Equality Delivery System – April 2012
Introduction: Using the NHS Equality Delivery System (EDS), which aims to improve the way in which people from different equality
groups are treated as patients, service users, carers, and employees we have completed a baseline assessment of our equality
and diversity performance. The assessment has involved gathering evidence for each of the NHS EDS goals and outcomes from
data, and feedback from patients and staff. Below are the gradings agreed by a project group.
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1.1 Services are
commissioned, designed
and procured to meet the
health needs of local
communities, promote wellbeing, and reduce health
inequalities
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
The gender, age and ethnicity of patients accessing our services
have been analysed (PATIENT EQUALITY DATA REPORT 2012). This
shows that for most of our services, the patients are representative of the
local population based upon their gender, age, and ethnicity. Currently,
there is limited data on other protected characteristics, such as disability
and sexual orientation, which have important health and wellbeing
implications. A plan is being developed to ensure that patient recording
IT systems have fields to record sexual orientation, religion / belief,
disability and pregnancy / maternity status. Due to confidentiality issues
rather than monitoring the number of transgender service users we will
be monitoring our transgender equality (gender reassignment) through
other methods.

Within our business strategy documents there are limited
references to how Central London Community Healthcare NHS Trust
(CLCH) will reduce health inequalities.

We have 8 clinical pathway leads for different clinical areas
including a health and well-being lead.

