Health and Wellbeing Coordination Group Meeting 31st July 2012
Agenda item number 4
HEALTH AND WELLBEING SHADOW BOARD MEETING
September 2012
Report Title:
Derbyshire NHS Organisations’ Equality
Delivery System (EDS) Performance
grades
Item No: 4
SUMMARY
1.1
This paper provides an overview of progress to date in implementing the NHS
Equality Delivery System (EDS) in Derbyshire and agreeing performance grades. This
is in line with the decision at the 16th September 2011 Health and Wellbeing Board
meeting when the Board agreed to receive a report on the EDS grades for NHS
organisations participating in the Derbyshire Inclusion Network.
1.2
The EDS is a tool for both current and emerging NHS organisations to use – in
partnership with patients, the public, staff and staff-side organisations – to review their
equality performance and to identify future priorities and improvement actions. At the
heart of the EDS is a set of 18 outcomes grouped under four goals (Better health
outcomes for all; Improved patient access and experience; Empowered, engaged and
well-supported staff; Inclusive leadership at all levels.) The 18 outcomes, detailed in
Appendix 1, focus on the issues of most concern to patients and their families, carers,
communities, NHS staff and Boards. It is against these outcomes that equality
performance is analysed and graded. Further summary background information on
the EDS and the recommended assessment process is set out in the attached EDS
factsheet at Appendix 2.
2.
Key progress
Key progress
& emerging
& emerging
considerations
considerations
2.1
The EDS tool recommends that Trusts in partnership with local interests, should
analyse their performance for each of the 18 outcomes, taking specific account of
each organisation’s evidence of taking steps to meet the needs of each protected
group and other vulnerable populations/groups as applicable.
2.2
Health organisations in Derbyshire, including the four new Clinical Commissioning
Groups (NHS Southern Derbyshire CCG; NHS North Derbyshire CCG; NHS Erewash
CCG: NHS Hardwick CCG) have implemented the EDS tool and embedded the
framework into their respective governance arrangements and activities.
2.3
The Derbyshire NHS organisations have undertaken a self-assessment of current
performance against the EDS outcomes, which has included a process of evidence
collection and engagement and consultation with local stakeholders.
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Health and Wellbeing Coordination Group Meeting 31st July 2012
Agenda item number 4
2.3.1
During the latter half of 2011 and during 2012, the Derbyshire Inclusion Network
established, in partnership with local health and voluntary sector organisations a pilot
group, the Derbyshire Community Health Equality Panel. The key remit of this panel
was to provide independent feedback on each Trust’s grading against the 18 EDS
outcomes. From March to August 2012 the Panel received and considered the EDS
evidence and organisational gradings from the following Derbyshire NHS
organisations, raising questions and seeking further evidence and clarifications as
appropriate:




Derbyshire Community Health Services NHS Trust
Derbyshire Healthcare NHS Foundation Trust
Derby Hospitals NHS Foundation Trust
NHS Derby City and NHS Derbyshire County, including the four Clinical
Commissioning Groups (NHS Erewash CCG; NHS Hardwick CCG; NHS North
Derbyshire CCG; NHS Southern Derbyshire CCG)
2.3.2
The Derbyshire Community Health Equality Panel’s valuable involvement, time and
independent questioning of Derbyshire NHS organisations’ EDS evidence proved
useful and informative. It helped to establish both strengths and areas for
development in each organisation’s approach to evidence collation and analysis as
well as informing the benchmarking and grading process.
2.3.3
Following the assessment process, all of the Derbyshire NHS organisations were
aligned in their overall EDS self-assessment grading of “Developing,” with each
organisation having different areas of particular strength and development. For each
of the above four NHS organisations, three of the strongest performing EDS outcomes
are listed in section 2.4 of this report along with three EDS outcomes where specific
development is planned for 2012/2013, for which three key planned actions are
highlighted.
2.4
2.4.1
NHS Derbyshire Organisations’ Strongest Performing EDS Outcomes & EDS
Outcomes Targeted for Development
Derbyshire Community Health Services NHS Trust
Three of the strongest performing EDS outcomes:
 EDS Outcome 1.1 Services are commissioned, designed and procured to meet
the health needs of local communities, promote well-being, and reduce health
inequalities
 EDS 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 dignity and privacy is prioritised
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Health and Wellbeing Coordination Group Meeting 31st July 2012
Agenda item number 4
 EDS Outcome 3.5: Flexible working options are made available to all staff,
consistent with the needs of patients, and the way that people lead their lives
Three of the EDS Outcomes Targeted for Development in 2012/13:
 EDS Outcome 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

