Annual Equality Report for 2015

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1 Annual Equality Report for 2015

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3 Contents Page Foreword 4 Executive Summary and Summary of Key Findings 5 Introduction to UCLH 8 Equality Delivery System 2 (EDS2) 10 Our Progress in Priorities for Appendix 1: Patient Information 26 Appendix 2: Workforce Information 49 Appendix 3: Types of disability 58 Appendix 4: Abbreviations and Acronyms 59 3

4 Foreword As the nominated Executive Leads for equality, diversity and inclusion for our patients and staff, we welcome you to the UCLH Annual Equality Report for Providing excellent care to all our patients is at the centre of all we do and we are proud that we do this with such a diverse workforce. To recognise the vital interdependencies between the experience of our staff and patients, this year we have chosen to publish our equality report for patients and staff as one integrated document. Our trust-wide diversity, equality and inclusion agenda has made good progress over the past year and underpins our objective of ensuring excellent patient and staff experience across UCLH. This report covers the period 1 January 2015 to 31 December We presented the report to our Executive Board in February We always strive to improve and have identified areas to prioritise over the next twelve months to ensure that we reduce discrimination; improve the experience of our patients and staff with protected characteristics; are transparent in our decision-making; identify the impact of our policies and service changes for patients, our staff and the communities we serve; and complete the evaluation of our progress against the Equality Delivery System 2 grading and objective setting process. The introduction of the Workforce Race Equality Standard in 2015 provides a helpful opportunity to focus on what we can do to ensure that our black and minority ethnic staff are treated as favourably as all other staff so that UCLH can capitalise on the best available talent, draw on the innovation we know diverse teams can bring and keep us connected to the diverse needs of the communities we serve. We know that managing staff with respect and compassion correlates with improved patient satisfaction, better patient outcomes and higher levels of patient safety. We are confident that the outcomes of these pieces of work will support us to deliver top-quality patient care, excellent education and world-class research. Ben Morrin Director of Workforce Executive Lead for Staff Flo Panel-Coates Chief Nurse Executive Lead for Patients 4

5 Executive Summary and Summary of Key Findings This report sets out the UCLH approach to equality, diversity and inclusion and meets our public sector legal duties outlined in the Equality Act (2010) in meeting the nine protected characteristics: Age Disability Gender reassignment Marriage and civil partnership Pregnancy and maternity Race Religion or belief Sex Sexual orientation. UCLH has a long history of commitment to equality and diversity with a truly diverse workforce serving diverse communities. We recognise that delivering our vision requires a workforce performing at its best who are able to be themselves whilst at work. In order to achieve this and meet both the spirit and the letter of legislation and best practice, it is important that we work closely with our staff, engaging with them in creating an accessible and inclusive organisation and working environment. In 2015 we published our first Workforce Race Equality Standard report and developed an action plan to address the areas where black and minority ethnic staff are treated less favourably than white staff. There is clear evidence that patients have a better experience where workforce race equality is good and improving. Securing tangible improvements against the Standard is important to us and we thus intend to publicly report against it every six months to transparently outline our progress and priorities for improvement. We continue to review our staff and patient-focused policies, undertaking an equality analysis assessment in line with guidance from the Equality and Human Rights Commission, updating them accordingly. 5

6 In 2015, we aimed to deliver better and more effective patient care that is inclusive, accessible and fair and some of these initiatives are described in this report. We work with different communities to achieve this, focusing on areas where our patients are keen to work with us to enhance care and treatment for people living in vulnerable circumstances: in sheltered and supported accommodation; the homeless and local people and patients with learning, physical, mental and social difficulties disabilities. We have further enhanced targeted specialist services including our African Women s Clinic and a wide range of services for children and young people. We have created a robust action plan to further improve services for patients with a protected characteristic in line with the Equality Act (2010). Having a clear profile of our patients and staff helps to advance equality of opportunity and meet the needs of our patients and staff in designing our services and the workplace. Our organisational culture, based on the UCLH values of Safety, Kindness, Teamwork and Improving, fosters good relations between different groups that result in more efficient and effective patient care, improved services for the public in a workplace welcomed by staff. The characteristics of our workforce are broadly consistent with the populations of our local boroughs in London, in terms of religion and ethnicity. We have stronger representation of females and staff from a black and minority ethnic background in our workforce than in the local population. This is, in part, due to the nature of the work we undertake and the impact of international recruitment campaigns to recruit new joiners into occupations for which there is a national shortage. The rich mix of our staffing helps us to better identify the needs of our staff and patients. Our newest international staff have made a valued contribution to UCLH that has been swiftly welcomed by patients and staff alike. The learning and development accessed by our staff is broadly consistent with the workforce as a whole, i.e. broadly speaking staff with all the protected characteristics have similar or better levels of access to learning and development. It is important that senior leadership and management at UCLH is representative of the wider workforce and the local community. There is work to do to encourage, support and develop women and individuals from black and minority ethnic communities so that they are in a position to put themselves forward for more senior roles. Yet we are making progress. Of four director roles recruited to in the last 24 months, two successful candidates are from ethnic minority communities and have since brought valuable experience from beyond the NHS and the UK. 6

7 There has been a detailed analysis of employees managed through formal employee relations processes which shows that staff in lower bands are more likely to go through a formal process than staff in higher bands. Taking the ethnicity of staff in these lower bands into account, the process does not appear to be disadvantaging those with a protected characteristic, but we are undertaking a detailed investigation and we expect to commit to further oversight and monitoring in 2016/17. Recording of ethnicity data on the Electronic Staff Record (ESR) has improved but, in order to prepare for the likely introduction of a Workforce Disability Equality Standard in 2017, we shall investigate why we currently have a discrepancy between disability data recorded on the ESR and that self-reported during the annual staff survey. We will be looking to NHS England for clearer definitions of disability to support that endeavour. We have made little progress in improving the need to capture data relating to and actions to support transgender individuals and that too shall be a priority. However the data quality of employee demographics for new starters is now much improved and to assess any remain need, we shall seek its audit in The publication of the Workforce Race Equality Standard in July 2015 highlighted the need to improve accessibility of senior and leadership positions for staff from a BME background. Listening sessions with BME staff are being held and mentoring and coaching places have been identified for BME staff. 7

8 Introduction to UCLH University College London Hospital NHS Foundation Trust (UCLH) is situated in the heart of London. Our vision is to deliver top-quality patient care, excellent education and world-class research. Our values of safety, kindness, teamwork and improving are at the heart of everything we do, both for our patients and for our staff. We are made up of six hospitals: 1. University College Hospital, including: Macmillan Cancer Wing Elizabeth Garrett Anderson Wing Hospital for Tropical Diseases Institute of Sport, Exercise and Medicine 2. National Hospital for Neurology and Neurosurgery 3. Eastman Dental Hospital 4. Royal National Throat, Nose and Ear Hospital 5. University College Hospital at Westmoreland Street 6. Royal London Hospital for Integrated Medicine Our activities comprise clinical, research and education work. We became one of the first foundation trusts in Giving staff, patients and members of the local community a greater say in how their hospitals are run is the driving force behind the creation of NHS foundation trusts. Greater involvement will bring lasting improvements to patient services and better health for communities. As a foundation trust, we remain firmly part of the NHS but we are free to manage our own budgets and shape the services we provide to better reflect the needs and priorities of our local community. Through our council of governors (until August 2014 called the governing body) we are able to listen to the views of patients, local people, staff and partners and by doing so, offer patients faster, better and more responsive healthcare. We provide academically linked acute and specialist services, both to the local population and to patients from across England and Wales. We balance the provision of nationally recognised specialist services with delivering highquality acute services to our local populations in Camden, Islington, Barnet, Enfield, Haringey and Westminster. We are one of England s five biomedical research centres (BRC) and we are a founding partner of UCL Partners, one of the UK s first academic health science centres UCLH is situated in the heart of London. 8

9 The Trust has three clinical boards (the Medicine Board, the Specialist Hospitals Board and the Surgery and Cancer Board), each led by a medical director, supported by divisional clinical directors, a divisional manager and a head of nursing. We also have good links with London South Bank and City Universities which offer high quality training and education for nurses and allied health professionals, as well as with the UCL Medical School. As we serve an incredibly diverse population, with equally diverse needs, understanding the demographic context in which we operate is crucial. Data for 2015 show that the largest age group of our local population is between the ages of 30 to 39, with the majority being female. Approximately 9.7% of our local population have a limiting long-term illness (disability). Our most represented patient ethnic group is White British at 41.1% followed by White/Any Other White Background at 10.1%. The least represented ethnic group in our patients are service users from a White/Black African mixed background representing 0.4% in total. The largest religion or belief for our local population is Christianity (26%) with 20% of our patients married or in a civil partnership and 20% single or never married. UCLH recognises that it is extremely fortunate to have a mix of employees from a diverse range of communities, beliefs and sexual orientations. The UCLH values of safety, kindness, teamwork and improving, introduced in 2012, are at the heart of all that UCLH does. A raft of evidence shows a positive link between staff experience and that of patients and the outcome of their care. In his publication NHS Staff Management and Health Service Quality: Results from the NHS Staff Survey and Related Data (2011), Professor Michael West stated: There is a spiral of positivity in the best performing NHS trusts. The extent to which staff are committed to their organisations and to which they recommend their trust as a place to receive treatment and to work is strongly related to patient outcomes and patient satisfaction. Climates of trust and respect characterise these top performing trusts. This is best evidenced by the link between ethnic discrimination against staff and patient satisfaction. The greater the proportion of staff from a black or minority ethnic (BME) background who report experiencing discrimination at work in the previous 12 months, the lower the levels of patient satisfaction. This contention provided the premise for our engagement action plan which had at its core the fact staff who displayed and lived the UCLH values shall help to make UCLH the best place to work and be treated. 9

