REPORT TO:
Council of Governors
MEETING DATE:
13 May 2014
SUBJECT:
Equality Delivery System (EDS2) - Review
AGENDA ITEM:
16
PRESENTED BY:
Denise Needle, Deputy Director Workforce (Development)
DATE
PREPARED:
30 April 2014
FOR:
Information and consultation
BACKGROUND
The 2010 Equality Act requires public bodies and those carrying out public functions to:
“Have due regard for the need to eliminate unlawful discrimination, harassment and victimisation; to
advance equality of opportunity; and to foster good relations between people who share a protected
characteristic and those who do not”
The original 6 Acts forming UK Equality Legislation have been brought together with some changes
and additions as the Equality Act 2010 which became law in October 2010 and covers individuals
and groups with the following protected characteristics:
Age
Disability
Gender Re-assignment (Trans)
Race
Religion or Belief
Gender (Sex)
Sexual Orientation
Marriage and Civil Partnership *
Pregnancy & Maternity *
* New to 2010
One part of the Equality Act 2010 is the Public Sector Equality Duty, and this applies to all
public bodies and others carrying out public functions. The three aims of the Equality Duty are to:
1. Eliminate unlawful discrimination, harassment and victimisation
2. Advance equality of opportunity between people who share a protected characteristic and
people who do not share it
3. Foster good relations between people who share a protected characteristic and people who
do not share it.
The Equality Duty is supported by specific duties that require us (as a public sector body) to
publish information (annually) on how we comply with the Equality Duty.
Using the Equality Delivery System (EDS) outcomes, the Trust is required to set and deliver on a
number of equality objectives to improve services to patients and the community and opportunities
to staff.
1
A. The Equality Delivery System (EDS)
The Trust has now signed up to the national EDS2 – which involves a revision of the first EDS
against a new set of outcomes. Please see appendix A for our initial review.
We are currently working to finalise our next set of objectives, as follows;
1. Hard to reach groups – develop understanding of who, where and what the issues are, which the
Trust could address. Seek support and help of Health Watch
2. Disabled staff – implementation of Disability Day Pledges and further exploration of issues with
staff and other stakeholders
3. Black and minority ethnic staff – further exploration of issues raised by the staff survey, with staff
and other stakeholders
4. Use new EPR to understand/analyse equality data in patient areas not previously possible to
further identify issues/areas for action.
B. Consultation process
We have undertaken a series of consultation events with patients, staff and other key stakeholders
over the last few months, including an on line survey and lunch-time sessions in Timeout restaurant.
SUMMARY
The Council of Governors is therefore asked to review the evidence in Appendix A, and confirm that
the proposed draft objectives represent a true reflection of the equality and diversity needs of Trust,
as outlined by the evidence review.
Denise Needle
Deputy Director of Workforce (Development)
30th April 2014
Page 2 of 7
APPENDIX A
Equality Delivery System 2 – Evidence Review
1.
Outcome
Evidence
Services are commissioned, procured,
designed and delivered to meet the health
needs of local communities
Positive Evidence for EDS2:
 2012/13 – the percentage of total complaints by ethnicity roughly corresponds with the
percentage of patient episodes of care by ethnicity. WSH Complaints Annual Report
2012/13
 “The provider had arrangements to promote effective care for people receiving care
and treatment, who were also living with dementia….This meant that staff had
improved access to advice and support to improve the experience of the service for
those people living with dementia.” CQC Inspection Report August 2013 - Care and
Welfare of People Who Use Services: People should get safe and appropriate
care that meets their needs and supports their rights.
Proposed grading: Achieving
2.
Individual people’s health needs are
assessed and met in appropriate and
effective ways
Negative Evidence for EDS2:
 JSNA – Recommendation 10. There are specific groups who may have difficulty in
accessing facilities and initiatives which aim to improve health, for reasons such as
language, cultural belief or disability. Particular attention needs to be given to address
the needs of these groups, for example, through outreach projects. Suffolk Joint
Strategic Needs Assessment
Positive Evidence for EDS2:
 2012/13 – the percentage of total complaints by ethnicity roughly corresponds with the
percentage of patient episodes of care by ethnicity. WSH Complaints Annual Report
2012/13
 “The provider had arrangements to promote effective care for people receiving care
and treatment who were also living with dementia….This meant that staff had improved
access to advice and support to improve the experience of the service for those people
living with dementia.” CQC Inspection Report August 2013 -Care and Welfare of
People Who Use Services: People should get safe and appropriate care that
meets their needs and supports their rights.
 Alerts system in place for learning disability and dementia to help flag these areas to
staff for people with additional needs. WSH EDS 2013 Review: Equality and
Diversity Objectives Action Plan
3

3.
Learning disability liaison nurse appointed. WSH EDS 2013 Review: Equality and
Diversity Objectives Action Plan
The Patient Experience Committee audits and surveys. WSH EDS 2013 Review
Proposed grading: Achieving

