NHS Equality Delivery System
Outcomes Framework
2013 – 2017
Document Control Sheet
NHS Equality Delivery System Outcomes Framework
2014 – 2017
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Equality and Diversity Impact
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2
Draft
Head of Corporate Affairs
SNCCG /
January 2014
Corporate Affairs and Complaints Manager
This document has been reviewed and updated from
Norfolk PCT policy. It follows national guidance,
therefore no further consultation undertaken at this
juncture.
No adverse impact identified
Governing Body
Due 11 March 2014
Corporate Affairs
January 2015
Corporate Affairs and Complaints Manager
Revision History
Revision Summary of changes
Date
14.09.12 Update
15.01.14 Update and Refresh
Author(s)
Anne Moates
Heidi Davey
Version
Number
V1
V2
Approvals
This document requires the following approvals either individual(s), group(s) or board.
Name
Title
Date of Issue
Version
Number
Governing Body
NHS Equality Delivery System
14.09.12
1
Outcomes Framework
2013 – 2017
Governing Body
NHS Equality Delivery System
Outcomes Framework
2013 – 2017
15.01.14
2
Page 2 of 24
Contents
Foreword
4
1 The Public Sector Equality Duty (PSED)
5
2 Embedding Human Rights
6
3 Discrimination
6
4 The NHS Equality Delivery System (EDS)
7
5 Equality Impact Analysis
8
6 Making it happen
9
7 Our Profile
10
8 Our Workforce
11
9 Involving Local People
11
10 NHS Norfolk’s Legacy
12
Appendix 1: Protected Characteristics
14
Appendix 2: Types of Discrimination
15
Appendix 3: EDS Objectives and Outcomes
17
Appendix 4: EDS Action Plan 2013/14
18
Appendix 5: Evidence used to identify priorities
23
Appendix 6: Glossary of Terms
24
Page 3 of 24
Foreword
NHS South Norfolk Clinical Commissioning Group (SNCCG) is committed to ensuring
equality, diversity, inclusion and human rights are central to the way we commission and
deliver healthcare services and how we support our staff.
The primary purpose of the Equality Delivery System (EDS) is to work in partnership with
NHS Organisations, patients, the public and other stakeholders. This will help us to assess
our performance, and enable us to agree what equality objectives should be prioritised and
the actions required. This EDS process will help to better identify, verify and effectively
align our services to meet the needs of all patient groups.
The EDS covers all those people with the 9 characteristics protected by the Equality Act
2010:









Age
Disability
Gender re-assignment
Marriage and civil partnership
Pregnancy and maternity
Race including nationality and ethnicity
Religion or belief
Sex
Sexual orientation
This framework sets out our commitment to these people and will be used to review
equality performance and identify future priorities and actions.
By following this framework and the included equality and diversity action plan, SNCCG
can ensure that it recognises, encourages and highlights the undoubted good practice and
evidence that already exists in SNCCG. In addition SNCCG can follow the plan to ensure
there is better and consistent engagement with our local communities, in which any gaps
are identified and addressed so that SNCCG becomes more reflective of the community it
serves.
Dr Jon Bryson
Ann Donkin
Chair
Chief Officer
January 2014
Page 4 of 24
1
The Public Sector Equality Duty (PSED)
The Equality Act 2010 replaces previous anti-discrimination laws with a single Act, making
it easier for people to understand. It also strengthens the law in important ways to help
tackle discrimination and inequality.
The Public Sector Equality Duty (PSED), which came into effect on 5 th April 2011, sets out
the responsibilities a public authority must undertake in order to ensure an environment
that fosters good relations between persons of differing protected characteristics.
Protected characteristics under the Equality Act 2010 are age, disability, gender
reassignment, pregnancy and maternity, race, religion or belief, sex and sexual orientation,
the nature of which is outlined at Appendix 1.
It is important to note that the EDS can be applied to groups of people who not afforded
protection by the Equality Act formally, but who face stigma in life both in general and
when trying to access services. Such groups include homeless people, sex workers,
people who use drugs and others who experience socio-economic disadvantage.
1.1
The Equality Duty requires public bodies to have due regard for the need to:



eliminate discrimination, harassment, victimisation and any other conduct prohibited
by or under the Act;
advance equality of opportunity between people who share a relevant protected
characteristic and people who do not share it; and
foster good relations between such people.
Although these three parts support each other and, in practice, they may overlap, it is
important to remember that they are different and that being successful with one of them
may not lead to the success of all three. For example, a new equal opportunities policy
that is not clearly explained when it is introduced may improve equality of opportunity, but
it may also create resentment if staff do not understand how it benefits everyone.
1.2
Public authorities must also demonstrate due regard for the need to:





remove or minimise disadvantages connected with a relevant protected
characteristic (for example, address the problems that women have in accessing
senior positions in the workplace);
take steps to meet the different needs of people who share a relevant protected
characteristic (for example, ensure that the needs of people who cannot speak
English are met);
encourage people who are a relevant protected characteristic to participate in public
life or any other activity in which they are under-represented (for example, take
steps to encourage more disabled, BME, LGBT people to apply for senior posts);
tackle prejudice (tackle hate crime for people with protected characteristics); and
promote understanding and partnership working (for example, through the
Community Cohesion Agenda)
Page 5 of 24
1.3
Specific Obligations
The CCG must act compatibly with the European Convention on Human Rights and
publish:



2
at least annually, sufficient information to demonstrate compliance with the PSED
across all functions. This includes using evidence and analysing the impact of
policies, plans, strategies, etc. against all protected characteristics;
equality objectives annually, revising them every four years; and
a range of equality data relating to workforce, services and demographics
Embedding Human Rights
The NHS Equality Delivery System (EDS) was developed by the NHS Equality and
Diversity Council with the aim of helping NHS organisations to improve their performance
concerning equality of opportunity and human rights, and to meet their duties under the
Equality Act 2010.
The Human Rights Act 2000 sets minimum legal standards that need to be met in order to
build communities and a wider society based on fairness, dignity and respect. A human
rights-based approach to equality recognises the following core values:
Fairness
Right to a fair trial;
Respect
Right to respect for family and private life, home and correspondence;
Equality
Right not to be discriminated against in the enjoyment of other human rights;
and
Dignity
Right not to be tortured or treated in an inhuman or degrading way.
SNCCG will apply these values to all its decision-making and will require providers with
whom it does business to do similarly.
3
Discrimination
SNCCG is committed to promoting equality of opportunity; respecting the diversity of our
staff and the community we serve; and to dealing with any incidents of discrimination that
may occur in a sensitive, robust way.
As an employer we have a legal duty to ensure that all people have equality of opportunity
to be considered for employment, training and promotion. As part of our strategic role, we
must also demonstrate how we will support those who provide services in promoting
equality and addressing the inequality, disadvantage and discrimination that people may
face during their lives.
We will establish mechanisms to ensure that we recognise, manage and lower the
incidence of discrimination by:

reviewing the results of local staff leaver and national staff surveys, taking action to
address issues identified;
Page 6 of 24



considering how the BME; LGBT; Disability and Long Term Conditions; and
‘Embrace’ staff networks established by NHS Norfolk may be supported following
transition by working in collaboration with other local CCGs;
using advocacy support from the Norwich and Norfolk Racial Equality Council; and
the
Multi-Agency Protocol for reporting hate crime/incidents
An explanation of the different types of discrimination that can occur is set out at Appendix
4
The NHS Equality Delivery System (EDS)
The EDS helps the NHS to:




deliver on the Government’s commitment to fairness and personalisation, including
the equality pledges contained in the NHS Constitution;
deliver improved and more consistent performance on equality;
respond to the Equality Act duty; and
develop commissioning plans that meet the needs of communities.
The EDS has 18 outcomes grouped within four goals, which are described at Appendix 3.
The outcomes have been developed to focus on the issues of most concern to patients,
carers, communities, NHS staff and their leaders. It is against these outcomes that
performance is analysed, graded and any action determined. The four goals are:
1.
2.
3.
4.
Better health outcomes for all
Improved patient access and experience
Empowered, engaged and included staff
Inclusive leadership at all levels
Our main priorities for action in this Framework, which are described at Appendix 4, set out
to ensure that:








equality, human rights and community cohesion are embedded in the way we work
and in the services we commission;
our Equality Impact Analysis processes are meaningful, understood and adopted
throughout the organisation;
action is taken to ensure our workforce reflects the diverse community we serve and
that there are no barriers to employment;
people who need access to the information we publish can do so;
contractors providing goods, facilities and services both to us and on our behalf meet
our procurement criteria for all equality areas;
our buildings and working practices are accessible to all;
we develop communication, consultation and involvement plans which evidence that
our actions will make a difference; and
priority is given to openness and transparency in all processes with particular
attention to best practice in dealing with complaints and concerns raised.
Page 7 of 24
4.1
Analysis and Grading
Analysis of performance against action plans gives rise to a system of nationally agreed
grading as follows:




Excelling
Achieving
Developing
Underdeveloped
-
Purple
Green
Amber
Red
Grading reflects the extent to which, for protected groups:





good outcomes are delivered;
the QIPP challenge is met;
the Equality Act duty is met;
commitments made under the NHS Constitution are delivered; and
effective use of evidence, for example the Joint Strategic Needs Assessment
(JSNA), is made.
SNCCG will analyse its performance against the outcomes for each group that is afforded
protected status directly, or by association, by the Equality Act. The analysis will be
evidence-based and transparent and will be conducted in partnership with:





minority communities and partnerships such as the Community Cohesion Network;
other voluntary and community organisations;
patients, those local groups that represent them and the public in general ;
staff; and
local authorities.
To achieve the EDS outcomes described, we will:






5
celebrate diversity and value difference;
be open, honest and accountable;
discuss, listen to and respect people’s views;
value staff and the contribution they make;
achieve through partnership; and
celebrate success and learn from experience.
Equality Impact Analysis (EqIA)
Equity in the provision of services does not ensure equality of access or equality of
outcome. For example, a person whose first language is not English may need
interpreting services or information provided in a different language to have an equal
opportunity of accessing that service; similarly, a person with a visual impairment may
require information in a different format. NHS and other provider estate must be
accessible to all and we need to consider how we will target services at specific group
where there is evidence of differences in take-up. For example, men between the ages of
16 – 44 are 50% less likely to visit a GP than women and this often leads to late diagnosis.
Men are also twice as likely as women to develop and die from the ten most common
cancers affecting both sexes.
Page 8 of 24
Equality Impact Analysis (EqIA) is a method by which we seek to narrow health
inequalities that exist between people from different ethnic backgrounds, people with
disabilities, men and women (including trans-gendered people), people with different
sexual orientations, people in different age groups, and people with different religions or
beliefs. We must screen all policy, strategy and service plans for their impact on people
from each of these groups. As commissioning organisations we must also consider
equality issues in any procurement process that we undertake, as the legal liability in
relation to the equality duty usually remains with the public body that issues the contract.
Decisions about the potential impact on these various groups must be evidence-based and
proportionate. An EqIA should not be an add-on at the end of a process – rather, it should
inform and strengthen that process and begin at the screening stage. If no significant
differential impact on any of the above groups is demonstrated, then this decision will be
published. Should the potential for a significant impact be identified (negative or positive),
a full EqIA must be undertaken and published.
6
Making it happen
The Chief Officer has overall accountability for delivery of the public sector equality duty
and providing organisational leadership in the on-going development of equality and
diversity.
.
The Head of Corporate Affairs has lead responsibility for the:



development, maintenance and review of SNCCG’s plan and commitments under
the national Framework;
main-streaming changes to legislative requirements into daily business by the
development and communication of relevant policy and procedure; and
publishing annually, details of progress against objectives concerning delivery of the
duty.
The Audit Committee will monitor progress of the organisation’s performance through
delegated arrangements from the Governing Body as described in the Scheme of
Delegation incorporated in the CCG’s Constitution and reflected in the Committee’s Terms
of Reference.
All staff are responsible for promoting, supporting and mainstreaming equality and
diversity throughout the organisation. The development of policy and procedure is
enhanced by ‘In a Nutshell’ guidance and the provision of 1:1 support in its application in
the early phases of implementation.
The Audit Committee will monitor progress of the organisation’s performance through
delegated arrangements. The Audit Committee will receive regular updates and written
demonstration of how SNCCG is currently ensuring that its EDS is being considered by all
staff
All staff are responsible for promoting, supporting and mainstreaming equality and
diversity throughout the organisation. SNCCG will ensure that all staff receives Equality
and Diversity Training as part of their mandatory training
Page 9 of 24
Both SNCCG Staff and the SNCCG Governing Body will be provided with a concise yet
detailed checklist of points of consideration to ensure that the SNCCG plan is applied
7
Our Profile
Key Themes
The CCG is aware that particular issues are known to affect particular groups of people,
with very strong relationships between mental health issues and diverse groups, for
example:







dementia is more prevalent in certain BME communities;
lesbian, gay, bi-sexual and trans-gender communities (LGBT) are known to be at
greater risk of depression and suicide;
alcohol abuse occurs more frequently among people with mental health problems;
within the gay community; and is a cultural issue within particular BME
communities;
the incidence of smoking is higher within the gay community and those with mental
health problems;
people within black and minority ethnic communities (BME) are more likely to suffer
from particular types of cancer than others;
people with disabilities experience many health issues and barriers to maintaining
and improving their health which the general population does not face; and
health issues related to poverty are likely to be more prevalent in BME communities
and among people with disabilities, who experience much higher levels of poverty
overall than the general population.
SNCCG is a predominantly rural area that comprises a mixture of arable farmland, river
valleys and watercourses, ancient woodland, wildlife sites and main district towns:
Thetford, Dereham, Attleborough, Watton and Diss. The population of South Norfolk is
estimated to be 223,000.
Priorities for improving health SNCCG include stopping smoking especially targeting
pregnant women, tackling alcohol misuse and addressing obesity in children by promoting
healthy lifestyles. With an ageing population, an increased focus is needed on prevention
and management of age related long term conditions such as dementia, diabetes and
cancers.
7.1
Key Demographics
The following information concerns the population in the North Norfolk District Council area
in 2011/12; it has not been possible at this time to secure the relevant Broadland District
data and this remains work in progress. The information which follows has been drawn,
variously, from data, including Census data, held on the Community Relations and
Equality Board website and Norfolk Insight.
7.1.1 Gender Split
Usual Male resident Population
Usual Female Resident Population
112,474
115,667
Page 10 of 24
7.1.2 Age Profile
Age
0 to 4
5 to 7
8 to 9
10 to 14
15
16 to 17
18 to 19
20 to 24
25 to 29
30 to 44
45 to 59
60 to 64
65 to 74
75 to 84
85 to 89
90 and over
Population
7589
4589
3021
8921
2088
3816
3204
7301
6859
26616
35221
14694
22598
14685
3932
2170
Percentage (%)
4.5
2.7
1.8
5.3
1.2
2.3
1.9
4.4
4.1
15.9
21.1
8.8
13.5
8.8
2.4
1.3
7.1.3 Number of people with a Disability / Long-term Health Condition (adults and
children)
Total 22,240: number of people whose disability / long-term health condition limits their
day to day activities ‘a lot’: 9238
Comparing the seven local council Districts of Norfolk, South Norfolk, at 17.9% of the total
population, has the lowest population of people with a disability / health problem.
7.1.4 Lesbian, Bisexual, Gay and Trans-Gender Communities
No figures are currently available for Norfolk but SNCCG are aware that a number of their
population are representative of this group
Page 11 of 24
7.1.5 Ethnic Groups in North Norfolk
Ethnic Group
Number of 124012
White British
White Irish
White Gypsy or Irish Traveller
White Other
Mixed - White and Black Caribbean
Mixed - White and Asian
Mixed - Other
Asian - Indian
Asian - Pakistani
Asian - Bangladeshi
Asian - Chinese
Asian - Other
Black - African
Black - Caribbean
Black - Other
Arab
Any other ethnic group
118,059
496
124
2,356
372
124
372
248
372
0
372
372
248
124
0
124
124
% of usual resident
population of district
95.2
0.4
0.1
1.9
0.3
0.1
0.3
0.2
0.3
0
0.3
0.3
0.2
0.1
0
0.1
0.1
Statistics relating to use of the translation and interpreting service INTRAN,
suggest that the three most commonly spoken languages in South Norfolk in
addition to English are Portuguese, Lithuanian, and Polish.
7.1.6 Religious Belief
Faith Group
Christian
Buddhist
Hindu
Jewish
Muslim
Sikh
Other religion
No religion
Religion not stated
Number
77,259
372
248
124
372
0
496
35,591
9,549
% of total population
62.3
0.3
0.2
0.1
0.3
0
0.4
28.7
7.7
7.1.7 Hate Crime Incidents January to December 2012
South Norfolk
Race
Homophobic/Transphobic
Faith
Disabled
Other
Number
22
4
4
2
1
Page 12 of 24
8
Our Workforce
SNCCG is an equal opportunities employer and provides employment opportunities and
advancement for all suitably qualified people regardless of age, disability, gender
reassignment, race, religion or belief, sex or sexual orientation.
We are committed to:


ensuring that equality forms part of our service planning and provision, and
employment practices; and
employing a diverse workforce that reflects the community we serve.
Our aim is to ensure that our workforce reflects the diversity of the South Norfolk
community. We recognise our responsibility to be a positive example of good practice to
other employers within the area and we are therefore committed to taking positive steps to
ensure that opportunities for employment are available to all without prejudice or
discrimination.
It is in both our best interest and those who work for us, to ensure that the attributes,
talents and skills available throughout the community are considered when employment
opportunities arise. Assessment for recruitment, selection, appraisal, training and career
progression purposes is based entirely on an individual’s ability and suitability for the work.
SNCCG is not only committed to a robust equal opportunities policy in recruitment and
selection but also to equal opportunities through training and development, appraisal and
promotion to retirement. We aim to promote a working environment that is sympathetic to
all employees and free from unacceptable behaviour such as discrimination, bullying,
harassment and intimidation. This responsibility is shared by everyone in the organisation.
We will develop ‘Family Friendly’ working policies which will provide all staff with the
opportunity to request flexible working and we will monitor the take-up of this policy.
We recognise that career progression, generally, is more difficult for women and people
from BME communities; and that access to support other than training is also important,
particularly for trans-gender people. The CCG is exploring, in collaboration with the wider
health community in Norfolk and Suffolk, ways in which staff from protected groups might
more easily communicate and support each other to resolve difficulties in the workplace.
9
Involving Local People
Meaningful engagement with patients, carers and communities across South Norfolk is an
underpinning principle of the EDS.
SNCCG will pay particular attention to identifying and engaging with groups and
individuals with protected characteristics who have been under-represented in the past.
We will seek to do this by:
Working with organisations that advocate on behalf of those under-represented and seek
their guidance about best practice. This will include:

Regular email, web-based and newsletter updates to stakeholders regarding
SNCCG’s activities, highlighting specific opportunities for engagement with underrepresented communities.
Page 13 of 24

Co-production of resources for under-represented communities with organisations
and service user involvement.

Engagement with the broad range of public and statutory sector forums across
Norfolk to ensure it is at the forefront of commissioning and consultation
developments, and with the on-going aims of the Norfolk Community Relations and
Equality Board.
Implementing Norfolk Guidelines ‘Accessibility Matters’ 1, 2 and 3 on the publication of
printed materials, accessibility of public events and development of consultation resources
and materials
Utilising equality impact analyses to plan and assess public involvement activities
(including information resources, workshops, events and consultations). This process is:

Embedded as part of the planning and evaluation function in all aspects of
SNCCG’s delivery of commissioning and communications.

Developed and monitored in conjunction with the Norfolk Community Relations and
Equality Board and other CCGs in Norfolk and Waveney.

Aimed at improving the experience of under-represented communities to ensure
they are not disadvantaged in any way by the events, communications or any
activities undertaken by SNCCG

When conducting an ‘informal’ consultation, carry out the procedure over a
minimum eight week period following Norfolk Compact guidelines
SNCCG consulted on the Equality and Diversity Delivery System with a wide range of
stakeholders at the beginning of November 2013. This process followed the COMPACT
minimum period for consultation guidelines and reflected section 242 of the consolidated
NHS Act 2006.
The stakeholders SNCCG has and will engage with spread across the public, statutory,
voluntary and community, faith and private sectors, with particular emphasis on working
with organisations that work with protected and under-represented communities and
related policies and specific issues.
NHS Norfolk’s Legacy
10
NHS Norfolk made significant progress in meeting its equality duties and SNCCG will seek
to continue the provision, development and membership of the following:

The INTRAN (Interpreting and Translation for Norfolk) Partnership which ensures
that people who cannot speak English or who are Deaf or hard of hearing are able
to access health care and provides alternative formats of information for disabled
people:
http://www.norfolk.gov.uk/Community_and_living/Equality_and_strong_communities
/Interpretation_and_translation_services/index.htm
Page 14 of 24





the comprehensive and searchable database of information in community
languages and alternative formats which is hosted by NHS Anglia Commissioning
Support Unit in conjunction with the five local CCGs: http://www.heron.nhs.uk/
Partnership work with the Norfolk Community Relations and Equality Board
http://www.equalitycohesionnorfolk.co.uk/
Linking with Norwich and Central Norfolk Mind via their diversity network and their
contacts with local BME communities www.norwichmind.org.uk
Signatories and supporters of Hate Free Norfolk Pledge
http://www.hatefreenorfolk.com/
Membership of the online resource ‘Your Voice ‘http://norfolk.yourvoice.co.uk/
-
Appendix 1
Protected Characteristics
Age
Being of a particular age/within a range of ages
Disability
A physical or mental impairment which has a substantial and long term adverse effect on
day to day activities
Gender
Being a man or a woman
Gender Reassignment
People who propose to, are doing or have undergone a process of having their sex
reassigned
Pregnancy and maternity
If a woman is treated unfavourably because of her pregnancy, pregnancy related illness or
related to maternity leave
Race
Includes colour, nationality, ethnic origins and national origins
Religion or belief/lack of belief
The full diversity of religious and belief affiliations in the United Kingdom
Sexual orientation
A person’s sexual preference towards people of the same sex, opposite sex or both
Marriage and Civil Partnership
Relevant in relation to employment and vocational training
Page 15 of 24
Appendix 2
Types of Discrimination
Direct discrimination
Direct discrimination occurs when someone is treated less favourably than another person
because of a protected characteristic they have or are thought to have (see below
Perception discrimination), or because they associate with someone who has a protected
characteristic (see discrimination by association below).
Discrimination by association
Already applies to race, religion or belief and sexual orientation, now extended to cover
disability, gender reassignment and sex. This is direct discrimination against an individual
because others think they possess a particular protected characteristic. It applies even if
the person does not actually possess that characteristic.
Indirect discrimination
Already applies to age, race, religion or belief, sex, sexual orientation and marriage and
civil partnership, now extended to cover disability and gender reassignment. Indirect
discrimination occurs where there is a condition, rule, policy or practice in the organisation
that applies to everyone but particularly disadvantages people who share a protected
characteristic. Indirect discrimination can be justified if it can be shown that the
organisation acted reasonably in managing their business, i.e. that it is ‘a proportionate
means of achieving a legitimate aim’.
A ‘legitimate aim’ might be any lawful decision that is made in running the organisation, but
if there is a discriminatory effect, the sole aim of reducing costs is likely to be unlawful.
Being ‘proportionate’ really means being fair and reasonable, including showing that less
discriminatory alternatives to any decision made have been looked at.
Dual discrimination
Dual discrimination is where a person is subject to direct discrimination on the grounds of
no more than two of the following protected characteristics: age; disability; gender
reassignment; race; religion or belief; sex and sexual orientation.
Harassment
Harassment is unwanted conduct related to a relevant protected characteristic, which has
the purpose or effect of violating an individual’s dignity or creating and intimidating, hostile,
degrading, humiliating or offensive environment for that individual.
Harassment applies to all protected characteristics except for pregnancy and maternity
and marriage and civil partnerships. People can now complain of behaviour they find
offensive even if it is not directed at them, and the complainant need not possess the
relevant characteristic themselves.
Third party harassment
This already applies to sex and has been extended to cover age, disability, gender
reassignment, race, religion or belief and sexual orientation.
Page 16 of 24
An employer can be held responsible for harassment of a worker by someone who does
not work for them, such as a customer. This is sometimes called ‘third party harassment’.
The organisation will be legally responsible if they know that their worker has been
harassed by someone who does not work for them twice before but fail to take reasonable
steps to protect the worker from further harassment. It does not have to be the same
person harassing the person on each occasion.
Victimisation
Victimisation occurs when an employee is treated badly because they have made or
supported a complaint or raised a grievance under the Equality Act; or because they are
suspected of doing so. An employee is not protected from victimisation if they have
maliciously made or supported an untrue complaint. There is no longer a need to compare
treatment of a complainant with that of a person who has not made or supported a
complaint under the Act.
Page 17 of 24
Appendix 3
EDS Objectives and Outcomes
Objective
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
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
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 Patients’ health needs are assessed, and resulting services
provided, in appropriate and effective ways
1.3 Changes across services are discussed with patients, and
transitions are made smoothly
1.4 The safety of patients is prioritised and assured
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 so that they can
understand their diagnoses, consent to their treatments, and
choose their places of treatment
2.3 Patients and carers report positive experiences of the NHS,
where they are listened to and respected and 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 the same work in the
same job being remunerated equally
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 patients, and the way that people
lead their lives
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 NHS Equality & Diversity
Competency Framework to recruit, develop and support strategic
leaders to advance equality outcomes
Page 18 of 24
Narrative
RAGP
Appendix 4: Equality Delivery System Outcomes Framework
Action and Improvement Plan 2013/14
Outcome
Current Position
Amber
1. Better Health outcomes for all
SNCCG will achieve
improvements in patient
health and patient safety
for all based on
comprehensive evidence
of needs and results
Action
With immediate effect, reports into the health needs of people with protected
characteristics will be routinely received by the Senior Management Team.
Patients and the public are routinely involved in the consideration of changes to the
commissioning and delivery of services. All formal engagement activities are analysed;
the results shared with those participating in the engagement; and recommendations
made in public documents.