10 Equality Delivery System 2 (EDS2) The EDS2 is NHS England s tool to ensure that the legal obligations of the NHS are met under the Equality Act of Implementation of EDS2 is based on achieving 18 outcomes grouped within 4 goals, namely: Goal 1 Better Health Outcomes Goal 2 Improved Patient Access and Experience Goal 3 - A Representative and Supportive Workforce Goal 4 - Inclusive Leadership The provisional grading of these goals has been undertaken by the Diversity and Equality Steering Group and endorsed by the Executive Board. The Diversity and Equality Steering Group is gathering evidence to support each of the provisional grades in preparation for a governor/stakeholder event in the spring. This will provide an opportunity to discuss and confirm the grades. A detailed action plan is under development and shall be finalised with our partners in April EDS2 outcomes Goal 1 Better health outcomes 1.1 Services are commissioned, procured, designed and delivered to meet the health needs of our communities 1.2 Individual patient health needs are assessed and met in appropriate and effective ways 1.3 Transitions from one service to another, for people on care pathways, are made smoothly with everyone well informed 1.4 When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse 1.5 Screening, vaccination and other health promotion services reach and benefit all local communities Goal 2 Improved patient access and experience 2.1 People, carers and communities can readily access hospital, community health or primary care services and should not be denied access on unreasonable grounds 2.2 People are informed and supported to be as involved as they wish to be about their care Provisional EDS2 grade Achieving Developing Achieving Achieving Developing Achieving Achieving 2.3 People report positive experiences of the NHS Achieving 2.4 People s complaints about services are handled Achieving respectfully and efficiently 10

11 EDS2 outcomes Goal 3 A representative and supported workforce 3.1 Fair NHS recruitment and selection processes lead to a more representative workforce at all levels 3.2 The NHS is committed to equal pay for work of equal value and expects employers to use equal pay audits to help fulfil their local obligations 3.3 Training and development opportunities are taken up and positively evaluated by staff 3.4 When at work, staff are free from abuse, harassment, bullying and violence from any source 3.5 Flexible working options are available to all staff consistent with the needs of the service and the way people lead their lives 3.6 Staff report positive experiences of their membership of the workforce Goal 4 Inclusive Leadership 4.1 Boards and senior leaders routinely demonstrate their commitment to promoting equality within and beyond their organisations 4.2 Papers that come before the Board and other major Committees identify equality-related impacts including risks and say how these risks are to be managed 4.3 Middle managers and other line managers support their staff to work in culturally competent ways within a work environment free from discrimination Provisional EDS2 grade Achieving Developing Achieving Developing Achieving Developing Developing Developing Developing 11

12 Our Progress in 2015 As an effective governance infrastructure, the well-established Diversity and Equality Steering Group continues to lead in setting the strategic direction as well as monitoring and providing assurance of delivery of our action plan. In 2015, we have continued to achieve successes through different initiatives to improve staff experience, patient experience and service delivery. Age Disability Gender reassignment Marriage and civil partnership Pregnancy and maternity Race Religion or belief Sex Sexual orientation. Progress for patients by Protected Characteristic Age the Children and Young Patients website Our children and young patient s website was launched in 2012 and was significantly enhanced in The website was designed to help our patients to feel more comfortable and better informed about the services we provide, the staff we employ and what they can expect when coming into contact with us. Working closely with our patients is what we believe in and the website was created with the help of patients and their families. The website includes an interactive guide to the services, films of patients in hospital talking about their experience, comments and advice from staff, as well as 12

13 personalised journeys through the site for patients. This has been designed for use of children with different requirements and expectations from their hospital experience by age group (0-6, 7-12 and 13-19). There is also a team of play specialists/activity coordinators to support children through invasive procedures and provide a welcome distraction. Details about these posts are included on the website. For more information and to access this website, please follow the link: Further work has been undertaken to expand the specific web-link for children and adolescents living with diabetes. This initiative, led by Rebecca Thompson (paediatric diabetic nurse consultant) and Laura Bull (paediatric diabetes dietician) together with our Communications team has proven extremely successful, winning the Quality in Care Diabetes awards for the best initiative in supporting self-care. Feedback from families and users of the webpage has been very positive with the how to videos overwhelmingly being evaluated as the best aspect of the webpage. This year, the team was excited to be able to add five new videos to the series. For more information and to access this page, please follow the link: Plans are also underway to update and further develop the teenage and young adults page on the UCLH website. As part of the update, plans are in place to establish a closed Facebook page. Again, patients are fully involved in the planning and development of this. The team are also working on the development of a video describing a patient s personal journey and experience of treatment within the ambulatory care setting (residing in a local hotel rather than in hospital while undergoing acute treatment). We plan to upload this onto our page on the UCLH website in For more information and to access this page, please follow the link: Age - Older patients To cultivate equality for our older population, UCLH has developed our services in several ways. Access to specialist services for older people now integrates a biweekly multidisciplinary older adults clinic. There is greater integration with hospital@home and the community in terms of links with local community matrons, a weekly frailty Hub for patients from local borough s that may have complex requirements and key links with Age UK support workers. Older people admitted via the emergency pathway have access to review by a consultant geriatrician 7 days a week, with specialist consultant review for older people sustaining hip fractures seen within 72 hours of admission. Our acute service for mental health now includes a specialist consultant for older people. Currently the specialist services for older people team has six medicine for older people consultants, a consultant nurse and three clinical nurse specialists within the older adults Assessment Team resulting in more expertise for the Trust. We estimate that on average 900 patients with dementia are admitted to UCLH each year. Training in dementia care was introduced in 2014 with 661 staff being trained in 2014 and 663 in Delirium guidelines and training with a focus on prevention is improving recognition and management of care of this patient cohort. UCLH has 13

14 signed up to John s Campaign and introduced a Carer s card to aid equal access to carers of older people. There have also been numerous developments within our elderly medicine wards including the following: Tea with Matron introduced on older peoples ward encouraging protected time for relatives/next of kin to meet with Matron about any anxiety/fear/concerns Dementia awareness day celebrated with a special Tea with Matron event with access to specialist nurses/information leaflets. T7 Award Winners of the trust Celebrating Excellence award for Top Quality Patient Care in 2015 for their improvements in patient experience of meal times, and were finalists in the national Kate Granger Compassionate Care Award. Charity bid from trustees received to purchase 2 handled bone china cups and saucers to improve the experience for older people during hot beverage rounds. Both wards for older people are now fully staffed with registered and nonregistered staff. Disability Learning Disabilities Our local borough of Camden s Joint Strategic commissioning plan 2013/16 confirms that people with learning disabilities are among the most vulnerable and socially excluded in our local society. There is evidence that people with learning disabilities have a greater need for healthcare, both due to social concerns such as housing and poor diet as well as being more susceptible then the general population to certain health conditions. As a group they continue to have inferior access to the care they need and poorer health outcomes. It is estimated there are around 500 people known to have a learning disability in Camden and a similar number in Islington. As a Trust we see a high volume of people with a Learning Disability from across the country accessing our specialist services, particularly at the NHNN. UCLH continues to have an active and representative Learning Disability (LD) steering group chaired by the Deputy Chief Nurse and co-chaired by the Consultant Nurse for Acute Care. UCLH appointed its first LD Clinical Nurse Specialist (CNS) in November Since taking up his post, he has focussed on direct patient support for inpatient areas and on improving the pathway through the Emergency Department. As a clinical expert, he is now receiving about 25 referrals from inpatient areas each month, a steady increase. The support he gives can range from telephone advice to spending time with patients and carers to helping staff with behavioural concerns. He now receives a daily alert for LD inpatients and those expected as admissions from the waiting list or as outpatient attendees in the next week. He has undertaken training in multiple areas to different staff groups, both clinical and non-clinical staff and volunteers. Seventy per cent of the Emergency Department staff have now received training and LD is now included in corporate induction for all new starters. He has improved links with our community partners and has helped plan elective admissions to improve the experience of LD patients, working with them to develop a new style of hospital passport. He is completing a 14

