Croydon Clinical Commissioning Group Public Sector Equality Duty Annual Report January 2017 January Version 4

Transcription

1 Croydon Clinical Commissioning Group Public Sector Equality Duty Annual Report January 2017 January 2018 Version 4

2 Welcome Introduction Organisational context CCG Leadership About Croydon Croydon CCG Commissioning Intentions 2018/ Meeting the Public Sector Equality Duties in Fostering Good Relations Partnerships Public Health Croydon Health Protection Forum Health and Wellbeing Board Community, Voluntary and Faith Sector Organisations (including Carers support) Croydon Healthwatch Safeguarding - Adults and Children in Croydon Domestic Abuse & Sexual Violence Partnership Action Plan Complaints / Patient Advice and Liaison Service (PALS) Interpreting service Serious Incidents (SI) Croydon CCG s Equality Case Studies Main Provider Organisations Croydon Health Services NHS Trust South London and Maudsley NHS Foundation Trust Worforce Race Equality Standard (WRES) Croydon CCG Worforce Information Croydon CCG Organisational Development Plan Equality & Diversity Training For CCG Staff and Governing Body Equality Objectives Progress in Equality Delivery System (EDS) Useful Information CCCG Public Sector Equality Duty Report Jan 2018

3 Welcome We are delighted to present this report highlighting our progress on equalities in has been another challenging year for Croydon CCG and its partners. Once again NHS England asked the CCG to deliver significant savings in order to deliver a financial balance in 2017/18. Despite implementing a financial recovery plan and delivering significant QIPP savings this year, the CCG remains in special measures. In January 2017, the decision was made to close a much loved mental health unit for women in Croydon and other decisions were taken about items the CCG would no longer prescribe. Over the coming months the CCG had to make more decisions about services it provided to meet the health needs of the people in Croydon. The focus was put on high priority services that meet the needs and delivered improved outcomes for the most vulnerable and people in crisis. Unfortunately the some services were not comparable to crisis support or urgent care and it was the CCG s task to make these decisions. If money was not an object the CCG would probably want to develop these services further but it was not in that position. In the midst of making these tough decisions, the CCG has ensured that the equality impacts on Croydon s communities have been researched and analysed to inform decisions and to give the opportunity to mitigate any negative impacts. The CCG also carried out substantial engagement to find out the views of local people and take them into consideration before any final decisions were made. In spite of these challenges, through our commissioning we are committed to improving health outcomes, reducing inequality and reducing health inequalities. This report brings together evidence, activities and recommendations that demonstrate how Croydon CCG is meeting the statutory duties under the Equality Act Highlights of achievements in 2017 include: Croydon CCG attained 12 out of 15 points achieving an overall rating of Green as part of NHS England s review of how CCG s across the country engage with local patients and public. Out of the five categories the CCG was assessed against, the CCG was judged good across three and outstanding in two. In April 2017, health and care partners in Croydon signed the Croydon Alliance Agreement to deliver the contract for Outcomes Based Commissioning (OBC) for over 65s.The alliance will be operating under the name One Croydon, and their vision Working together to help you live the life you want will support the delivery of the strategic visions of all partners. IAPT and changes to prescribing engagement: we used equalities data to guide the engagement and worked with CVA to engage communities we were especially concerned about as being most affected by change. Winterbourne Transforming Care Targets with respect to learning disabilities: additional resource has been invested in the management of the risk relating to the Winterbourne Transforming Care targets resulted in targets being met and the risk is being managed within acceptable levels. As in 2016, this year s report focuses on how the CCG has been meeting the three aims of the general duty of the Equality Act 2010 with examples and case studies. Having been Assistant Clinical Chair of Croydon CCG since its inception in 2013 and a local GP in Thornton Heath for over 20 years I was delighted to become CCG Chair from 1 st July Dr Tony Brzezicki s planned term as Chair and his retirement from the 3 CCCG Public Sector Equality Duty Report Jan 2018

