population statistics and patient data are described based on age, ethnicity
and gender. This provides the Trust and our stakeholders with a basic set of data on which
we can build in future years.
What is the difference between a referral and a caseload figure?
A ‘caseload’ is all the people who are currently receiving care from the Trust. This may be
considered to be the Trust’s ‘population’.
‘Referrals’ are new cases coming into our services.
Our ‘caseload’ data will provide the best comparison between our patients and the local and
national population profile. Other data has been used to supplement ‘caseload’ where this is
available.
76
If we can reduce barriers and improve access to our services then changes will firstly show in
the demographic make-up of referrals which will in turn influence the demographic make-up of
our caseload data. However the speed of changes will depend on the rate of ‘turnover’, that is
how quickly our patients can access our services, complete their treatment and be
discharged. This rate of ‘turnover’ varies a great deal between different services.
Comparison between Trust, local and national populations by age
2gether Gloucestershire
Gloucestershire*
UK*
Trust
Trust
Local
Local
National
National
Age Group
caseload
Percentage Population Percentage Population Percentage
0-9
843
6.04%
66
11.07%
7305
11.73%
10-14
800
5.73%
35
5.95%
3567
5.73%
15-19
929
6.66%
38
6.42%
3912
6.28%
20-24
840
6.02%
35
5.85%
4310
6.92%
25-29
761
5.45%
32
5.32%
4250
6.83%
30-34
779
5.58%
31
5.24%
3891
6.25%
35-39
746
5.35%
38
6.32%
4202
6.75%
40-44
907
6.50%
46
7.67%
4632
7.44%
45-49
928
6.65%
46
7.68%
4566
7.33%
50-54
756
5.42%
40
6.74%
3981
6.39%
55-59
591
4.24%
37
6.27%
3578
5.75%
60-64
535
3.83%
40
6.70%
3764
6.04%
65-69
508
3.64%
32
5.36%
2932
4.71%
70-74
556
3.99%
26
4.30%
2468
3.96%
75-79
812
5.82%
21
3.55%
2002
3.22%
80-84
1037
7.43%
16
2.76%
1493
2.40%
85+
1624
11.64%
17
2.81%
1411
2.27%
Comparison between Trust, local and national populations by gender
2gether Gloucestershire
Gloucestershire*
UK*
Trust
Trust
Local
Local
National
National
Gender
Caseload Percentage Population Percentage Population Percentage
Female
7513
53.85%
302
50.86%
31619
50.78%
Male
6438
46.15%
292
49.14%
30643
49.22%
77
Comparison between Trust, local and national populations by ethnicity
2gether Gloucestershire
Gloucestershire*
UK*
Trust
Trust
Local
Local
National
National
Ethnicity
Caseload Percentage Population Percentage Population Percentage
Description
A
10249
93.80%
531.8
90.26%
45682
83.35% White: British
B
58
0.53%
4.5
0.76%
574
1.05% White: Irish
C
232
2.12%
16.5
2.80%
1933
3.53% White: Other White
D
61
0.56%
3.0
0.51%
311
0.57% Mixed: White and Black Caribbean
E
5
0.05%
1.0
0.17%
132
0.24% Mixed: White and Black African
F
17
0.16%
2.3
0.39%
302
0.55% Mixed: White and Asian
G
35
0.32%
1.9
0.32%
243
0.44% Mixed: Other Mixed
H
34
0.31%
8.6
1.46%
1434
2.62% Asian or Asian British: Indian
J
23
0.21%
3.0
0.51%
1007
1.84% Asian or Asian British: Pakistani
K
11
0.10%
1.4
0.24%
392
0.72% Asian or Asian British: Bangladeshi
L
20
0.18%
1.3
0.22%
386
0.70% Asian or Asian British: Other Asian
M
83
0.76%
3.2
0.54%
615
1.12% Black or Black British: Black Caribbean
N
26
0.24%
3.3
0.56%
799
1.46% Black or Black British: Black African
P
29
0.27%
0.6
0.10%
126
0.23% Black or Black British: Other Black
R
12
0.11%
3.8
0.64%
452
0.82% Chinese or Other Ethnic Group: Chinese
S
31
0.28%
3.0
0.51%
423
0.77% Chinese or Other Ethnic Group: Other
Comparison between percenages on caseload by specific services, Trust caseload overall and local and