15 series of films showing ways to access our services, which will be available online and via DVD by April Following an audit of the care patients with LD received, he is now working with both the pain team and nutrition team to improve this aspect of care. His focus for the forthcoming year will be improving the elective admission pathway, to undertake a more comprehensive audit and to develop e-learning to widen the numbers of staff receiving training. Disability - Sensory Impairment UCLH continues to work closely with charities such as the British Deaf Association, SignHealth UK, DeafBlind UK, The Royal Society for Blind people and various advocates who are experts in their field. Improvement and equal access to services is of paramount importance. Feedback from patients and experts has highlighted the fact that this particular group of patients feel anxious when they attend for their appointments as they are not sure whether they will miss their names being called. We have therefore acted on this and introduced hand held buzzers across our main outpatient sites. The buzzers light up, flash and vibrate when the patient is called. We have also carried out a hearing loop audit across the Trust sites, ensuring that all areas are fitted with hearing loops or have portable ones available for use. Staff continue to show real interest in British Sign Language (BSL); those who have already acquired these skills are now meeting on a regular basis with a professional to maintain these skills, so that they are able to assist patients or visitors who can only communicate via BSL. We are also exploring sourcing funding to enable the growing number of staff who wish to learn BSL to be able to do so. The 2015 Deaf Awareness Week was well received by both staff and patients. The week concluded with a talk given by the British Deaf Association, making staff aware of the NHS England Accessible Information Legislation (part of the Health and Social Care Act (2012)) which makes it necessary for the Trust to produce a communication strategy on how it will meet the needs of patients with communication needs such as those with sensory loss, disability or limited English speakers by July The Trust is aiming to launch its Deaf and Sensory Loss Champions this year following a Training Day Workshop which will see patients and staff learning alongside each other with the same common goal in mind - improving patient experience and access to services at UCLH. Disability Access Arrangements and processes for disabled patient parking have been reviewed and improved during There has been much consultation with patients and governors to achieve these improvements. This work will continue in 2016/17. Gender reassignment UCLH offers a pioneering highly specialist national service in the UK for children and adolescents. As the first commissioned endocrine liaison clinic by the Tavistock and Portman NHS Foundation Trust, we offer a comprehensive, multi-organisational, multi-disciplinary assessments service for those up to the age of 18. We also provide specialist physical assessments and medical interventions enabling initial stages of gender transition through hormonal reassignment and partially reversible 15

16 treatments. With a growing cohort of over 500 young trans individuals registered and active within UCLH we are the largest UK liaison service and act as a resource and support within the NHS for newer endocrine Gender Identity Development (GID) services in Leeds and Belfast, and to be extended to Wales and other regions of England in 2016, and additionally to GPs within the wider community. Marriage and civil partnership During 2015 the Trust was able to facilitate the marriage of at least three patients on-site and one patient off-site, all of whom were receiving palliative care. Our policy for marriage and civil partnerships has been updated to reflect recent legislative changes involving same sex marriage. The chaplains, amongst others, are being regularly consulted about the possibility of individual patients getting married, both by civil and religious ceremonies. Pregnancy and maternity Maternity services have continued to ensure that our services offer high quality, family centred-care that is easily accessible, consumer driven and offer choice for all members of the diverse population we serve. The maternity service continues to develop innovative care packages to improve the quality of care and information that women receive during their pregnancy. Highlights from 2015 include: The Continuity of Carer programme: Women told us that they wanted continuity of care during their pregnancy and complained about waiting times in clinic areas. Since September 2015 we have introduced three midwifery-led teams to ensure women have continuity of care and access to a named midwife, which has prompted very positive feedback from both patients and the midwives who work in the teams. Managing waiting times: The maternity team has committed to inform patients about any long delays in clinics and update information every half hour. This includes the staff booking in women providing approximate wait times; a text service to recall women when they are ready to be seen, enabling those who wish to leave the clinic until it is time for their appointment; self-booking-in kiosks will be introduced in February 2016 to reduce waiting times; specialist paging devices to alert women who are hard of hearing when the midwife or doctor is available to see them. We have also recently launched a series of short video clips on birth options after a previous caesarean section, available at These were developed through focus group work with ten patients from our antenatal services, and are also available on You Tube. In view of the growing challenges presented by obesity, a Healthy Living Class for pregnant women has been trialled, giving them the opportunity to learn how to exercise safely, led by a physiotherapist, with advice on cooking and eating healthily provided by a dietician. The team is now looking for bigger premises to continue this innovative venture. The maternity team has also developed a series of short video clips on safe exercise in pregnancy, available on the UCLH maternity services website for women who might wish to exercise in the privacy of their own home. 16

17 The maternity helpline is now firmly embedded into the service, and has recently been subject to audit. It is the main portal for women to access advice in our maternity services, with over 21,000 calls being taken in November We are also developing other ways that women can make contact with our services e.g. we have recently introduced an response service for non-urgent queries for women cared for by hospital based-midwifery-led teams, as well as a telephone response service for both antenatal and postnatal women who are cared for by our local community teams; this will be available from 9 am until 8 pm, after which women will use the telephone helpline service. We are hoping that this will ensure the helpline service is predominantly used for urgent queries. Our maternity internet portal is currently being developed, and will include links to information leaflets for pregnant women whose first language is not English, so as to ensure equal access of information for all. Increasing numbers of same sex couples use our maternity services, and as a minority group we want to be sure that we are meeting their needs. In 2016 we intend to explore their experience of pregnancy and use of the maternity services throughout the NCL network. Support for women with Female Genital Mutilation (FGM) through revitalisation of the African Women s Clinic and implementation of an e-learning tool grows from strength to strength. The cultural change programme for maternity staff, which commenced in April 2014, continues in-house to ensure all staff are cognisant with cultural competence. The number of midwives who have undertaken or are undertaking BSL training has increased to 5, and more midwives will be trained to use this important communication skill in All our staff now have access to an internet BSL service, alongside the interpretation services we already offer. Through 2015 a significant number of midwives have been trained to provide acupuncture therapy for women in labour, and our homeopathy service has grown from strength to strength with increased numbers of couples requesting this service. We are currently working hard to ensure that the Maternity Services Liaison Committee has an audible voice about the services we provide for our local community and we will listen to what they tell us about those services and act upon any thing we could do better. We remain committed to ensuring that UCLH maternity services are a real choice for all women and their families, and we are constantly trying to evaluate the services we provide to ensure they are fit for purpose. Race The African Women s Clinic - AT UCLH, we feel passionate about making services fair and accessible to disadvantaged communities. Our multi-disciplinary team has worked hard to achieve outstanding results in this area, offering confidential assessment, deinfibulation (opening up of the scar tissue to restore the normal vaginal opening) following FGM and support for women who have had FGM. Over the last year, this service has been reinvigorated and expanded to provide increased 17

18 capacity for women and their families in response to the campaign within UCLH and nationally. Yana Richens OBE, consultant midwife, and Professor Sarah Creighton, consultant gynaecologist, were presented with the award by the Royal College of Midwives and praised for their important, innovative and pioneering work in this area. This has been supported by Baroness Ruth Rendell, Patron of the FGM National Clinical Group. (Left to right) Sarah Creighton, Baroness Ruth Rendell, Yana Richens Religion or belief In December 2015, the Trust completed a refurbishment of the UCH chaplaincy area to ensure a continued welcome to people of faith and of no faith, both for patients, visitors and staff. Following the move of urology and thoracic patients to UCH at Westmoreland Street, a room has been identified there as a potential quiet room for patients, staff and visitors who wish to pray, be quiet or meditate. Planning for the necessary refurbishment for this room and the adjoining areas is well underway. The small Sabbath room within the UCH chaplaincy centre is increasingly well used. Both Jewish patients and their families, mainly from more observant communities, welcome the room s availability, especially over the Sabbath and Jewish festivals. The fourth annual celebration of a Keertan Deebar on 10 th December 2015 was a great success. The local Sikh community and students prayed for the hospital. The Trust is always seeking to extend its engagement with both local and London-wide world faith communities. The chaplaincy team continue to assist in the on-going training of nurses and nursing assistants in matters concerning the practice of some patients religious beliefs, particularly around diet and when patients are dying. An afternoon organised jointly with the mortuary staff for student nurses was particularly successful and will be repeated. The dedicated bereavement suite that opened in 2014 has been extended in 2015 to provide a separate waiting area for bereaved families. This has provided a much enhanced and improved space for grieving families and friends where they can talk to the bereavement team when trying to sort out the affairs of their loved ones who 18

19 died within a UCLH hospital. The bereavement team is confident that it has enabled them to deliver their sensitive services in a dignified, welcoming and comfortable space. Sex UCLH places the privacy and dignity of its patients high on its agenda and offers dedicated separate inpatient clinical space for both male and female patients. When planning any new facilities, this is considered in detail and incorporated into all design of additional clinical space. Patient Experience and Patient & Public Involvement (PPI) Delivering high quality patient experience and customer service is one of UCLH s top ten objectives and is measured through patient feedback. In 2015, 61,613 patient surveys were completed across UCLH. Patient feedback is important as it tells us what we are doing well and importantly, what we can improve. Each survey asks patients their age, gender, ethnicity, and whether they have a disability; this information allows us to monitor if we are meeting the needs of all of our patients. A breakdown of patient demographics for inpatient feedback can be seen in Appendix 1. Patient information and PPI functions are part of the patient experience team. The team works together to embrace diversity and equality, making conscious efforts to ensure all activities are inclusive. Examples include: The Emergency Department Divisional Clinical Director met with the Chinese community, telling them about how best to use A&E and what to do when it is not an emergency. A patient engagement programme has taken place as part of the redevelopment of the Emergency Department. Workshops have been held with different patient groups including patients with specific access needs (visually impaired, blind, deaf, etc.), patients with learning disabilities and patients with mental health conditions. The feedback from the workshops has been used to guide the redevelopment of the department. The Patient Information Co-ordinator has been working with the UCH outpatients department to make the most commonly-read general patient information leaflets accessible to more patients. The leaflets have been compiled into a top ten set. This includes information such as Having an X- ray and How to get your views heard in easy read formats as well as leaflets on managing pain and the patient and visitor comment card. The team has also continued to support a number of projects with diversity and equality in mind. These include the introduction of a carer s card, allowing more flexible visiting times for carers and continuing to work with partner organisations to redistribute free items of clothing from surplus stock to the AMU ward, paediatrics and the homeless team. 19