EDS Outcome 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

EDS Outcome 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
Three key actions for 2012/13 are:
 Ensure Equality Analysis is undertaken to a high standard for all key decisions
 Embed equality monitoring across all service areas and take action to improve
the quality and robustness of employee data.
 Increase staff and Board member awareness and understanding of the
equalities agenda and build on the organisation’s cultural competence
2.4.2
Derbyshire Healthcare NHS Foundation Trust
Three of the strongest performing EDS outcomes:
 EDS Outcome 1.1 Services are commissioned, designed and procured to meet
the health needs of local communities, promote well-being, and reduce health
inequalities
 EDS 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 dignity and privacy is prioritised
 EDS Outcome 3.5: Flexible working options are made available to all staff,
consistent with the needs of patients, and the way that people lead their lives
Three of the EDS Outcomes Targeted for Development in 2012/13:
 EDS Outcome 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
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Health and Wellbeing Coordination Group Meeting 31st July 2012
Agenda item number 4
 EDS Outcome 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
 EDS Outcome 4.3: The organization uses the NHS Equality & Diversity
Competency Framework to recruit, develop and support strategic leaders to
advance equality outcomes
Three key actions for 2012/13 are:
 To continue to review all services, policies and plans using equality impact
analysis methodology and engagement to demonstrate good equality
governance and informed decision making.
 Enhance diverse representation across the Trust, particularly focusing on
increasing the proportion of BME people in senior positions.
 To increase inclusive practice and leadership by embedding the Competency
Framework for Equality & Diversity Leadership.
2.4.3
Derby Hospitals NHS Foundation Trust
Three of the strongest performing EDS outcomes:
 EDS Outcome 1.1: Services are commissioned, designed and procured to
meet the health needs of local communities, promote well-being, and reduce
health inequalities
 EDS Outcome. 2: Individual patients’ health needs are assessed, and resulting
services provided, in appropriate and effective ways
 EDS 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
Three of the EDS Outcomes Targeted for Development in 2012/13:
 EDS Outcome 1.3 Changes across services for individual patients are
discussed with them, and transitions are made smoothly
 EDS Outcome 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
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Health and Wellbeing Coordination Group Meeting 31st July 2012
Agenda item number 4
 EDS Outcome 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
Three key actions for 2012/13 are:
 Transformation of services will embed Equality Impact Risk Assessments into
their processes
2.4.4

Review of recruitment and selection processes and progression opportunities
for BME employees

Assessment and support plan for middle managers skills and practices in
delivering equality and inclusion in teams
NHS Derby City and NHS Derbyshire County, including the four Clinical
Commissioning Groups (NHS Erewash CCG; NHS Hardwick CCG; NHS North
Derbyshire CCG; NHS Southern Derbyshire CCG)
Three of the strongest performing EDS outcomes:
 EDS Outcome 1.1: Services are commissioned, designed and procured to meet
the health needs of local communities, promote well-being and reduce health
inequalities
 EDS 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 dignity and privacy is prioritised
 EDS Outcome 3.5: Flexible working options are made available to all staff,
consistent with the needs of patients, and the way that people lead their lives
Three of the EDS Outcomes Targeted for Development in 2012/13:
 EDS Outcome 2.1: Patients, carers and communities can readily access
services, and should not be denied access on unreasonable grounds
 EDS Outcome 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
 EDS Outcome 4.3: The organisation uses the NHS Equality & Diversity
Competency Framework to recruit, develop and support strategic leaders to
advance equality outcomes
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Health and Wellbeing Coordination Group Meeting 31st July 2012
Agenda item number 4
Three key actions for 2012/13 are:
 Through relevant mechanisms with service providers (e.g. contracts, Service
Level Agreements) improve patients, carers and communities’ access to health
services so that services are more readily accessible and deliver a better
experience.
 Review the Expressions of Interest process, with a view to ensuring that it
includes systematic equality profiling and documenting of applicants’ progress
through the recruitment and selection procedure.
 Increase the capacity of leaders to support and motivate their staff to work in
culturally competent ways within an environment free from discrimination,
utilising opportunities for using the NHS Equality & Diversity Competency
Framework to improve the level of inclusive leadership
2.5
Following a review of the DCHEP pilot, NHS Trusts in the Derbyshire Inclusion
Network will continue to work with key stakeholders to ensure that there is a
sustainable partnership engagement model for the on-going consultation and
involvement of local diverse communities in the annual EDS review and grading
process.
2.6
By April 2013 NHS Trusts will need to demonstrate how they have been implementing
their EDS development action plans and the resultant improvements in the EDS
outcome grades, effectively involving all stakeholder populations.
RECOMMENDATION
3.1
It is recommended that the Derby City Health and Well-Being Board note this report
and the 2012 overall ‘developing’ EDS grading outcomes for:




Derbyshire Community Health Services NHS Trust
Derbyshire Healthcare NHS Foundation Trust
Derby Hospitals NHS Foundation Trust
NHS Derby City and NHS Derbyshire County, including the four Clinical
Commissioning Groups (NHS Erewash CCG; NHS Hardwick CCG; NHS North
Derbyshire CCG; NHS Southern Derbyshire CCG)
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Health and Wellbeing Coordination Group Meeting 31st July 2012
Agenda item number 4
3.2
3.3
It is recommended that the Derby City Health and Well-Being Board:
 Note and approve the collaborative approach that has been undertaken in
relation to the NHS Equality Delivery System assessment process in
Derbyshire
 Note the proposal that there is a sustainable partnership engagement model
for the on-going consultation and involvement of local diverse communities in
the annual EDS review and grading process.
It is recommended that the Derby City Health and Well-Being Board receive the next
annual EDS summary grading report for Derbyshire NHS organisations in May 2013.
REASONS FOR RECOMMENDATION
4.1
Recommendations 3.1 and 3.3.ensure that the Health and Well-Being Board is aware
of the NHS Equality Delivery System key performance strengths and improvement
priorities of NHS organisations in Derbyshire.
4.2
Recommendation 3.2 endorses the value of both continued collaborative
arrangements and also emphasises the importance of ensuring that the annual EDS
review and grading process is underpinned by a sustainable partnership engagement
model with local diverse communities.
SUPPORTING INFORMATION
5.1
At the heart of the EDS is a set of 18 outcomes grouped under four goals (Better
health outcomes for all; Improved patient access and experience; Empowered,
engaged and well-supported staff; Inclusive leadership at all levels.) The 18
outcomes, detailed in Appendix 1, focus on the issues of most concern to patients and
their families, carers, communities, NHS staff and Boards. It is against these
outcomes that equality performance is analysed and graded. Appendix 2 sets out the
EDS background and supporting key processes.
Author:
Harinder Dhaliwal, Assistant Director of Engagement, Derbyshire Healthcare
NHS Foundation Trust and Anita Thomas, Assistant Director, Equality,
Inclusion and Human Rights, NHS Derby City and NHS Derbyshire County
Cluster on behalf of Derbyshire Inclusion Network.
Sponsor: Kathryn Blackshaw, Acting Chief Executive, Derbyshire Healthcare NHS
Foundation Trust
Date:
17th August 2012
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Health and Wellbeing Coordination Group Meeting 31st July 2012
Agenda item number 4
IMPLICATIONS
Financial and Value for Money
1.1
The EDS evidence review and collation process, and the associated identification of
gaps and improvement priorities can help to inform health services’ commissioning
priorities to deliver better health outcomes and improve patient access and
experience. It helps providers to respond better to CQC, registration and quality
account requirements.
Legal.
2.1
The EDS is a vehicle that will help NHS organisations to meet their statutory public
sector general equality duty obligations (Section 149 of the 2010 Equality Act), which
came into force on 5 April 2011.
Personnel
3.1
The EDS supports organisations’ workforce strategies and plans – promoting
conditions for inclusive working. It also encourages organisations to advance the
recruitment of a diverse workforce that is representative of the communities being
served.
Equalities Impact
4.1
The EDS tool helps Derbyshire NHS organisations to ensure that they consider and
anticipate how different groups of people (including people with the nine “protected
characteristics”) will be affected by their decisions/activities, helping organisations to
deliver policies and services which are safe, efficient and effective and accessible to
all target groups (including high risk groups/those who experience the poorest health
and outcomes).
Health and Safety
5.1
Delivery of the EDS helps support compliance with Health and Safety
obligations.
Environmental Sustainability
6.1
No specific ramifications.
.
Asset Management
7.1
No specific ramifications.
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Health and Wellbeing Coordination Group Meeting 31st July 2012
Agenda item number 4
Risk Management
8.1
The NHS Equality Delivery System (EDS) is designed to drive improvements in
equality performance and embed equality into mainstream NHS business. It can
help to inform the identification and management of risks to providing safe and
effective services and meeting statutory duties.
Corporate objectives and priorities for change
9.1
At the heart of the EDS is a set of core 18 outcomes grouped under four goals
(Better health outcomes for all; Improved patient access and experience;
Empowered, engaged and well-supported staff; Inclusive leadership at all levels.)
These are directly relevant to the delivery of the Department of Health’s “White
Paper – Liberating the NHS.”
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