4 CCG Governing Body precipitated my appointment, however we are very pleased that Tony has generously agreed to continue to support the CCG as a clinician on the Planned Care work stream. We are also delighted to have appointed Dr Tom Chan to the GP representative post of Medical Director on our Governing Body. After more than five years establishing and leading Croydon CCG, Paula Swann stepped aside as Accountable Officer. Paula led the organisation through a very difficult period from its inception. We continue to build upon the strong foundations and transformation programmes that are Paula s legacy. From the 5th June, Andrew Eyres has been covering the Accountable Officer role for NHS Croydon CCG alongside his role as Accountable officer for Lambeth CCG. Croydon and Lambeth CCGs continue to operate as two separate, but neighbouring organisations and each remains an independent body with statutory responsibilities and accountabilities. The scale of the financial challenge will mean we may have to continue to make measured, but difficult decisions in the short term. At the same time we need to progress transformation, engaging and involving stakeholders, GP members and Croydon residents with openness and transparency and taking them with us on the journey towards sustainable health and care in Croydon. We are very grateful to our staff and GP membership for their hard work, support and commitment to getting it right for our diverse population and finding new ways to make savings and efficiencies. Dr Agnelo Fernandes Clinical Chair Croydon Clinical Commissioning Group 4 CCCG Public Sector Equality Duty Report Jan 2018

5 1 Introduction The Equality Act 2010 provides a legal framework to strengthen and advance equality and human rights. The Act consists of general and specific duties: The general duty requires public bodies to show due regard to: Eliminating unlawful discrimination or any other conduct prohibited by or under the Act Advancing equality of opportunity between persons who share a protected characteristic and persons who do not share it. Fostering good relations between people who share a relevant protected characteristic and people who do not share it. There are nine protected characteristics covered by the Equality Act: Age, Disability, Gender re-assignment, Marriage and civil partnership, Pregnancy and maternity, Race including nationality and ethnic origin, Religion or belief, Sex (male/female), Sexual orientation. The specific duties require public bodies to publish relevant, proportionate information showing how they meet the Equality Duty by 31 January each year, and to set specific measurable equality objectives by 6 April every four years starting in Both general and specific duties are known as the Public Sector Equality Duties (PSED). As a statutory public body, the NHS Croydon Clinical Commissioning Group must ensure it meets these legal obligations and intends to do so by publishing information demonstrating how the organisation has used the Equality Duty as part of the process of decision making. 1.1 Organisational context Croydon Clinical Commissioning Groups (CCG) assumed statutory responsibilities from 1 April GPs in Croydon have come together as the Croydon Clinical Commissioning Group. Croydon CCG is responsible for assessing the healthcare needs for the population of Croydon and co-coordinating and paying for services to meet those needs through hospital, community and mental health services. As a membership organisation, our GP member practices work in 6 GP networks, to address problems that are arising, and to see how local services can be improved and better co-ordinated. Croydon CCG s constitution commits the organisation to work towards meeting the public sector equality duties and reduce health inequalities. We recognise that, as commissioners of services, we must account for not only our own organisational equality performance but also that of the providers of services that we commission. The CCG purchases a range of services from the NEL Commissioning Support Unit (including Equality and Diversity service), which supports the CCG to discharge its statutory responsibilities, including those within the Equality Act NHS England provides strategic policy guidance and performance monitoring through its national Equality and Health Inequalities team. 5 CCCG Public Sector Equality Duty Report Jan 2018