20 Progress for staff by Protected Characteristic In 2015, the Board asked the Director of Workforce and the Chief Nurse to identify key initiatives which would support staff and improve staff experience. One of the key themes identified was to provide a safe environment for all our staff which better sought to support colleagues at risk of harassment, violence or bullying. In December 2015, the Board agreed to provide additional funding to improve the personal safety of all our staff to provide enhanced levels of conflict resolution training and to develop training for line managers so that they can better support their staff when they are subjected to bullying, abuse or violence in the workplace. These programmes will start in the Spring of 2016 and their impact against each protected characteristic shall be evaluated. Age The average age of a UCLH employee is younger than the national average. UCLH has made good progress in 2015 in developing new career entry points into the NHS for young people including young people not in education and training and those living in the least privileged areas of our local communities. At the end of the calendar year, 49 apprentices were working at UCLH. Plans are being developed to extend apprenticeship opportunities wherever possible with a view to doubling the number of apprentices by the end of Improving support for our most junior and newest staff is important to us. In 2015, we were the first NHS employer to be accredited as a London Living Wage Employer and Good Jobs Partners committing to new employment opportunities for local young people in partnership with local colleagues and Citizens UK a network for voluntary and community organisations. We also offer new flexible working opportunities for older staff who are nearing retirement and opportunities for staff to retire and return to work so that we do not lose valuable and highly specialist skills. Many staff who have retired in 2015 have returned as volunteers and continue to make a huge contribution to first contact services with our local public and patients. Disability In May 2014, UCLH became the first organisation in the UK to be certified by the International Disability Management Standards Council for its support for employees with disabilities. However, despite a comprehensive policy and a support programme for staff with disabilities, the staff survey results for 2015 show a disappointing experience for staff who declare themselves to be disabled on the staff survey. There is a significant discrepancy between the staff who self-report that they are disabled on ESR and the staff who declare themselves to be disabled via the NHS staff survey in response to the question: Do you have a long-standing illness, health problem or disability? By longstanding, we mean that it has lasted, or will last, for at least 12 months. During the last year, we offered support to over 1,650 staff who sought and gained support through our occupational health and staff psychology services. Confidential survey responses confirm those services are highly rated by a significant majority of 20

21 staff who utilise them. Yet it is now a priority for us to explore the inconsistencies between the staff survey s results and wider qualitative evidence. Race Analysis of ethnicity in referrals and self-referrals to occupational health and staff psychology services shows that BME staff are less likely than white staff to be referred for work-related stress, but this may again be related to the distribution of BME staff by band with more staff in higher bands receiving support for work-related stress. The pattern is however reversed when staff are referred for a disciplinary or clinical incident (although numbers of referrals are low). Work is underway to hold focus/listening events with staff to better understand their concerns. During the summer of 2015, our core HR teams reviewed how they could identify and mitigate any risks of unfair referral for investigation. Race Discrimination Our staff survey results from 2014 and 2015 suggest that some staff with protected characteristics, particularly those who report they are disabled or from a BME background, feel they suffer from discrimination. During 2015, UCLH launched the What is Discrimination? programme in conjunction with the Royal College of Nursing and our Staff Partners to explore the reasons why a high number of staff report that they feel discriminated. More than seventy staff attended the launch event with Cecilia Aim, the President of the Royal College of Nursing, and a further hundred staff have attended half-day workshops. The feedback from staff has been extremely positive in helping staff address unconscious bias and difference. Individual concerns from staff are addressed sensitively and staff are supported by trained professional colleagues in our Staff Psychology Service and the Occupational Health Department. Race- Workforce Race Equality Standard UCLH published its first Workforce Race Equality Standard in July The standard is an important reference point for our work and we have chosen to utilise it regularly and publish our progress every six months (rather than every year). Our second report was thus released in January The standard has been useful in highlighting race equality as a significant issue within the organisation and an action plan was developed to address key concerns. Performance in the January 2016 publication demonstrates improvements in recruitment, selection and performance management of staff. Work is underway to probe why BME staff are less likely to be shortlisted and appointed than white staff and why they are less likely to be internally promoted. Race - Black History Cecilia Anim, President of the Royal College of Nursing (RCN) made an inspirational speech during the launch of the What is Discrimination? programme for staff in October 2015 and celebrating black and ethnic minority heritage is a core theme of our extensive arts and heritage programme 21

22 Race - the Children of UCLH Staff Within central London we recognise that our staff face higher than average costs in seeking childcare. As well as affording childcare vouchers through a salary sacrifice scheme, we prioritise subsidised nursery provision for those of our staff joining us from foreign communities and in our most junior roles. Our Mousehole Nursery is a beacon for diversity. With an extremely diverse workforce and with children attending the nursery from all over the world, diversity is celebrated and used to enrich the experience of children and staff. The majority of our nursery places are allocated to staff who have joined UCLH from abroad and provides invaluable support to these workers. Race - Celebrating Excellence The annual Celebrating Excellence Awards Ceremony for 2015/16 recognised staff who have excelled in fifteen categories. Award winners were nominated by over 1,000 patients and staff. Thirty per cent of the finalists and 46% of the eventual winners were from the BME community. Sex Our female workforce exceeds that of our local, national and pan-london comparisons. Indeed where almost all general populations have a broadly 50:50 female to male ratio our employee demographic is 71% female to 29% male representation. Although the female workforce is 71% of the overall workforce at all grades, this split is not reflected in higher grades. The medical and dental in training workforce is equally split between male and female staff and although the representation of males in consultant level posts is lower, representation is becoming more equal year on year. The population of very senior management sees a reversal of the representation described for lower bands. In November 2015, a women s network was launched for aspiring leaders to encourage women to support one another. The network was initiated by two of our female directors and has since attracted over 40 female leaders and managers working across UCLH. The launch event was very successful and UCLH was represented at a national conference for accelerated leadership innovation at the year s end. In 2016, we intend to invest in the network and encourage it to set out a programme of action to use international evidence to further drive improved support for female leadership. Sexual orientation UCLH has been working in partnership with Stonewall since 2012 and in 2013 became a Stonewall Diversity Champion. We submitted our fourth bid to the Healthy Lives Index in September 2015 reflecting patient care and staff priorities. The results for our latest assessment have shown that we have significantly increased our performance in this competitive process from 206 th in 2012/13 to 167 th in 2014/15. The LGBT Network group has over 80 members and has achieved the following in 2015:- 22

23 Career coaching has been given by network members to LGBT staff this year. Information on how to access this is distributed to all staff at induction. Walking group in London Pride for the 4th consecutive year, attended by LGBT members and straight allies. LGBT awareness-raising event delivered from a public stall in the hospital atrium during IDAHOT week. Close collaboration with Transport for London (TfL), Guys & St Thomas s and London Ambulance NHS Trust this year. TfL LGBT Network donated their rainbow crossing to UCLH to help celebrate IDAHOT and the NHS Equality, Diversity and Human Rights week This was displayed in our main atrium for all staff and patients; we are the only Trust in the UK to have done this. Bi-monthly collaboration with members from all protected characteristics at the Trust Diversity and Equality Steering group. The LGBT Network Group hosted a joint IDAHOT stall with colleagues from care of the elderly. A stand at the UCLH Annual Festive Open Event In December 2015, to showcase our latest service developments, treatments and technology and to engage with our patients and wider public who had the opportunity to talk to our staff and get information ranging from how to provide first aid, become a UCLH member, and join the NHS to learn more about our diversity and equality work and progress within the Trust. Policy Review Policies are reviewed regularly; all policies reviewed in 2015 have all been assessed to ensure they promote equality and that staff with a protected characteristic are not disadvantaged in any way. Many of our workforce policies have been amended to include new provisions premised on national and international evidence that encourages procedural change to encourage equality and combat risks of inequality. 23

24 Priorities for 2016 We have identified a number of priorities for These will be defined within the setting of UCLH business plans. The EDS2 and the equality and diversity action plan will be monitored by the Diversity and Equality Steering Group which will make a regular progress report to the Executive Board. Patient Priorities: Ensure that data can be collected on all protected characteristics for patients and that multiple disabilities can be recorded Develop a video describing a patient s personal journey and experience of treatment within the teenage and young adult ambulatory care setting (residing in a local hotel rather than in hospital while undergoing acute treatment) Further develop the teenage and young adult page on the UCLH website, including establishing a closed Facebook page Improve access and information for disabled patients to UCLH by completing a disabled access scoping exercise across our main sites (funded by the Trustees and conducted by a non-profit making company, DisabledGo). The provision of this access information will not only assist disabled people, but also older people, carers and people with young children. Equally, the information will be of value to people with a temporary illness or mobility issue, who will need to know more about the provision available and to non-english speakers who can access information in their own language. Work will also to improve access to parking for disabled patients Expand Muslim prayer facilities within the chaplaincy area and review access to chaplaincy/prayer facilities for patients and staff on all sites Further roll out of dementia friendly environment across the Trust Ensure that UCLH has a system in place to meet the needs of patients with specific communication requirements by July 2016 to meet the requirements of the NHS England Accessible Information Legislation Complete a series of films showing ways to access our services for patients with learning disabilities and develop work on the care of patients with learning disabilities within both the pain and nutrition teams to improve this aspect of care Improve the elective admission pathway for patients with learning disabilities, and develop an e-learning module to widen the numbers of staff receiving training Launch the Deaf and Sensory Loss Champions in 2016 following a Training Day Workshop which will see patients and staff learning alongside each other with the same common goal in mind, improving patient experience and access to services at UCLH; further roll out deaf awareness training across the Trust Introduce self-booking-in kiosks in maternity to reduce queue wait times Develop the maternity internet portal to include links to information leaflets for pregnant women whose first language is not English, so as to ensure equal access of information for all 24