Amber
The CCG and participants are equal partners in engagement processes, with each
party’s expectations and ground rules agreed at the outset.
Green
SNCCG will achieve
improvements in patient
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.
All activities are aligned with the CCG’s 5-year strategic plan, the content of which is
informed by the JSNA and previous reports into the health needs of people with
protected characteristics.
1.3 Changes across services are
discussed with patients and transitions
are made smoothly.
1.4 The safety of patients is prioritised
and assured
Action
With immediate effect, EIAs for each public involvement activity will be undertaken to
monitor (and where appropriate take steps to improve) the experience of protected
groups involved in consultation events to ensure they are not disadvantaged.
Whilst formal links with the BAME community exist, the CCG will establish meaningful
links, perhaps in collaboration with other Norfolk and Waveney CCGs and the wider
health sector, to ensure that representation from all protected groups is secured and
involved in engagement activity.
The CCG will explore ways in which to both seek and provide feedback following one
year of a new service’s implementation.
Clinical Quality and Patient Safety Committee established, with monthly reports to both
the Governing Body and Council of Members.
The Head of Clinical Quality and Patient Safety who is also the Registered Nurse
Member of the Governing Body is a member of the East Anglia Quality Surveillance
Group. Action
Clinical Quality Review Meetings with service providers (CQRM) are in place, where
action planning arising from Serious Incidents and Never Events is followed up.
Page 19 of 24
RAGP
Narrative
Outcome
Current Position
Amber
Amber
2.1 Improved access to services for
migrant workers
2.1 Clinical awareness of barriers
experienced by Lesbian and bisexual
women to NHS services
Effective use of interpretation and translation, through INTRAN partnership. Monitoring
of INTRAN usage informs requirement for different formats and languages.
Action
Patients to be provided with the appropriate supporting information at the initial point of
contact. All information on commissioned services is made readily available in
alternative formats and languages including those for people with disabilities.
Pilot project with third sector organisations specialising in advice and support services
for migrant workers.
Action
Health trainer service to deliver life style support to migrant workers, including smoking
cessation, in their own language.
To discuss and develop in collaboration with other local CCGs a DVD on giving advice
about how to access NHS services.
Norfolk LGBT project has identified projects which enable engagement with the LGBT
community in South Norfolk. An example of which is working I partnership with Age UK
and Older People Forum to assess the needs of the older LGBT community and involve
them in setting up social support groups in the area.
Action
Amber
Engage with the Norfolk LGBT Project to develop an action plan to address Health
issues for the SNCCG LGBT population
Green
The NHS should improve
accessibility by ensuring
that all supporting
information is available in
all required formats and
provided upfront at point
of initial contact. In
addition the NHS should
deliver the right services
for those targeted by
ensuring that they are
useful, usable and used
in order improve patient
experience
2.1 Patients, carers and communities
have knowledge of and are supported to
access all services commissioned
Amber
2. Improved patient access and experience
2.3 Patients and carers report positive
experiences of the NHS where they are
listened to and respected and 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.
Improved patient experience of commissioned services. Case studies and patient
stories inform priorities and identify areas for improvement, through commissioned
research and unannounced visits by Healthwatch.
Action
Governing Body to determine how to effectively receive and utilise patient stories.
To receive and monitor Friends and Family data from protected groups.
Complaints are handled respectfully and efficiently. Complaints and claims monitoring
informs commissioning decisions, patient care pathways and improves access to
services.
Action
To ensure that complaint monitoring identifies any gaps in the receipt of complaints from
protected groups which could indicate barriers to accessing the service .To identify
issues reported by protected groups to ensure service improvements.
Page 20 of 24
RAGP
Narrative
Outcome
Current Position
Narrative
3.1Quality of working lives of all staff
does not vary because of a protected
characteristic. Our staff are more able to
understand and respond to the needs of
South Norfolk’s diverse patient population
and communities
3.4 Staff is free from abuse, harassment,
bullying, violence from both patients and
their relatives and colleagues, with
redress being open and fair for all.
3.6 Workforce is supported to remain
healthy, with a focus on addressing major
health and lifestyle issues that affect staff
and the wider population.
RAGP
Amber
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.
Amber
Amber
3. Empowered, engaged and well-supported staff
Outcome
Workforce monitoring is used to identify whether there are areas where improvements
can be made. This includes the monitoring of grievances and disciplinaries access to
training, exit interviews. Relevant policies and procedures will be equality impact
analysed to ensure that no staff suffer any detriment on the grounds of a protected
characteristic.
Action
Protect established legacy staff networks;
ensure networks’ continued support and involvement in the impact analysis of relevant
policies and procedures.
Link with other local NHS organisations to ensure that staff networks are available due
to the nature of SNCCGs small workforce numbers
Research data e.g. ERINN report is used to inform policy. NHS staff survey results
taken forward where appropriate. Stonewall Workplace Index used to inform actions.
Action
All staff know how to report any incidents related to discrimination through internal
policies and procedures and are supported to do so.
Occupational health feedback, improved staff survey results and workplace health
initiatives. The legacy Staying Healthy at Work (SHAW) Strategy will be implemented to
ensure that the workforce is supported.
Action
Occupational Health contract in place
Current Position
4. Inclusive leadership at all levels
4.1 The Council of Members, Governing
Amber
NHS organisations
should ensure that
equality is everyone’s
business, & everyone is
expected to take an
active part, supported by
the work of specialist
equality leaders and
champions
Body and Senior Leaders conduct and
plan their business so that equality is
advanced and good relations fostered,
within their organisations and beyond.
Through governance structures the Council of Members and Governing Body receive
information on progress. The Governing Body, which includes a lay member with the
lead on patient and public participation matters, will be engaged and receive training
presentations on understanding their EDS responsibilities. They will be involved in
steering how SNCCG EDS plan is being implemented throughout the organisation.
Page 21 of 24
Appendix 5
Evidence used to identify priorities