national populations by age
2gether Gloucestershire
Gloucestershire
UK
Memory
Monitoring
Trust
Local
National
Age Group
CYPS
LD
Service
caseload
Population Population
0-9
37.63%
0.09%
0.00%
6.04%
11.07%
11.73%
10-14
33.96%
0.43%
0.00%
5.73%
5.95%
5.73%
15-19
25.81%
5.66%
0.00%
6.66%
6.42%
6.28%
20-24
0.76%
11.31%
0.00%
6.02%
5.85%
6.92%
25-29
0.85%
9.51%
0.04%
5.45%
5.32%
6.83%
30-34
0.49%
10.11%
0.04%
5.58%
5.24%
6.25%
35-39
0.36%
6.77%
0.00%
5.35%
6.32%
6.75%
40-44
0.13%
11.57%
0.18%
6.50%
7.67%
7.44%
45-49
0.00%
12.60%
0.27%
6.65%
7.68%
7.33%
50-54
0.00%
10.71%
0.75%
5.42%
6.74%
6.39%
55-59
0.00%
7.46%
1.11%
4.24%
6.27%
5.75%
60-64
0.00%
7.28%
2.04%
3.83%
6.70%
6.04%
65-69
0.00%
3.08%
4.43%
3.64%
5.36%
4.71%
70-74
0.00%
2.40%
8.50%
3.99%
4.30%
3.96%
75-79
0.00%
0.60%
16.47%
5.82%
3.55%
3.22%
80-84
0.00%
0.34%
24.48%
7.43%
2.76%
2.40%
85+
0.00%
0.09%
41.70%
11.64%
2.81%
2.27%
78
Comparison between percenages on caseload by specific services, Trust caseload overall and local and
national populations by gender
2gether Gloucestershire
Gloucestershire
UK
Memory
Monitoring
Trust
Local
National
Gender
CYPS
LD
Service
caseload
Population Population
Female
39.52%
43.96%
61.71%
53.85%
50.86%
50.78%
Male
60.48%
56.04%
38.29%
46.15%
49.14%
49.22%
Comparison between percenages on caseload by specific services, Trust caseload overall and local and
national populations by ethnicity
2gether Gloucestershire
Gloucestershire
UK
Memory
Monitoring
Trust
Local
National
Ethnicity
CYPS
LD
Service
caseload
Population Population
Description
A
90.70%
95.43%
96.40%
93.80%
90.26%
83.35% White: British
B
0.26%
0.28%
0.86%
0.53%
0.76%
1.05% White: Irish
C
3.67%
1.40%
2.06%
2.12%
2.80%
3.53% White: Other White
D
1.50%
0.28%
0.00%
0.56%
0.51%
0.57% Mixed: White and Black Caribbean
E
0.05%
0.28%
0.00%
0.05%
0.17%
0.24% Mixed: White and Black African
F
0.41%
0.28%
0.06%
0.16%
0.39%
0.55% Mixed: White and Asian
G
0.77%
0.09%
0.00%
0.32%
0.32%
0.44% Mixed: Other Mixed
H
0.31%
0.19%
0.23%
0.31%
1.46%
2.62% Asian or Asian British: Indian
J
0.36%
0.00%
0.06%
0.21%
0.51%
1.84% Asian or Asian British: Pakistani
K
0.15%
0.00%
0.00%
0.10%
0.24%
0.72% Asian or Asian British: Bangladeshi
L
0.21%
0.09%
0.00%
0.18%
0.22%
0.70% Asian or Asian British: Other Asian
M
0.77%
0.47%
0.29%
0.76%
0.54%
1.12% Black or Black British: Black Caribbean
N
0.31%
0.47%
0.00%
0.24%
0.56%
1.46% Black or Black British: Black African
P
0.36%
0.19%
0.00%
0.27%
0.10%
0.23% Black or Black British: Other Black
R
0.00%
0.09%
0.06%
0.11%
0.64%
0.82% Chinese or Other Ethnic Group: Chinese
S
0.15%
0.47%
0.00%
0.28%
0.51%
0.77% Chinese or Other Ethnic Group: Other
Background
It is the aim to create an interactive report that will enable an update of diversity information
for the Trust at any point it is required. Based on an initial discussion with Carol Sparks –
Deputy HR Director it is proposed to concentrate on readily available information (gender, age
and ethnicity) initially. Three communities were identified as being of interest because known
barriers or health inequalities exist. These three communities are:
79

Black and minority ethnic communities

Eastern European people

Travellers
The ability to distinguish the latter two has only been available to Trust staff since the
implementation of RiO in April and November 2010 respectively.
accuracy for the data is fairly limited at present.
This means that the
Similarly, there is little national and local
data about these two groups as they have been traditionally included in the ‘White Other’
category (C).