25 Workforce Priorities Complete the EDS2 grading exercise with our stakeholders and develop a comprehensive action plan Review the equality and diversity objectives and set out new objectives for the period 2017 to 2020 Publish the Workforce Race Equality Standard twice each year with a following report to the Executive Board Reduce discrimination across all protected characteristics and roll out the What is Discrimination? programme to areas identified as hot spots Identify initiatives to reduce levels of bullying and harassment experienced by staff from all protected characteristics Undertake a detailed analysis of formal cases investigated by Employee Relations to understand why staff in lower bands are more likely to go through a formal process Review the Equality Impact Assessment process and documentation for policies and service reviews Improve the recording of staff demographics relating to disability, sexual orientation, transgender and religion/belief; audit staff demographics recorded on the ESR and implement any actions arising from the audit Implement a range of initiatives to improve the experience of staff with specific protected characteristics: Improve the experience of our BME staff as evidenced in the WRES and staff survey, to include: o Undertaking market-research amongst BME staff at UCLH to better understand why there is a higher incidence of reporting that UCLH does not provide equal opportunities for career progression/promotion amongst this group and consider what further action can be taken to address this from a policy and/or training perspective, including mentoring and coaching support staff with protected characteristics to enhance their opportunities for promotion including to director level positions o Undertaking further analysis of recruitment data to understand whether there are specific areas, bands or staff groups within which a BME candidate is less likely to be appointed at interview and implement actions to address this o Evaluating our training offering to hiring managers in relation to recruitment and exploring the further development of the interview skills training with a view to improving the proportion of BME staff who are offered a post compared to white applicants o Undertaking a review of a sample of interview panels to understand whether BME staff are well-represented as hirers and consider whether the policy should be more prescriptive in this respect Improve the experience of our disabled staff who report a significantly worse experience at work via the staff survey in most key findings, developing a detailed action plan for this work Improve the experience of our lesbian, gay, bisexual and transsexual staff with a view to entry into the Stonewall Top 100 Employers Index by

26 Patient Information Appendix 1 PATIENT DATA This report provides information for period of 1 st January 2015 to 31 st December Some information may be outside this time frame. Where this is the case, we have specified this under each relevant section. The data relates to patients accessing the Trust s services during the reference periods described above, either as inpatients or outpatients receiving treatment. The inpatient survey data relates to a sample of consecutively discharged inpatients who attended the Trust in June, July or August The report of this survey was published in February We understand the importance of recognising the patient profile in comparison to the profile of our local population we serve, we have compiled data on the population of North Central London and produced an internal report to reflect this within the Trust. This enables us to monitor our local population trends disaggregated by protected characteristics as much as possible in order to identify the needs of our patients and communities and eliminate discrimination, advance equality and good relations. Each protected characteristic is shown, where possible, against the following information in line with the Equality and Human Rights Commission s (EHRC) revised guidance from December 2011 to publish proportionate information on our service users or those affected by our policies and decisions, including: Access to services or participation rates for people with the different protected characteristics; Patient satisfaction with services including any complaints; Performance information for functions which are relevant to the aims of the general equality duty mortality rates; Complaints about discrimination and other prohibited conduct from service users; Details of engagement with service users; Quantitative and qualitative research with service users - inpatient surveys; Assessments of impact on equality; Details of policies and programmes that have been put into place to address equality concerns. 26

27 Table 1: Patients by Race/Ethnicity Nationality Total AFRICAN 42,923 ANT OTHER ETHNIC GROUP 67,821 ANY OTHER ASIAN BACKGROUND 22,966 ANY OTHER BLACK BACKGROUND 10,305 ANY OTHER MIXED BACKGROUND 11,319 ANY OTHER WHITE 127,837 BANGLADESHI 23,957 BRITISH 521,812 CARIBBEAN 25,964 CHINESE 10,878 INDIAN 31,393 IRISH 22,856 NOT STATED 60,346 NULL 262,708 PAKISTANI 10,400 WHITE AND ASIAN 5,964 WHITE AND BLACK AFRICAN 4,527 WHITE AND BLACK CARIBBEAN 6,206 Grand Total 1,270,182 Table 2: Patients by religion or belief 27

28 INPATIENT SURVEYS Every year, we commission Picker Institute Europe to undertake the independent research of our inpatients. The results of this research are then published in an annual Inpatient Survey report. These annual surveys are required by the Care Quality Commission (CQC) for NHS acute trusts in England. Our latest survey is based on a sample of consecutively discharged inpatients who attended the Trust in June, July or August The report of this survey was published in February We, like all trusts, use a standard methodology and standard questions, as specified by the NHS Patient Survey Co-ordination Centre, based at Picker Institute Europe. The questionnaire reflects the priorities and concerns of patients and is based upon what is most important from the patient s perspective. Inpatient Survey Key Findings - Of the 1650 inpatients who were asked to complete our Inpatient Survey in 2014, 765 responded, giving a response rate of 46%. The demographics of respondents are outlined below: Gender: 54% male, 46% female Age Range: 17% were aged 16-39; 29% were aged 40-59; 25% were aged and 29% were aged 70+. Ethnic Background: 75% White, 2% Multiple, 5% Asian/Asian British, 8% Black/Black British, 0% Arab or Other ethnic group, 9% not known. There is no information available on the experiences of patients by demographics as this was not part of the Picker analysis in Local inpatient survey In addition to the annual survey carried out by Picker Institute Europe, we give our patients the opportunity to complete a survey when they are discharged from UCLH, giving us real time feedback. This survey consists of 29 questions which are based on the national inpatient survey results and includes the Friends and Family Test question. This allows us to track our progress in real time and highlights areas that are performing well, and areas that need improvement. Local Inpatient Survey Key Findings - 11,690 local inpatient surveys were completed in The demographics of respondents are outlined below: Gender: 50% male, 50% female Age Range: 6% aged 16-24; 13% aged 25-34; 14% aged 35-44; 18% aged 45-54; 19% aged 55-64; 17% aged 65-74; 9% aged 75-84; 4% aged 85+ Ethnic Background: 77% White, 2% Multiple, 9% Asian/Asian British, 8% Black/Black British, 3% Arab or Other ethnic group, 2% would rather not say. When broken down by gender, age and ethnic background there is a no significant difference between the Friends and Family Test scores for these patient groups: 28

29 Friends and Family Test Gender FFT % recommended score Male 97% Female 96% Age FFT % recommended score % % % % % % % % Ethnic Background FFT % recommended score White 97% Asian 97% Black 97% Multiple 96% Other 96% 29

30 ENSURING EQUAL ACCESS TO COMPLAINTS UCLH recognises that inequality of access to the complaints process may be influenced by educational background, cultural issues and language, disabilities and learning difficulties. Therefore, we endeavour to make the complaints process easy to access through a number of ways including providing support to complainants who wish to make a complaint but are unable to do so in writing or make a complaint themselves. Approximately 31 complainants were supported this way in Other methods of support include directing all complainants to the NHS Complaints Advocacy Service (Voiceability) for further support, offering complaints translation services, the use of sign language and Type Talk, producing complaints leaflets that can be translated into different languages on request and advertising the availability of Type Talk service provided by the Royal National Institute for the Deaf on the Trust s website. Our information about how to make a complaint or raise a concern includes an easy read format developed by Camden Easy Read Group and the complaints manager has attended the Trust workshop led by people with learning disabilities in Camden. Over the last few years a number of initiatives were launched at UCLH to improve awareness of how to raise concerns or complain about care. An updated leaflet on raising a concern or making a complaint was developed and 7,000 leaflets have been distributed across all sites, and to all departments and wards. Information about complaints and access to advocacy services has been improved on the Trust website and is included in the patient admission pack (The Welcome Pack) which was launched in This pack includes a handy leaflet explaining who to contact with concerns and how to complain if they still have issues that have not been addressed. In 2015 a call for concern number was introduced. This is available at every bedside and puts patients or their relatives in touch with a senior nurse. If the area of concern is one that can be addressed without using the formal complaints process then UCLH staff and the complaints team will try to facilitate this and will check this approach has resolved any concern. Standards for complaint responses were introduced in 2014 with greater clinical involvement; all departments now use clinical staff to respond to clinical areas of concern either directly or in conjunction with managers. The CQC regulates complaints under Outcome 17 of the essential standards of quality and safety. UCLH had several CQC visits in 2013, including a visit to the complaints department. The last inspection in November 2013 found that: the Trust had good systems in place for dealing with complaints and that generally services were safe, effective, caring and responsive to patient s needs and well led. When we inspected we saw many examples of good care. We were impressed by the dedication of the doctors and nurses we saw and the high level of support they were given as well as the mutual respect shown within teams, leading to high levels of care. We were also impressed with the emphasis placed at all levels from the Trust s board and governors down to the ward level on putting patients first. Another inspection is due in March