The Trust engages with community groups to address health
needs of local communities including: being an active member of the
K&C and Westminster BME Health Forum; running a Stakeholder
Reference Group with representatives from protected groups; having
representatives from refugee groups and disability organisations sitting
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on the CLCH Equality & Human Rights Committee; and partnership with
national LGBT charity Stonewall to improve how we work with LGBT
patients including displaying their health inequalities posters.
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1.2 Individual patients’
health needs are assessed,
and resulting services
provided, in appropriate
and effective ways
 All patients have a care plan with planned goals using a variety of
assessment methods and they are involved in setting their goals. The
Health Records Audit ensures consistency but there are no comparisons
made based upon the patient’s protected characteristics.
 From the Patient Experience data (PREMS) there were no significant
differences based upon the age, ethnicity, disability and gender of the
patients asking if they involved in the planning of their care and
treatment. See Patient Experience Surveys: Equality data summary
report 2012
 The methods used to ensure that patients with additional
communication needs have their health needs assessed properly
include: Language Line is used for telephone interpreters for patients
who do not speak English; Face to face interpreting usage has
significantly increased in 2011 / 12 (approximately 20%) across all inner
London boroughs which indicates that our staff are systematically using
face to face interpreters. This shows we are communicating more
effectively with patients whose first language is not English; British Sign
Language Interpreters are provided for communicating with deaf
patients; and text appointment reminders provide alternative
communication for people with hearing impairments (reading information
rather than using telephone), people who not speak English as a first
language (information can be translated on their mobile phones), and
visually impaired (mobile phones can provide information in audio
format).
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1.3 Changes across
services for individual
patients are discussed with
UNDER-DEVELOPED
 From the consultation with patients and interest groups (SUMMARY
PRIORITY 12/13
OF EDS CONSULTATION AND PATIENT DATA), three quarters (74%)
said they took an active part in decisions about care, treatment and place
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them, and transitions are
made smoothly
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of treatment. There were no significant differences based upon most
protected characteristics except disability (from the Diabetes User Group
however as the sample is small the results may not be representative but
it is worth noting).
 There are 8 pathway leads to have integrated ‘pathways’ these make
sure that the patient journey is more organized around the needs of the
patient rather than the expertise of the clinical staff. Services are being
reorganised around the patient themselves.
 Although some services have specific procedures to ensure smooth
transitions between services there is no standard handover procedure for
use across all services. There are plans for better integration in our
district nursing services and we are recruiting health co-ordinators for the
district nursing services to link the patient’s discharge from hospital with
their ongoing care via the GP practice and community nursing service.
 Accessible formats are provided but only if requested. Some
information such as complaints leaflet is currently being translated into
easy read. Some services have translated patients discharge notes and
information into other languages.
 The government’s principle of ‘no decision made about me without
me’ is followed by CLCH, and we measure patient’s reported outcomes
to collect information on the effectiveness of our healthcare.
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
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 An Equality Statement is displayed in all sites which states that
patients will be treated fairly regardless of their protected characteristic.
 All bedded services are single-sex accommodation.
 The Quality and Patient Safety report is reported back monthly to the
board, and the Learning from Experience Group
 Mandatory adult Safeguarding and child protection training is provided
to all staff.
 The Addressing Violence and Aggression at Work Policy includes a
system of recording incidents. Datix incident reporting is systematically
used to report any patient safety risks and / or near misses.
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Unacceptable behaviour from patients (aggressive or violent behaviour)
will be issued a yellow card (via a letter) setting out specific conditions. A
red card will be issued if these conditions are not met and the patient will
be excluded from all CLCH. This is to assure the safety of both patients
and staff.
 There are business continuity plans in place with the emergency
planning team have specific procedures for emergencies and planned
events to ensure that our services continue.
1.5 Public health,
vaccination and screening
programmes reach and
benefit all local
communities and groups
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 Public health vaccination programmes through the school nursing
provision is provided to all children therefore benefit all protected groups.
 Community nurses provide flu vaccinations to priority groups.
 Smoking cessation programmes target protected groups and deliver
outreach with BME groups (eg. Queens Park Bangladeshi Association)
and faith based groups.
 Tuberculosis screening provided by the Healthcare team at
Wormwood Scrubs Prison.
 Sickle & Thalassaemia Service in Hammersmith & Fulham will screen
pregnant women and partners to confirm if they are carriers.
 As part of mandatory staff training, within the E&D session information
on low take up of cervical screening by women with learning disabilities
is given. Staff are advised that if they are working with women with LD to
raise awareness on the importance of having cervical screening.
 Homeless Health team in Westminster provided to homeless people
who have barriers accessing services.
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 See 1.2 on communication methods used.
 Single Point of Access for some services provide one telephone
number for patients to book appointments, this is planned to be available
for other services.
 Patient information is analysed and presented annually, to assess
access to our services for patients from protected groups (however some
data is not recorded on the national patient recording systems.
2.1 Patients, carers and
communities can readily
access services, and
should not be denied
access on unreasonable
grounds
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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
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 Complaints team has a system in place to record some of the
protected characteristics of complainants.
 Datix incident reporting will record any risks for patients accessing
services. We also have planned mystery shoppers that will assess our
services and we will have patients with learning disabilities undertaking
mystery shopping within our walk-in centres.
 From the patient feedback, a large minority of respondents from the
BME Health Forum said they were not given information about the
services available to make a decision about health care and did not take
an active part in decisions about care, treatment and place of treatment.
 Requests for same sex clinicians are acted upon and where
logistically possible complied with (we have lower number of male
clinicians compared to female).
 Patients can request access to their health records and are involved
in their patient reported outcomes measured outcomes (PROMS).
 Patient Experience data shows there were no significant differences
based upon age, ethnicity, gender and disability in the responses to how
patients felt their care and treatment was explained in a way that they
could understand.
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 From the Patient Experience data (PREMS) there were no significant
differences based upon the age, ethnicity, disability and gender of the
patients.
 From the patient feedback the majority (82%) reported they were
treated with respect and dignity by community health staff.
 Some human rights training has been provided to clinical staff (mostly
those in bedded services).
 An organizational wide Human Rights Policy is in place.
 A Patient and Public Engagement (PPE) Strategy has been produced
and PPE activities are planned.
 CLCH has produced a set of values and behaviours that staff are
expected to follow including: “I provide services which are safe, effective
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and deliver a good experience”; “I embrace difference, diversity and
fairness”; “I treat people with courtesy, dignity and respect”. These
values and behaviours are displayed at all sites for patients and staff are
expecting to demonstrate how they meet these behaviours as part of
their annual appraisal.
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2.4 Patients’ and carers’
complaints about services,
and subsequent claims for
redress, should be handled
respectfully and efficiently
 There is a standard complaints procedure and PALS service. Some
work on raising awareness of the complaints procedure with patients is
required.
 Complaints team has a system in place to record some of the
protected characteristics of complainants. However, the team has
reported difficulties in asking for this information whilst a patient or carer
is making a complaint.
 The response and timing of responding / dealing with complaints is
reported back to the Board and the Learning from Experience Group.
 Annual staff survey 2011 showed that 56% of staff respondents
thought that CLCH acted fairly with regard to progression / promotion
regardless of protected characteristics but 8% did not perceive this to be
the case and 36% did not know.
 Recruitment and selection procedures alongside the change
management policy are followed for both internal and external posts.
 In the 2010/11 Equality Workforce data report showed no differences
between candidates being shortlisted and appointed based upon the
protected characteristics.
 Recruitment and selection training provides information on how
people on interview panels ensure that bias does not influence their
decisions.
 Some feedback from staff through the Equality Delivery System found
they perceived that recruitment and selection processes were not always
followed for senior appointments. In particular through the change
management processes. However this could be due to lack of internal
communication following results from restructuring proposals. This could
DEVELOPING
PRIORITY 12/13
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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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
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be an unjustified perception by some staff.
 Better transparency of recruitment and selection outcomes is
required. In particular appointments made at a senior level and the
change management process. Promoting more widely the appointments
of staff as a result of restructuring plans.
 CLCH provides work experience placements for school children and
recruitment team work closely with K&C Volunteer Bureau by delivering
job search workshops to their unemployed service users.