The Traveller Community
Unfortunately the information available for this group is particularly small and therefore does
not constitute a statistically significant sample for this report.
The Eastern European Community
This is a relatively new community in Gloucestershire and work udnertaken by the Community
Development Worker Team suggests that language barriers and lack of knowledge of the
services the Trust provides may hinder individuals accessing our services.
80
Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11
3
2
16
8
5
5
14
7
6
9
1
1
3
1
1
1
2
1
14
13
14
29
31
33
34
45
45
50
50
42
13
9
13
14
41
30
61
71
51
15
42
64
2
1
1
1
1
1
2
1
1
1
14
10
22
8
1
30
40
External referrals
Internal referrals
Total Caseload
Total attendances
Admissions
Inpatients Discharges
Occupied Bed Days (excl on leave)
Referrals
Internal referrals
Average
6
1
33
35
1
0
11
Caseload
External referrals
Total Caseload
60
18
16
14
12
10
8
6
4
2
-
50
40
30
20
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
Apr-11
Mar-11
Jan-11
Dec-10
Nov-10
Total attendances
Feb-11
-
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
Apr-11
Mar-11
Feb-11
Jan-11
Dec-10
Nov-10
10
Occupied Bed days excl. Leave
Total attendances
Occupied Bed Days (excl on leave)
80
70
60
50
40
30
20
10
-
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
Apr-11
Mar-11
Feb-11
Jan-11
Dec-10
Nov-10
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
Apr-11
Mar-11
Feb-11
Jan-11
Dec-10
Nov-10
45
40
35
30
25
20
15
10
5
-
There is a wide spread of services that in the past twelve months provided a service to this
group. There are slightly more men than women who receive Trust services and there is a
wide spread in age groups.
81
Black and Minority Ethnic Communities
Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11
44
20
41
43
40
32
26
60
35
20
25
20
17
19
14
10
15
13
18
19
22
17
18
11
385
391
387
398
412
400
393
404
398
399
410
388
655
665
788
718
888
791
887
953
941
918
890
763
3
4
3
2
4
3
4
6
6
4
1
2
4
3
5
2
2
3
6
7
6
2
3
1
480
539
438
384
436
382
424
381
461
418
412
378
Referrals
Total Caseload
Total attendances
Oct-11
Sep-11
Aug-11
Nov-10
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
Apr-11
Mar-11
Feb-11
Jan-11
Dec-10
-
Jul-11
10
Jun-11
20
May-11
40
30
Mar-11
50
Jan-11
60
Feb-11
450
400
350
300
250
200
150
100
50
-
70
Nov-10
Average
34
16
397
821
4
4
428
Caseload
External referrals
Dec-10
Internal referrals
Apr-11
External referrals
Internal referrals
Total Caseload
Total attendances
Admissions
Inpatients Discharges
Occupied Bed Days (excl on leave)
Occupied Bed days excl. Leave
Total attendances
Occupied Bed Days (excl on leave)
1,200
600
1,000
500
800
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
Apr-11
Mar-11
Feb-11
Jan-11
Dec-10
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
Apr-11
Mar-11
Feb-11
100
-
Jan-11
200
Dec-10
200
Nov-10
300
400
Nov-10
400
600
There is a fairly equal spread between genders and a wide variety of services with have input
with clients in this group.
S Slottje – Information Department
29/11/2011
Gloucestershire County Health Profile: The Annual Report of the Director of Public Health 2009 –
2010
1
2
Department of Health (2010) Healthcare for Single Homeless People, London. [online] Available
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3
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4
Grenier, Paola (1996) Still Dying for a Home: An update of Crisis’ 1992 investigation into the link
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http://www.crisis.org.uk/data/files/publications/still dying for a home.pdf
5
6
Homeless Link (2009) Policy Briefing: Drugs and Alcohol, London. [online] Available from:
http://www.homeless.org.uk/sites/default/files/Drugs_and_Alcohol.pdf
7
Homeless Link (2010) The Health and Well Being of Homeless People: Evidence from a national
audit, London. [online] Available from: http://
www.homeless.org.uk/sites/default/files/HomelessHealthAuditPilot_Interim report_0910.pdf
Kessler RC, Amminger GP, Aguilar-Gaxiola S et al (2007) “Age of onset of mental disorders: a
review of recent literature.” Curr Opin Psychiatry, 20(4), pp.359-64.
8
Kim-Cohen, Julia, Caspi, Avshalom, Moffitt, Terrie E, Harrington, HonaLee, et al. (2003) “Prior
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