31 Monitoring Each division within UCLH also has a monthly governance meeting, where complaints and Patient Advice and Liaison Service (PALS) data is also considered alongside other indicators of quality care such as patient survey data, infection, falls, pressure ulcers, clinical incidents, and staffing information. The ward quality boards display the number of complaints. A scorecard is available for each ward and complaints are part of the Performance Book which is reviewed across the organisation each month. A monthly complaints monitoring meeting is chaired by the Head of Quality and Safety and attended by representatives from PALS, complaints, patient experience, nursing and patient governors/representatives. Other staff are invited as required. This meeting receives reports from PALS and complaints teams and a monthly thematic analysis. This allows real time feedback of emerging concerns from contacts to PALS and complaints and escalation to appropriate senior staff or the Board if emerging concerns about any area or aspect of care are noted. Issues identified from this thematic review are escalated to appropriate staff or committees and progress tracked through the Complaints Monitoring Group. A complaints report is presented every six months to the Trust s Quality and Safety Committee (QSC) which again triangulates evidence between complaints and other quality measures. Complaints and PALS data are used in the revalidation process for medical staff and will be used for other healthcare professionals, in line with post Francis recommendations. Complaints, PALS and expectations of how staff should act and improve patient experience are all part of the corporate UCLH induction for all new staff. A quarterly patient experience pack was developed in 2015 and shared with the Patient Experience Committee, the Quality and Safety Committee, the Board of Directors and Commissioners. An Annual Complaints Report is produced and is taken to the QSC, the PEC and the Trust Board and is available on the Trust website. An Annual PALS & Report is taken to the Patient Experience Committee. The Chief Executive signs off all complaint responses. The Chief Nurse and Chairman see all complaints and non-executive directors review all complaints and their responses on a rotational basis. The Trust Board receives a summary of the QSC minutes and since February 2015 each Board commences with a patient story, using issues from a complaint and what the trust has done to learn from the issues raised. The Chairman and complaints manager hold a rotational complaints forum in the divisions on issues and themes arising from complaints and how we can improve. A criticism by Francis was that complaints were not shared with Subject Matter Experts, e.g. falls at Mid Staffordshire were all managed by individual departments, and with no central complaint team, no one person had an overview for the whole Trust. At UCLH we ensure that subject matter experts are copied into complaints 31

32 relating to their area of expertise, e.g. the falls lead is copied into every complaint referencing a fall. Complaints that may indicate safeguarding issues or serious incidents are discussed in a safety huddle and passed to the safeguarding lead as appropriate. When complaints are received there is evidence that learning takes place but continual ways for improvement in complaints handling and learning lessons continues. PATIENT SATISFACTION AND COMPLAINTS BY PROTECTED CHARACTERISTICS Age and Patient Satisfaction UCLH measures inpatient satisfaction using electronic keypads (PDAs personal digital assistant). Patients are asked specific survey questions to gain more information about the care provided to them. For the reporting period, the group of in-patients most satisfied with the care they received were 85+ years old. Age and Complaints In the reference period, UCLH received 790 complaints. The largest patient age group making complaints is aged 26 to 55 years (37%), followed by years and over (17%). The chart below illustrates this in further detail. If a visitor is complaining or someone who has not accessed the Trust s care then we do not have access to their age. 32

33 Disability We have tried to improve the capture of concerns that relate to a disability this year, especially as the system will only allow one disability to be captured. Although this has been achieved, it is hoped that further improvements can be made. Hearing impairment Hearing impaired patients brought a number of concerns to the attention of PALS over this period and raised nine formal complaints. Issues included changed dates for surgery, checking that a BSL interpreter had been booked for an appointment, concern about environmental impact on lip reading and a request for correspondence about their admission arrangements. Sight impairment No complaints were received that specifically indicated this impairment as a factor but feedback has been received about some signage that has been shared with the facilities department. Learning Disability Five complaints were received, mainly from the next of kin or an advocate. Concerns raised included the lack of routine for the patient during their stay, the impact of changing appointments on the patient and the impact of a patient being nil by mouth for long periods of time. These complaints have been shared with the learning disability lead and the new Clinical Nurse Specialist and we have received feedback of improved subsequent admissions following this intervention. Mobility impairment Five complaints were received from patients identified as having mobility impairment. Themes were access to blue badge parking spaces and space for a wheelchair in a particular clinic and bathroom. The others related to criteria for transport or the type of transport provided. As a result of contacts to PALS and complaints, a group to improve the parking experience for patients with reduced mobility was set up in 2015 and a number of work streams are currently underway. Mental health Four complaints were linked to mental health concerns. Examples of the issues raised included care in the emergency department prior to being transferred to another hospital, staff not taking into account the patient s mental health when planning care for a physical problem, support or involvement of family members, interactions between medications and request to allow companions to use transport with the patient. 33

34 Cognitive impairment There were two complaints linked to cognitive impairment, the concern was that no allowance had been made for additional support during transfers. This has been flagged to the transport team and additional training on cognitive impairment implemented. Gender Reassignment and Patient Satisfaction Data for gender reassignment is not currently being recorded in terms of patient satisfaction. Gender Reassignment and Complaints Data on gender reassignment is not currently being recorded in terms of complaints, as the numbers are so small it may allow individual complainants to be identified. Marriage and Civil Partnership and Patient Satisfaction Data for marriage and civil partnership is not currently being recorded in terms of patient satisfaction. Marriage and Civil Partnership and Complaints Data on marriage and civil partnership is not currently being recorded in terms of complaints. Pregnancy and Maternity and Patient Satisfaction Data for pregnancy and maternity is not currently being recorded in terms of patient satisfaction. We are putting plans in place to include this protected characteristic in future. Pregnancy and Maternity and Complaints Maternity complaints are reviewed within the Women s Health division and action plans developed. Race/Ethnicity and Patient Satisfaction There were no complaints specifically relating to failure to accommodate religious/cultural beliefs in Most of our survey respondents were White British (n790), followed by patients from Any Other White background (n781) and White Irish (n378). The group of patients who rated our care highly were White/Asian (91.4%) followed by White/Irish (90.4%), White/British (89.9%) and Any Other White background (89.8%). The group of patients that rated the care they received the lowest at 81.4% were Bangladeshi. This will be explored further in We are committed to ensuring we treat all patients equally and effectively and try to encourage all patients 34

35 to feel comfortable to declare their ethnicity in order for us to incorporate this information in our decision making process about patient care we provide. Race/Ethnicity and Complaints The Trust recognises the importance of knowing a patient/complainant s ethnicity, especially where translation or advocacy services are required. We have received the most complaints from White British service users. This is, however, in proportion with our patient profile and the community we serve. However, this does not mean forgetting those whom English is not their first language, for example, or those who may feel they do not know how to complain. The data is dependent on the patient s electronic record and so we are unable to capture the ethnicity of non-patients, we also know many patients do not wish to provide ethnicity or other demographics and so the second largest group of complaints by race remains undefined. Similarly to other areas, we are aiming to improve the data collection in The following chart depicts the number of complaints filed by ethnicity: 35

36 Complaints by Patient Ethnicity (KO41(A)) the below table is updated White British % Not stated % White - other white 43 5% Other ethnic category 26 3% Black African 9 1% Black Caribbean 11 1% White Irish 10 1% Other Black 9 1% Other Asian 9 1% Indian 12 2% Chinese 5 0% Bangladeshi 2 0% Mixed white and black African 2 0% Mixed white and Asian 3 0% Pakistani 3 0% Mixed white and black Caribbean 4 0% Other mixed 3 0% Religion or Belief and Patient Satisfaction We do not hold any data disaggregated by religion or belief for patient satisfaction separately. However, we have been collecting this data under our annual Inpatient Surveys. Religion or Belief and Complaints We do not hold data for complaints disaggregated by this protected characteristic. Gender and Patient Satisfaction The satisfaction rates for both male and female patients were generally high, with men reporting higher rates at 90.3%, whilst women reported 88.8%. There were no complaints in 2015 about patients receiving care in a mixed sex ward. However there were two complaints when care had been requested to be provided by a particular gender and despite the best efforts of the team this had not been possible. 36

37 Gender and Complaints The majority of complaints received were filed by women at 59%. This is a reduction compared with 2014 when 63% of complaints were filed by women, and we have seen an increase in the number of males submitting complaints. However, this is in proportion with our patient profile which indicates that we treat more women than men overall. Sexual Orientation and Patient Satisfaction Data for sexual orientation is not currently being recorded in terms of patient satisfaction. We are putting plans in place to include this protected characteristic in future. 37

38 Sexual Orientation and Complaints Similarly to the above, data on sexual orientation is not currently being recorded in terms of complaints. We are putting plans in place to include this protected characteristic in future. No complaints have been linked to concerns about not making sufficient allowance for sexual orientation in this period. 38