CLCH Job Evaluation Policy sets outs the process for determining DEVELOPING
the band and therefore pay within the Agenda for Change structure for all
staff.

Due to the merger with 4 organisations, there are some differences
in banding for similar jobs. There is a process for addressing these
anomalies including a review of our admin and clerical posts.

The pay and grading of staff is determined by the Agenda of
Change using nationally agreed arrangements.

From the staff survey 2012 results, 91% have been appraised in
last 12 months; 44% feel there are good opportunities to develop their
potential at work (compared to 38% average for other community trusts).

81% had received job-relevant training, learning or development in
the last 12 months (compared to 82% average for other community
trusts). 46% had well structured appraisals in last 12 months (highest
scoring community trust).

The Staff Outstanding Achievement Awards 2012 have recently
been launched to recognize the achievements of our staff.

There are some staff who have reported that they have insufficient
clinical supervision, there is a clinical supervision policy. There are also
the professional development team to assist with supervision practices.
3.4 Staff are free from
 From the staff survey 2012 results, 13% of staff have experienced
abuse, harassment,
harassment etc from patient and relatives within the last 12 months
bullying, violence from both (compared to 16% from other London Trusts); 15% have experienced
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
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PRIORITY 12/13
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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
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harassment, bullying or violence from staff in last 12 months (17% other
London trusts).
 All staff are informed of ‘Addressing Bullying and Harassment at
Work’ Policy through E&D session on mandatory training.
 15 Dignity at Work advisers have been recruited and trained, these
are staff who volunteer to provide impartial and confidential telephone
support to other staff.
 Hotspots from 2011 staff survey received harassment & bullying
workshops from E&HR team.

From the staff survey 2012 results, 67% used flexible working
options.

Flexible working policy is open to all staff regardless of their legal
right to request flexible working.

Collection and monitoring of protected characteristic needs
improving to monitor who

Improve collection from employee health of staff with disabilities
who they recommend required reasonable adjustments.
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
From the Staff survey 2012 results, 21% of staff felt under
pressure in last 3 months to attend work when feeling unwell (same as
average community trust results).

Health & well-being strategy has been produced.

Health eating and physical exercise initiatives are available to staff.

Monthly aromatherapy sessions are available to staff, which takes
place at different sites.

Recent Stop Smoking campaign was promoted to staff.

Flu vaccines provided to all staff.
UNDER-DEVELOPED
 The Equality and Human Rights Committee is chaired by Director of
PRIORITY 12/13
HR. However, there are no Non-Executive Director members of this
group.
 The Chief Executive has been involved in several E&D events
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good relations fostered,
within their organisations
and beyond
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including the LGBT History Month event and presents the certificates on
the empowerment programme for BME staff.
 Equality and diversity is not considered systematically within board
papers.
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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

As previously mentioned all staff are required to attend the E&D
session on the mandatory training. This includes tips on providing a
culturally sensitive service.

Effective line management training will provide some guidance.
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
Both E&D leads within the organization have completed the ILM
Level 4 course in managing E&D within organisations as part of the
framework. Both have board level sponsors for developing their proposal
as part of the course and will in due course give presentations to the
Executive Management team outlining their proposals.

Provide leadership to BME Staff Network and LGBT Staff Network.
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For further information or to request this report in accessible or alternative format please contact:
Lesley Soden, Head of Equality by email lesley.soden@clch.nhs.uk
Telephone: 020 7998 1407
Post: 7th Floor, Westminster City Hall, 64 Victoria Street, London, SW1E 6QP.