6 1.2 CCG Leadership Croydon CCG has identified a clinical equality lead that along with the executive team is actively supporting the development and delivery of equality work streams. All Governing Body members have a collective and individual responsibility to ensure compliance with the public sector equality duty, which will in turn secure the delivery of successful equality outcomes for us, both as a commissioner and an employer. A Lay Member has been appointed to the CCG s Governing Body to lead on patient and public involvement. The Lay Member has oversight responsibility for ensuring that the voice of the local population is heard in all aspects of the CCG s business, and that equal opportunities are created and protected for patient and public involvement and engagement. The Chief Officer has responsibility for ensuring that the necessary resources are available to progress the equality and diversity agenda within the organisation and for ensuring that the requirements of this framework are consistently applied, co-ordinated and monitored. The Chief Officer is actively engaged in leading the CCG s responsibilities for PSED. The Director of Quality and Governance has operational responsibility for: Developing and monitoring the implementation of robust working practices that ensure that equality and diversity requirements form an integral part of the commissioning cycle Working with the NEL Commissioning Support Unit (NELCSU) to ensure that equality and diversity considerations are embedded within their working practices Ensuring that the Governing Body, staff and member practices remain up to date with the latest thinking around diversity management and have access to appropriate resources, advice, and informal and formal training opportunities All line managers have responsibility for: Ensuring that employees have equal access to relevant and appropriate promotion and training opportunities. Highlighting any staff training needs arising from the requirements of this framework and associated policies and procedures. Support their staff to work in culturally competent ways within a work environment free from discrimination 6 CCCG Public Sector Equality Duty Report Jan 2018

7 2. About Croydon Population and Population Growth The borough is home to 382, 304¹ people and this is expected to reach 465,600 in 2041² Children Approximately, 17,700 (23%) of children in Croydon live in low income families³ Croydon has the one of the highest number of looked after children of any London borough due to the high numbers of unaccompanied asylum seeking children (UASC) looked after by the borough. As of the middle of February 2017 there were a total of 813 looked after children in Croydon, of these 402 were UASC looked after children and 411 were local looked after children. Croydon is unique to other London boroughs as the UK Border Agency headquarters are located within its boundaries which means proportionally a larger number of unaccompanied asylum seeking children UASC are housed within the borough. 4 Older Adults In Croydon 17% of older people were income deprived. This is ranked as 87th out of the 152 upper tier local authorities with a rank of 1 being the most deprived. 5 Deprivation Croydon became relatively more deprived compared to other local authorities in England between 2010 and Although there have been some changes in the individual rankings of LSOAs within the borough there remains geographic inequality in the distribution of deprivation in the borough with the North and South East of the borough remaining more deprived. The Index of Multiple Deprivation (IMD) 2015 data ranks Croydon as the 19th most deprived London borough out of 32 London boroughs, and Croydon was ranked the 70th most deprived authority out of the 326 district authorities in England. ² Disability 14.6% (53,113) Working age people in Croydon have day-to-day activities limited a little or a lot. 6 Mental Health Approximately 1.04% of patients registered in Croydon in 2012/13 had been diagnosed with a mental health condition. This is higher than the national average of 0.84% but is in line with the average for London of 1.03%.² Ethnicity and Migration Currently, 50.7% of Croydon's population (all ages) are Black, Asian and Minority Ethnic (BAME) groups. By 2025 this is predicted to be 55.6% % of people living in Croydon speak English. The other top languages spoken are 1.5% Tamil, 1.4% Polish, 1.2% Gujarati, 1.1% Urdu, 0.7% French, 0.6% Portuguese, 7 CCCG Public Sector Equality Duty Report Jan 2018

8 0.4% Turkish, 0.4% Malayalam, 0.4% Spanish. 6 Around 20,000 people move into the borough each year from the rest of the UK. In 2016, more people left Croydon for other areas of the UK than moved into Croydon from other areas in the UK. 20,656 people moved into Croydon while 23,458 people moved out of Croydon, resulting in a net loss of 2,802 people. These figures vary depending on age range however; internal migration accounted for a net loss of 2,012 people aged 0-19 and a net loss of 1,652 people aged 35 or over but resulted in a net gain of 862 people aged International migration Across all age groups, more people moved into Croydon from areas other than the UK than left to live abroad. 4,762 people moved into Croydon while 2,155 people moved out of Croydon, resulting in a net gain of 2,607 people. Younger people (aged 0-19) were the age group seeing the largest net gain in the year (1,023 people). Across the borough, the net gain of those entering the borough from outside the UK did not offset the numbers leaving for other areas of the UK, migration as a whole resulted in a net loss of 192 people.7 Country of Origin Statistics 68.7% of people living in Croydon were born in England. Other top answers for country of birth were 3.6% India, 2.5% Jamaica, 1.5% Ghana, 1.5% Pakistan, 1.5% Sri Lanka, 8 CCCG Public Sector Equality Duty Report Jan 2018