39 ACCESS TO INTERPRETING SERVICES AND LANGUAGE LINE It is recognised good communication when accessing healthcare is critical. This is why limited English Speakers and those with sensory impairment always have access to an interpreter to facilitate their hospital appointments. As UCLH is situated in the heart of one of the most cosmopolitan cities in Europe it is almost impossible for us to know what a patient s communication needs will be, unless this information has already been given to us via the referring practitioner. However the Trust has made the following commitment to ensure that all our patients communication needs are met: The Trust has responded positively to NHS England Accessible Information Legislation which is part of the Health and Social Care Act (2012) which stipulates that the Trust must have a system in place by July We have to ensure that we meet the needs of patients with specific communication requirements. We have been working closely with various charitable organisations and patient representatives, to produce a communication standard to ensure that all our patients have equal access and we meet their preferred communication needs. The Trusts interpreting service is provided via LanguageLine Solutions (LLS). LLS provides the Trust with a 24/7 365 day service for both Telephone and Face to Face interpreting. Although the Trust default is the Telephone Interpreting Service which provides access to over 200 languages and dialects, we also appreciate there will be occasions when Face to Face interpreting is required, to ensure effective communication with patients and for certain appointments for example BSL, Deafblind, and Mental Health. We have also produced a welcome video in BSL which is accessible via our website, this gives the Deaf and hard of hearing patients an overview of how they can best access the service and the types of communication support that is available. During the financial year 2014/2015 we spent 738, on interpreting, and from January 2015 to December 2015 booked 14,134 Face to Face interpreting sessions. The divisions that accessed most telephone interpreting services were Women s Health and Accident & Emergency. The divisions which were the largest users of Face to Face interpreting services were The Royal National Throat Nose & Ear Hospital, The National Hospital for Neurology & Neurosurgery and the UCH Macmillan Cancer Centre. UCLH News, the magazine for members, is currently produced quarterly and the articles are translated into Bengali, Chinese and Turkish. Large print word document versions are also sent to those members with visual impairments 39

40 OUR COUNCIL OF GOVERNORS AND UCLH MEMBERSHIP Our Council of Governors is made up of 23 elected governors (four public governors from local communities; 12 UCLH patients; one carer of a patient and six staff) and 10 appointed governors from partner organisations representing our key stakeholders. The 23 public, patient and staff governors are elected by their membership constituencies. The Council of Governors is chaired by UCLH s Chairman who also chairs the Board of Directors. Governors represent the views of their members. For more information on our Council, please see: The Council of Governors is a valued and effective body advising the Trust on issues that are important to patients and the wider community. It works with the Trust to ensure we provide the best possible services to our patients. The governing body is not responsible for the day-to-day running of the Trust but works with the Board of Directors to produce the Trust s future plans. It ensures that the voices of members and partners inform the Trust s decisions. Its statutory responsibilities are described in the Trust s constitution. UCLH has a published membership development strategy which sets out the plan governors agreed to maintain, grow and develop membership, effectively communicate with members and engage and encourage member involvement. This is available on the UCLH website. The strategy will be reviewed in 2016 and will aim to put engagement with members and the encouragement of involvement first. The membership office and our governors have engaged with a number of communities during the year including a coffee morning with Camden Somali Age UK on dementia, two meetings at the Camden Chinese Community Centre about emergency care, and a joint meeting with members from Camden and Islington NHS Foundation Trust focussed on looking after people s physical and mental health. An analysis of the governors shows that currently 17 governors are male and 14 are female, with two posts currently vacant. Two of the governors (one elected governor and one stakeholder governor) are from a black and minority ethnic group. 40

41 EQUALITY ANALYSIS (EA) AND OUR POLICIES AND DECISION MAKING We firmly believe that the best way to consider the effect on different groups protected from discrimination by the Equality Act 2010 is by regularly undertaking policy decision-making process reviews to consider the effect on different groups (for example, disabled, LGBT, women, young persons, etc.). This helps us to recognise any potentially negative consequences and to assess the effectiveness of our policies, practices, activities and decisions. In the past year, a number of policies and functions have been reviewed to ensure that they reflect the latest diversity and equality requirements. Any work carried out in this area has been based on the EA, including incorporating the Equality Impact Assessments (EIAs) from previous years. EIAs have been mainstreamed through the Trust s policy approval process. This has remained a key area of focus for us as we embarked on the transition to the EA s approach. At the initial stages of all policy reviews, we start with the EA. If the policy relates to only some of the protected groups, we make sure that we consider the impact on all of the groups as one target group may often have other protected characteristics within it. The EA is further carried out at all stages of our policy making. It is ongoing and cyclical in nature. We aim to consider any likely effects prior to policy implementation. In order to ensure that all our policies, both existing and new, are regularly updated and reviewed, we have set up an audit assessment and identified a timetable for reviews and amendments. This helps us to keep on track and deliver our functions in a way that meets the equality duty. We follow the Step-by-Step guide for EA (Equality analysis and the equality duty: A guide for public authorities) as published by Equality and Human Rights Commission to ensure that the results of the EA inform policy development. Please see link for more details: ysis_guidance.pdf. This process includes the following aspects: Having appropriately trained and supported decision-makers. Checking all our policies for their relevance to equality issues. Although not historically carried out, we now aim to check all of our policies against the nine protected characteristics. This has been incorporated into our EA template. Paying particular importance to those policies affecting our workforce, service users and communities, but aim to review all polices. Aiming to publish our decisions made in our policies to ensure openness and transparency Scoping our policies related to equality. This includes identifying the relevant protected groups the policy relates to as well as the relevant parts of the 41

42 general equality duty, evidence available, information gaps and any relevant stakeholders to involve (for example, our staff or trade unions). Identifying any potentially negative effects or discrimination as well as ways to advance equality of opportunity and to foster good relations. Addressing inequalities the Trust is not solely responsible for. Recording the EAs for transparency and introducing a structured, Trust-wide EA template to do this. Providing relevant EA training. Creating action plans to enable the policy implementation. Regular monitoring and reviewing of policies. Considering ways to measure the implemented policies. Seeking stakeholder involvement and engagement for feedback. Ensuring a consistent approach to policy embedding into the wider Trust. Establishing and maintaining a reliable source of diversity and equality information available for easy access to all policy and decision-makers across the Trust. Having an internal governance system in place in order to quality check any EA carried out. This is currently done through our Diversity and Equality Steering Group (DESG) forum with representation from different departments of the Trust. 42

43 EQUALITY MONITORING INFORMATION ABOUT OUR PATIENTS/ SERVICE USERS Please note that the information provided in this section of the report only relates to our compliance with the first aim of the general equality duty that refers to eliminating discrimination, harassment and victimisation and any other conduct that is prohibited by or under the Equality Act (2010) Our patients by age Grand Total 125, , , , , , ,249 56,761 7,304 1,270,182 The largest age group of our patients/service users who accessed our services in different ways between January 2015 and December 2015 is 30 to 39 years at 18.78% (n238,531). The number of patients accessing our services was relatively stable from January 2015 until November 2015 with March being higher. The following chart illustrates the breakdown of our service users by age over the last few months. Our patients by disability Our records show that 9.7% (n123,328) of our patients are disabled. We also record the type of disability when our patients come into contact with us. Please see Appendix 3 for more information on the types of disability of our patients. 43

44 The chart below depicts the breakdown of disabled patients who used our services in 2015 by month. The proportion of disabled patients seems to have been very similar each month and only increased in numbers when the total patient number increased. Our Gender reassignment information UCLH provides gender reassignment services as part of the Urology Directorate. The service is currently not taking any more patients in order to concentrate on the care and support of those already being treated. Service users by marriage and civil partnership The following chart illustrates the 2015 trends by month for this protected characteristic. It highlights that about half of our data is unknown. 44

45 Pregnancy and maternity information We had 96,948 patients who accessed our maternity services between January and November 2015, the highest proportion of which were White British at 20.2% (n19,598), followed by Any Other White Background at 13.8% (n13,381) and Any Other Ethnic Group at 8.3% (n8,005). 0.7% (n649) of our maternity patients declared themselves as having a disability. However, a large proportion of this data remains undefined (63.5%). 28% of our maternity patients reported to be married or in a civil partnership. The largest proportion of our maternity patients declared themselves as Christian in religion at 8.9%. However, again a large proportion of this data remains undefined (75.1%). Our patients by race/ethnicity Data on race/ethnicity is classified according to the breakdown used in the 2001 census. Our most represented patient ethnic group is White - British at 41.1% (n521,812) followed by White - Any Other White Background at 10.1% (n127,837). The least represented ethnic group in our patients are service users from a White and Black African mixed background representing 0.4% (n4,527) in total. A significant proportion of race/ethnicity data for our patients has been undefined at 25.4% (n232,054). The following chart depicts the 2015 trends for our service users by race broken down by months. It shows that although the number of patients has fluctuated, the proportion of different ethnicities has remained relatively stable. 45

46 A breakdown of information on our patients race/ethnicity can be found at the beginning of this appendix. Our Patients by Religion or Belief 51% of our patient data on religion or belief is undefined. 26% (n337,199) of patients for whom we hold this information identified themselves as Christian. The following chart illustrates the 2015 religion or belief trends by month. 46

47 We are working on improving our reporting systems to decrease the undefined data in order to ensure that this protected characteristic is being captured properly. This would help us to identify the needs of people from different religious or belief backgrounds in terms of their care, treatment and preferences when they come into contact with us. Our patients by gender Most of the people who accessed our services in 2015 were female at 59.4% (n756,008). Compared to our local population, this is slightly higher as the percentage of females in North Central London is 52%. It has been suggested that women access health services more than men. This figure may be in line with this suggestion. In 2007, according to The State of Equality in London Report 2008 published by Greater London Authority, 51.1 per cent (3,834,500) of London s population was female (women and girls), which means there are over 164,100 more women and girls than boys and men in London. 47

48 The chart below illustrates the trends for patients by gender over the last year. Our patients by sexual orientation Data for patient sexual orientation is not currently being recorded. We are putting plans in place to include this protected characteristic in future. 48

49 Workforce Information Appendix 2 Analysis of the Workforce Religion/Belief FTE Percentage Non-Christian (including atheist) 2, Christian 2, Do not wish to disclose Undefined 2, Total 8, Disability Disabled Not disabled 4, Not declared Undefined 3, Total 8, Marriage/civil partnership Married 2, Civil partnership Not declared/undefined 5, Total 8, Age , , Total 8, Ethnicity White 4, BME 3, Undefined Not stated Total 8,