Transitions from one service to another, for
people on care pathways, are made
smoothly with everyone well-informed
Positive Evidence for EDS2:
 Effective Discharge Planning Team in place. Complex discharges involve the multidisciplinary team and external partners. WSH EDS 2013 Review
Proposed grading: Achieving
4.
5.
When people use NHS services their safety
is prioritised and they are free from
mistakes, mistreatment and abuse
Proposed grading: Achieving
Screening, vaccination and other health
promotion services reach and benefit all
local communities
Proposed grading: Achieving
6.
People, carers and communities can readily
access hospital, community health or
primary care services and should not be
denied access on unreasonable grounds
Positive Evidence for EDS2:
 Dr Foster Hospital Guide December 2013 named West Suffolk Hospital as Trust of the
Year 2013 for the Midlands and East of England Region. WSH recorded lower than
expected death rates and demonstrated that it delivers the same quality care at
weekends as during the week. Dr Foster Hospital Guide December 2013
Comment
It is not the primary function of acute trusts to provide these services which are generally
provided via primary and community providers. The trust screens and vaccinates its own
staff as required by their employment and achieves this through the Occupational Health
Service.
Positive Evidence for EDS2:
 Month on month patient/carer surveys are used to maintain or make further
improvements to accessing the Trust services. For example, car parking and areas for
20 minute waiting have been improved. Senior clinical and HR staff attended and
made pledges at a county wide Disability Involvement Event in 2013. WSH EDS 2013
Review
Proposed grading: Achieving
7.
People are informed and supported to be as
involved as they wish to be in decisions
about their care
Positive Evidence for EDS2:
 Learning difficulties and those with dementia (generally older people). Trust specific
Equality objective has been met, with evidence of patients being informed and
supported in their diagnoses and decisions about their care, especially those patients
with Learning difficulties and those with dementia. WSH EDS 2013 Review
Proposed grading: Achieving
8.
People report positive experiences of the
NHS
Proposed grading: Achieving
9.
People’s complaints about services are
handled respectfully and efficiently
Positive evidence for EDS2:
 WSH Patient Experience Questionnaires show high levels of satisfaction with all the
areas surveyed. The data is collected anonymously so it is impossible to analyse by
protected characteristics. There were no comments in the questionnaires that
indicated unfavourable treatment resulting from an individual having a protected
characteristic. WSH Patient Experience Survey 30/10/13 to 22/1/14
Positive evidence for EDS2:
 100% of complaints received in 2012/13 were acknowledged within three working days
- West Suffolk NHSFT Complaints Annual Report 2012/13
Page 4 of 7



Proposed grading: Developing
Fair NHS recruitment and selection
10. processes lead to a more representative
workforce at all levels.
Proposed grading: Achieving
11. Training and development opportunities are
taken up and positively evaluated by all staff
Proposed grading: Achieving
12. The NHS is committed to equal pay for work
of equal value and expects employers to
use equal pay audits to help fulfil their legal
obligations
Proposed grading: Achieving
13. When at work, staff are free from abuse,
harassment, bullying and violence from any
source
Proposed grading: Developing
85% of complaints were addressed within the first written response, which is above the
Trust’s target of 75%. West Suffolk NHSFT Complaints Annual Report 2012/13
Eight complaints were referred to the Parliamentary and Health Service Ombudsman in
2012/13. The PHSO did not instigate any further investigations although the Trust was
asked to review and send further apologies for two of the complainants. West Suffolk
NHSFT Complaints Annual Report 2012/13
CQC Standard Complaints: People should have their complaints listened to and acted
on properly. Provider met this standard – comments and complaints people made were
responded to appropriately. Care Quality Commission – Inspection Report August
2013
Positive evidence for EDS 2:
 Independent audit of Trust’s Recruitment and Selection processes with regard to
applications from overseas established that there was no evidence of discrimination at
any stage of the process although resulting successful applicants were not as diverse
in their race or religion as in the number of applicants overall. WSH EDS 2013 Review
Positive evidence for EDS2:
 Training and development opportunities are routinely evaluated for all staff groups and
no evidence was found of staff reporting that they have fared less well as a result of a
protected characteristic. Junior Doctors Induction Survey 2013, Preparing for
Professional Practice Evaluation 2013
 A high percentage of staff (range 78 -85%) of staff report receiving job-relevant learning
or development in the past 12 months – National Staff Survey 2012
Positive evidence for EDS2:
 All staff, and therefore all protected groups, have nationally determined and locally
agreed equal pay and related terms and conditions. The Trust is fully engaged with
staff and unions and any potential or perceived unfairness in relation to pay and
conditions are fully investigated with subsequent feedback to those concerned. WSH
EDS
Positive evidence for EDS2:
 Significantly less black and minority ethnic staff experiencing physical violence from
patients relatives or the public in last 12 months than other staff with protected
characteristics – National Staff Survey 2012
 Both the Grievance and Bullying and Harassment policies were updated in line with
staff engagement concerns in May 2013. Communication about the role and further
recruitment of staff advisors was rolled out across the Trust. WSH EDS 2013 Review
Negative evidence for EDS2:
 Significantly more disabled staff experiencing harassment, bullying or abuse from staff
in last 12 months – National Staff Survey 2012
 Around double the amount of staff aged 31-40 and 51+ reported they experienced
discrimination at work in the past 12 months by comparison with staff aged 16-30 and
41-50. National Staff survey 2012
Page 5 of 7
14. Flexible working options are available to all
staff consistent with the needs of the service
and the way people lead their lives
Positive evidence for EDS2:
 Trust can demonstrate through ESR and staff rostering data as well as staff
engagement that all staff have the opportunity of a range of flexible working, that are
consistent with the needs of patients. WSH EDS
Proposed grading: Achieving
15. Staff report positive experiences of their
membership of the workforce
Proposed grading: Developing
Positive evidence for EDS2:
 Consensus across age ranges (89-94%), gender (89-92%), disability (89-92%) that the
trust provides equal opportunities for career progression or promotion - National Staff
Survey 2012