9 1.3% Nigeria, 1.1% Ireland, 0.9% Kenya, 0.9% South America. 6 Life Expectancy Life expectancy is 9.7 years lower for men and 6.1 years lower for women in the most deprived areas of Croydon than the least deprived areas³ Mortality Mortality rates for cancer and cardiovascular disease in Croydon are equal to or better than the London and national average. ³ Gender Approximately 51% of the population is female. Approximately 49% of the population is male. 7 Lesbian, Gay, Bisexual Of the total Croydon population, 2.6% or 9,940 people are estimated to be lesbian, gay or bisexual. 7 Office of National Statistics 2015 (percentage in London) Religion and Faith 56.4% of Croydon s population identified itself as being Christian, followed by 20% who identified with no religion, 8.1% as Muslim, 6% as Hindu, 0.7% as Buddhist and 1.2% with other religions³ Source:¹ ONS* = values aggregated from the Office for National Statistics (ONS) small area population estimates ² Croydon Borough Profile 2015, ³Croydon Health Profile 2017, 4 Croydon Council Looked After Children Sufficiency Plan March 2017, ³Croydon Observatory 2017, ONS, 6 Census 2011, Table QS303UK, 7ONS 2016 mid-year population estimate, 8Office of National Statistics 2015, 9 Director of Public Health Report Croydon CCG s Commissioning Intentions 2018/19 The CCG s intentions for 2018/19 are used to signal significant contractual changes to providers of the care and treatments to be offered. The intentions build on the agreed initiatives in the two -year contracts ( , ) and support consistency with the priority areas of SW London partners in the sustainability and transformation plans (STP). The commissioning intentions presentation provided an update in the following areas: 9 CCCG Public Sector Equality Duty Report Jan 2018

10 Strategic Context Engagement Financial Context Planned Care Mental Health Primary Care Urgent Care Out of Hospital (including OBC) Medicines Management Learning Disabilities Women & Children Contracting The CCG will commission services that are clinically appropriate, affordable, deliver good outcomes and demonstrate value for money. The Croydon CCG Commissioning Intentions cover the following broad headings: Planned Care Vision & Transformation Mental Health Primary Care Urgent and Emergency Care Out of Hospital Outcome Based Commissioning for over 65s in Croydon Medicines and Pharmacy Learning Disabilities Women & children Children and Young People Contracting Approach The CCG will work with SWL to consider new contractual forms for 2018/19. This will include engagement with providers on any proposed changes and for Croydon in the context of existing approaches around Outcomes Based Commissioning. 3.2 Croydon Transformation Board On 27 July 2017 senior leaders from across the Croydon health and care system met to relaunch the refreshed Croydon Transformation Board. This group will meet to consider how we might best work together to improve the health of Croydon people, the quality of care available to them and to ensure that as a system we can deliver the best possible outcomes within the resources we have available between us. The Board recognised that, given the shared challenges and the ambitions cross-system working is key to delivering improved health outcomes and enhanced value for Croydon citizens. Transforming services to become more prevention focused, more joined up and more responsive to the different needs of communities and individuals is at the core of how we would wish to work together in partnership. The Board is drawing on the learning from our Outcomes Based Commissioning of services for older adults, which drew together partners from across the public sector to 10 CCCG Public Sector Equality Duty Report Jan 2018