Health and Social Care Needs Assessment for Adults in Norfolk, Great Yarmouth and Waveney with Learning Disabilities, Autism or
Asperger syndrome (2011) http://www.norfolkinsight.org.uk/Custom/Resources/LDNeedsAssessment.pdf

Working Towards Eradicating Racism in the Norfolk May 2011 undertaken on behalf of Norfolk NHS by the University of East Anglia
http://www.norfolk.nhs.uk/sites/default/files/The%20ERINN%20Report-%20ten%20years%20on%20(17.05.2011).pdf

BME Health Needs Survey 2010 undertaken on behalf of NHS Norfolk by the University of East Anglia
http://www.norfolk.nhs.uk/sites/default/files/BME%20Health%20Needs%20Survey%20for%20NHS%20Norfolk-1.pdf

Stonewall - Prescription for Change: Lesbian and bisexual women's health check (2008)
http://www.stonewall.org.uk/documents/prescription_for_change.pdf
Page 22 of 24
Appendix 6
Glossary of Terms
BME
Black and Minority Ethnic
EDS
Equality Delivery System
EQIA
Equality Impact Analysis
ERINN
Eradicating Racism in Norfolk NHS
INTRAN
Interpreting and Translation for Norfolk
JSNA
Joint Strategic Needs Assessment
LGB
Lesbian, Gay and Bisexual
LGBT
NHS Norfolk includes transgendered people at part of its staff network.
NNREC
Norwich and Norfolk Racial Equality Council
LINks
Local Involvement Networks (Healthwatch from October 2012)
PPG
Patient Participation Group
PPIE
Patient and Public Involvement and Engagement
QIPP
Quality, Innovation, Productivity and Prevention
SES
Single Equality Scheme
SHAW
Staying Healthy at Work
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