Relatively consistent levels of job satisfaction across age ranges, gender, disability and
ethnic background (3.40 – 3.73) – National Staff Survey 2012

Relative consistency in recommendation of trust as a place to work or receive
treatment across age ranges, gender, disability and ethnic background (3.58 – 4.23 –
National Staff Survey 2012
Negative evidence for EDS2:
 Significantly less black and minority ethnic staff than white staff believe the trust
provides equal opportunities for career progression or promotion (83-92%) – National
Staff Survey 2012
 Significantly more black and minority ethnic staff report experiencing discrimination at
work in the last 12 months than white staff (21-9%) – National Staff Survey 2012
 Generally disabled staff at the lower (positive) and higher (negative) end of scale for
measures of job satisfaction, recommending trust as a place to work/be treated,
experiencing discrimination etc – National Staff Survey 2012
16. Boards and senior leaders routinely
demonstrate their commitment to promoting
equality within and beyond their
organisations
Proposed grading: Achieving
Positive evidence for EDS2:
 Trust Board engages with equality issues through the Annual Equality Report
discussion and action.
17. Papers that come before the board and
other major committees identify equalityrelated impacts including risks, and say how
these risks are to be managed.
Positive evidence for EDS2:
 The front sheet of all Board papers will be amended to incorporate this aspect.
Proposed grading: Developing
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18. Middle managers and other line managers
support their staff to work in culturally
competent ways within a work environment
free from discrimination.
Proposed grading: Developing
Positive evidence for EDS2:
 Consensus across age ranges (89-94%), gender (89-92%), disability (89-92%) that the
trust provides equal opportunities for career progression or promotion - National Staff
Survey 2012

Relatively consistent levels of job satisfaction across age ranges, gender, disability and
ethnic background (3.40 – 3.73) – National Staff Survey 2012

Relative consistency in recommendation of trust as a place to work or receive
treatment across age ranges, gender, disability and ethnic background (3.58 – 4.23 –
National Staff Survey 2012
Negative evidence for EDS2:
 Significantly less black and minority ethnic staff than white staff believe the trust
provides equal opportunities for career progression or promotion (83-92%) – National
Staff Survey 2012
 Significantly more black and minority ethnic staff report experiencing discrimination at
work in the last 12 months than white staff (21-9%) – National Staff Survey 2012
 Generally disabled staff at the lower (positive) and higher (negative) end of scale for
measures of job satisfaction, recommending trust as a place to work/be treated,
experiencing discrimination etc – National Staff Survey 2012
Potential sources of evidence surveyed
1. Care Quality Commission – Intelligent Monitoring Report: Report on West Suffolk NHS Foundation Trust 21 October 2013 – no evidence for EDS2
2. Care Quality Commission – Inspection Report August 2013
3. West Suffolk NHSFT 2012 Staff Survey
4. West Suffolk NHSFT Complaints Annual Report 2012/13
5. NHS Choices Website – 21 patient reviews – no evidence for EDS2
6. WSH Annual Report and Accounts (including Quality Accounts) 2011/12 – no evidence for EDS2
7. Joint Strategic Needs Assessment for Suffolk 2011
8. WSH Patient Experience Questionnaires 30/10/2013 to 22/1/2014
9. WSH Equality Delivery System
10. EDS 2013 Review
11. Dr Foster Hospital Guide 2013
12. WSH Junior Doctors Induction Survey 2013
13. WSH Preparing for Professional Practice Evaluation 2013 (new foundation doctors)
February 2014
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