11 provide integrated, sustainable high quality services for Croydon residents over 65. The Board will to test the extent to which similar models and approaches can be used, not just for different age ranges, but also for specific groups of the population, for example, those with complex needs. The Croydon Transformation Board is made up of senior representatives from Croydon Council, NHS Croydon CCG, Croydon Health Services NHS Trust, Healthwatch Croydon, South London and the Maudsley NHS Foundation Trust and the Croydon GP Collaborative. 3.3 South West London Sustainability and Transformation Plan / South West London Health and Care Partnership In December 2015, health and care systems were asked to come together to create their own ambitious local blueprint for implementing the Five year Forward View, covering up to March 2021, known as Sustainability and Transformation Plans (STPs). The six CCGs in South-West London, Croydon, Kingston Merton, Richmond, Sutton and Wandsworth CCGs, established collaborative arrangements to meet their shared and interdependent commissioning responsibilities. However, the SWL STP (South West London Strategic Transformation Plan) effectively superseded the SWL Commissioning Collaborative and before that Better Services Better Value (BSBV). The STP covers a much wider footprint across health and social care with the aim of addressing existing and emerging challenges. The south west London draft plan was submitted to NHS England in September 2016, then published in November South West London Health and Care Partnership Since 2016, NHS, local councils and the voluntary sector in south west London have strengthened their commitment to working together to deliver better care for local people as the South West London Health and Care Partnership. A local approach works best, and organisations providing health and care in six London boroughs have come together as four local partnerships, acting as one team to keep people healthy and well in Croydon, Sutton, Kingston & Richmond, and Merton & Wandsworth. The South West London strategy for health and care supports the NHS and wider partners to plan across South West London where appropriate supported by individual, locally focused health and care plans. South West London Sustainability and Transformation Plan (STP) was published in November 2016, following significant engagement across South West London commissioners, providers and local authorities. Whilst implementation of local plans continues, a refresh is being undertaken in order to support even greater local planning and delivery. The refresh aims to have a greater focus on keeping people healthy and intervening with support earlier, as soon as vulnerable people start to become ill. It will aim to stop people from becoming more unwell and give them the right support in their own home so that they don t need to be admitted to hospital. If people do go to hospital, we want to 11 CCCG Public Sector Equality Duty Report Jan 2018

12 get them safely home, so they can recover more quickly in their own bed, with the right care and support. A two-step approach to refreshing the South West London strategy for health and care is being undertaken: Stage One: November South West London Health and Care Partnership: one year on is a discussion document published on 30 November 2017 which outlined Health and Care commitments and priorities for the next two years, summarised the South West London context including financial and clinical challenges, and our delivery so far. The document is available for consideration at: Stage Two: December 2017 June Developing Local Health and Care Plans for each of the four Local Transformation Boards (LTBs): For Croydon this will set the Croydon Transformation Board s vision; model for health and care; local context and challenges; actions to address local financial and clinical sustainability issues and meet the health and care needs of the local population. We will co-produce these plans with local authorities and wider partners. Croydon s health and care transformation plan will inform the South West London Sustainability and Transformation Partnerships refresh. 4. Meeting the Public Sector Equality Duties in 2017 The Equality Act 2010 requires the CCG to pay due regard to the three aims of the general duty of the Act. The three aims are to: Eliminate unlawful discrimination or any other conduct prohibited by or under the Act Advance equality of opportunity between persons who share a protected characteristic and persons who do not share it. Foster good relations between people who share a relevant protected characteristic and people who do not share it. Below are examples of the CCG s activities during 2017: 4.1 Carrying out Equality Analysis to - highlight positive and negative impacts on protected characteristics and other local disadvantage groups, giving an opportunity to mitigate any negative impacts - aid decision making Equality Analyses carried out in 2017: - Foxley Lane Women s Unit: Case for Change - IVF (In Vitro Fertilisation) and ICSI (Intra-cytoplasmic Sperm Injection) services in Croydon - Self-care initiative - Cancer - Head and Neck Service - Out of Hospital Programme 12 CCCG Public Sector Equality Duty Report Jan 2018