50 Best 20% Above average Average Lower than average Worst 20% NHS Staff Survey Results for 2015 Key Finding Number of Respondents Result 2014 Result Category BME White Male Female Disabled/ Long term health condition Nondisabled Overall staff engagement KF1 place to work or receive treatment KF2 satisfaction with patient care KF3 role makes a difference to patients KF4 staff motivation at work KF5 recognition and value by managers KF6 good communication with senior management KF7 able to contribute to improvements KF8 satisfaction with level of responsibility and involvement KF9 effective team working KF10 support from immediate managers KF11 % appraised in past 12 months KF12 quality of appraisals KF13 quality of non mandatory training/ development KF14 satisfaction with resourcing and support KF15 flexible working patterns KF16 % working extra hours KF17 % suffering work-related stress KF18 %pressure to attend work when unwell

51 Key Finding KF19 interest in and action on health wellbeing KF20 % experiencing discrimination KF21 equal opportunities for career progression /promotion KF22 % physical violence from patients/visitors KF23 % physical violence from staff KF24 % reporting violence KF25 % harassment, bullying & abuse from patients/ visitors KF26 % harassment, bullying & abuse from staff KF27 % reporting bullying, harassment & abuse KF28 % witnessing errors etc KF29 % reporting errors etc KF30 fairness of procedures for errors etc KF31 confidence in reporting unsafe clinical practice KF32 effective use of patient feedback Q17b % staff discrimination at work from manager and colleagues Result 2014 Result 2015 Category BME White Male Female Disabled Long term health condition Non -disabled * 8* * National average for BME staff is 13% and for white staff 6% The results of the staff survey clearly show that our disabled staff and those who chose to report a long term health condition affecting them in 2015, reported a worse experience in the workplace for most key findings and this will be explored in 2016, along with the significant difference between staff reported as disabled on the ESR and self-reported as disabled and/or being affected by a health condition using the different NHS staff survey definition. The results for BME staff relating to discrimination, equal opportunities and harassment and bullying raise clear concerns which will also be prioritised in our action plan. However, BME staff satisfaction in many other areas is very positive. 51

52 Organisation by band and ethnicity Band % White % BME % Undefined/ Not stated Apprentice Band 1 and Band Band Band Band Band Band 8A Band 8B Band 8C Band 8D Band Very senior managers/directors Medical and dental staff in training Medical and dental consultants Total The percentage of the workforce that is BME reduces as staff reach higher pay grades. This applies to both medical and non-medical staff. This is more acute for the female workforce than the male workforce. This can also be demonstrated by the proportion of people identified as supervisors within ESR. There is a lower representation of people from BME backgrounds who are identified as supervisors than the proportion of employees overall who are from BME backgrounds. This is likely to be highly correlated with the grade differential. Further analysis is required to assess whether these findings are mirrored in the general population in order to present solutions to promoting NHS careers for people from BME backgrounds. % of all employees % of supervisors Female 71.40% 70.10% LGBT 2.60% 3.50% Non-Christian (incl Atheism) 27.30% 19% Identify as having a disability 0.64% 0.50% BME 40.91% 25.43% 52

53 Organisation by band and gender Band % Female % Male Apprentice/student Band 1 and Band Band Band Band Band Band 8A Band 8B Band 8C Band 8D Band Very senior managers/directors Medical and dental staff in training Medical and dental consultants Total The overall workforce is 71% female. These data show that the percentage of female staff starts to reduce significantly at Band 8C and reduces to 21% at the level of very senior manager/director. The Board of Directors The Board of Directors has 15 members. Four of the Board members are female and 10 are male, with one post being currently vacant. There are no Board members from a black and minority ethnic background. The current selection process for our next Non-Executive Director is placing emphasis on how we can ensure it best allows for improved diversity at the Board level. 53

54 Recruitment and selection data All applications % Shortlisted % Appointed % Gender Male 12, , Female 26, , , Not stated Total 38, , , Ethnicity White 14, , , BME 23, , Not stated 1, Total 38, , , Sexual Orientation Heterosexual 33, , , Gay/lesbian Bisexual Not stated 3, Total 38, , , Transgender No 11, , Yes Not stated 27, , , Total 38, , , These data show that BME staff are less likely to be shortlisted than their white counterparts and even less likely to be appointed from shortlisting. 54

55 Internal Promotions There were 441 people employed at UCLH on 15 th February 2016 that were employed on the same date in 2015 at a lower grade. The diversity of the people who were promoted by at least one grade between February 2015 and 2016 is shown in the table below staff from a BME background are under-represented. % of cohort promoted Feb % of all employees 2015 to Feb 2016 Female 71.40% 74.60% LGBT 2.60% 4.08% Non-Christian (incl Atheism) 27.30% 30.39% Identify as having a disability 0.64% 1.59% BME 40.91% 31.75% The data have been further analysed by Agenda for Change pay band: Bands 1-4 % of all employees % of cohort promoted Feb 2015 to Feb 2016 Female 19.48% 17.69% LGBT 0.57% 1.36% Non-Christian (incl Atheism) 5.42% 7.48% Identify as having a disability 0.31% 0.91% BME 16.52% 14.29% Bands 5-7 % of all employees % of cohort promoted Feb 2015 to Feb 2016 Female 48.76% 52.38% LGBT 1.23% 2.27% Non-Christian (incl Atheism) 12.39% 21.09% Identify as having a disability 0.44% 0.68% BME 25.08% 16.78% Band 8 and above % of all employees % of cohort promoted Feb 2015 to Feb 2016 Female 8.15% 4.54% LGBT 0.33% 0.45% Non-Christian (incl Atheism) 2.24% 1.81% Identify as having a disability 0.06% 0.00% BME 1.93% 0.68% These data show that BME staff in Bands 5 to 7 are less likely to be promoted than staff in bands 1 to 4. 55

56 Employee Relations Cases The Workforce Race Equality Standard, published in July 2015, raised concerns that more BME staff were subject to formal employee relations processes than white staff. This prompted us to carry out the following and more detailed analysis of our data. Ethnicity 2015 Closed 2015 Live Grand Total % BME White Not stated or not defined Total More staff from a BME background are subject to formal ER processes. As there are fewer BME than white staff the likelihood of BMS staff being subject to formal ER processes is higher than for white staff. Gender 2015 Closed 2015 Live Grand Total % Female Male Total Although slightly more female staff are subject to formal ER processes, the likelihood of male staff being subject to formal ER processes is higher as the proportion of male staff to female staff is lower. Disability 2015 Closed 2015 Live Grand Total % Not disabled Disabled Not stated or not defined Total These data relating to disability are not statistically valid as 59.8% of cases do not have disability/non-disability recorded. Pay Band 2015 Closed 2015 Live Grand Total % Band Band Band Band Band Band Band Band Band Medical/dental Total Staff on bands 2 to 6 are most likely to be subject to formal ER processes. We intend to review whether there is any evidence of unconscious bias in our performance management 56

57 early in 2016/17. Initial analysis shows that there is not a significant difference between the proportion of live ER cases who are from BME backgrounds the proportion of employees from BME backgrounds when you take pay band into account. 57

58 Types of Disability Appendix 3 The types of disability recorded for our patients were as follows: Asthma Blind with visual impairment Deaf with hearing impairment Deafblind Dementia Dyslexia Dysphasia Dyspraxia Epilepsy Impaired mobility Learning disability Mental health problems 58

59 Appendix 4 Abbreviations and Acronyms This includes a list of abbreviations and other terms that may have been used in the report. We encourage you to see clarification if you find any of the terms unfamiliar. BME BSL CCCC CQC D&E DESG DH EA EAs EB EDC EDH EHRC EIA ER ESR FGM GEO GID HTD KPI LGBT LINks NHNN NHSCIC PALS PHSO POP QS QSC RCN RLHIM RNTNEH ToR UCH UCL UCLH UCLP Black and Minority Ethnic British Sign Language Camden Chinese Community Centre Care Quality Commission Diversity and Equality Diversity and Equality Steering Group Department of Health Equality Act Equality Analysis Executive Board Equality and Diversity Council Eastman Dental Hospital Equality and Human Rights Commission Equality Impact Assessment Employee Relations Electronic Staff Record Female Genital Mutilation Government Equalities Office Gender Identity Development Hospital for Tropical Diseases Key Performance Indicator Lesbian, Gay, Bisexual and Transgender (Transsexual) Local Involvement Networks National Hospital for Neurology and Neurosurgery The National Health and Social Care Information Centre Patient Advice and Liaison Service Parliamentary and Health Service Ombudsman Productive Outpatient Programme Queen Square Quality and Safety Committee Royal College of Nursing The Royal London Hospital for Integrated Medicine Royal National Throat Nose and Ear Hospital Terms of Reference University College Hospital University College London University College London Hospitals NHS Foundation Trust UCL Partners Academic Health Science Partnership 59

60 Karin Roberts, Trust Lead for Equality and Diversity and Sue Beatson, Lead for Patient Equality and Diversity 2 nd Floor North 250 Euston Road London NW1 2PG Karin.roberts@uclh.nhs.uk and Sue.beatson@uclh.nhs.uk Website: We can provide the information in this report in a different format such as large print, Braille, audio version or an alternative language