13 - Re-procurement of the Improving Access to Psychological Therapy (IAPT) services Eliminating Discrimination and Advancing Equality of Opportunity 4.2 Cardiology Service Catheterisation Laboratory ( Cath Lab ) (read the full Case Study on page 29) The cath lab is part of Croydon Heart Centre at Croydon University Hospital that was officially opened in October The new Centre gives the people of Croydon the state-of-the-art facilities that are purpose-designed to meet the needs of the 30,000 patients seen each year. The cath lab is where tests and procedures including ablation, angiogram, angioplasty and implantation of pacemakers / ICDs are carried out. staffed by a team of different specialists, usually led by a cardiologist. different to an operating theatre, where surgery such as a heart bypass operation is completed under a general anaesthetic. Cardiovascular disease (CVD) is an umbrella term for all diseases of the heart and circulation, including heart disease, stroke, heart failure, cardiomyopathy, and atrial fibrillation. For Bangladeshis, Indians and Pakistanis, and people with an African Caribbean background, cardiovascular risk can be higher than for the rest of the UK population. Other risk factors that can significantly increase the risk of developing cardiovascular disease, include age, gender and family history. 4.3 Community Diabetes Service (read the full Case Study on page 30) The intention of the Community Diabetes Service is to meet the community needs of diabetic patients that are suitable for tier three services and encompasses an integrated care approach with collaboration from all service stakeholders, including patient, carer, healthcare professional, healthcare organisational third and voluntary sector and commissioners. The services are planned in alignment with national standards, local population needs and emerging best practice. The Service is staffed by a Multi-Disciplinary Team, comprising a consultant, diabetic nurse specialists, dieticians and health care assistants. The service is based at two sites in Croydon: Parchmore Medical Practice, Thornton Heath Network and Selsdon Park Medical Practice, New Addington / Selsdon Network. 4.4 Intermediate Gynaecology Service The Intermediate Gynaecology service is a community based service for women aged 16 and above who have attended their GP with a gynaecological symptom/indicator. 13 CCCG Public Sector Equality Duty Report Jan 2018

14 The service provides advice and treatment relating to Long Acting Reversible Contraception. The service will have strong links to the Genito-Urinary medicine and Sexual health clinics (commissioned by Croydon Council), as well as the Termination of Pregnancy service (currently being re-procured by Integrated Commissioning Unit, Croydon). The service has a duty of care to all patients who show signs of, or who are at risk of, Female Genital Mutilation. Staff are trained and able to comply with all relevant referral pathways, guidance, legislation and good practice guidance in relation to FGM. 4.5 Joint Commissioning Executive (JCE) of the Clinical Commissioning Group (CCG) and Croydon Council Joint Commissioning Executive (JCE) of the Clinical Commissioning Group (CCG) and the Croydon Council was established in 2015 to strengthen the effectiveness of joint commissioning within the Borough. The key functions of the Joint Commissioning Executive include: Provide the overall strategic vision and drive to deliver jointly commissioned outcomes. Take a strategic overview to identify opportunities for joint commissioning of integrated models of service delivery across health and council services. Ensure Croydon continues to use evidence based commissioning practices, informed and supported by public health expertise. Oversee and review progress against the delivery of the agreed commissioning intentions. The joint commissioning activity between the Council and CCG will contribute to: longer, healthier lives for everyone in Croydon increased healthy life expectancy and reduced differences in life expectancy between communities increased resilience and independence for the people of Croydon a positive experience of care reference: The Joint Health and Wellbeing Strategy Key successes of the programme are outlined below under each of the work areas. Children services CAMHS strong progress has been made against the delivery of the Local Transformation Plan at all tiers of the system. The average wait time for routine mental health services is now 7.8 weeks from referral, the ASD waiting list has also decreased by over two-thirds and a crisis care team is in place, which is significantly improving A&E liaison. Review of children s health services a high level vision for children s health services has been developed by a new children s health steering group as part of the 14 CCCG Public Sector Equality Duty Report Jan 2018

15 framework for review of services. This is in the context of the South West London Sustainability and Transformation Plan. Maternity personalisation and choice. Croydon is one of the 7 national pilots, with the roll out of maternity choice budgets being on target. Maternity patient experience, the Family and Friends Test (FFT) scores for Croydon Health Services maternity unit are consistently good. Health visiting there has been improved performance on 3 of the 5 mandated health checks compared to the position when the service was transferred to the Council. Further work will be taking place to increase delivery of mandated services in line with resources. Family Nurse Partnership - an in-depth review of the programme has taken place including considering its value for money, impact and future commissioning options. The service outcomes delivered are strong and the review is providing the platform for detailed service remodelling which will take place this year. School nursing a revised commissioning strategy has been put in place as part of wider review. Weight management the re-commissioning of the service is underway. Older People A formal commissioner and provider Alliance has been entered into by 6 partners across the health and social care system in Croydon on a 1+9 contract term. This is currently in year one, the transition year with a formal decision to be taken in December 2017 for extension into the 2-10 year period. This lays the foundation for integrating our services with a focus on outcomes for our over 65s in Croydon that promotes prevention, self care and person centred services. The Better Care Fund narrative and activity plan for the next year has been codeveloped by the CCG and The Council (Through the BCF Executive Group) for submission on 11 September. The ibcf plan has also been developed by the BCF Executive Group, alongside the refreshed S75 Agreement. Mental Health There has been continued expansion of the Croydon Improving Access to Psychological Therapies (IAPT) Service supporting people with Common Mental Illnesses, such as anxiety and depression. The Access rate has increased year on year from 3.75% in 2013/14, with a planned performance trajectory of 11.1% for 2017/18. The service is currently undergoing a re-procurement with further expansion in service capacity planned for 2018/19 and increasing service capacity throughout the life of the contract. The CCG continues to work with SLaM (South London and Maudsley NHS Foundation Trust) and Local Authority colleagues in the Discharge Task and Finish group to unblock barriers to patient discharge from Mental Health Acute beds. This work has led to a reduction in the number of bed days lost due to patients being delayed transfers of care. This work has also resulted in the reduction in the length of stay in mental health acute beds, with more people being effectively discharged into the community. Community Mental Health Services have been expanded to enable a 15 CCCG Public Sector Equality Duty Report Jan 2018

16 greater number of people to access services in the community; aiming to reduce the reliance on inpatient services. This includes increased capacity of the Mental Health Primary Care Support Service and Assessment and Liaison Services which are both primary care facing. The Home Treatment Teams Personality Disorder Services and the Early Intervention in Psychosis Service have all been expanded, enabling greater resource of Secondary Mental Health provision in the community. The Early Intervention in Psychosis Service is also meeting the national standard of patients achieving the 2 week waiting times for assessment and implementation of an appropriate package of care. All Age Disability 0-65 Progress is being made to achieve the most appropriate placements and outcomes for the Transforming Care cohort. Successful move on s have taken place for 4 people, including 3 residential placements and one supported living. Care and treatment & Treatment Reviews have been carried out with everyone. There is robust dialogue regarding the NHSE specialist commissioned cohort which currently stands at 9. High Needs Project the project which started in March 2016, has both supported improved outcomes for people and has delivered savings of 950k. This has been achieved through negotiating with providers to reduce package costs, supporting people to move to more independent care provision and ensuring people are funded from the correct part of the Health and Social Care system. There are some joint commissioning posts in place for mental health and learning disabilities. Integrated commissioning arrangements and benefits need to be evaluated and reviewed to support understanding of the most effective commissioning structures and models. Public Health Live Well Programme The Live Well website 'Just Be' launched in November There has been good uptake of the website; o 3,406 website users. o 546 completed health MOT. Key members of the Live Well team are in post and have completed training. The face to face service started in April. The Primary Care commissioning process started in April and has been completed. We have 11 pharmacy sites providing the face to face service which supports residents in health lifestyle choices such as smoking cessation, healthy wealth management, physical activity and reducing high risk drinking. The Secondary Care commissioning process started in May and has been completed. Croydon University Hospital has been awarded the contract providing a face to face service from the hospital site, targeting inpatients. The JCE is currently developing joint commissioning intentions for 2018/ CCCG Public Sector Equality Duty Report Jan 2018

17 5 Fostering Good Relations 5.1 Patient and Public Involvement (PPI) in the commissioning cycle Croydon CCG is dedicated to commissioning the best possible services for the people of Croydon. Key to this is including Croydon residents in everything we do, from helping us to monitor the quality of services, through feeding back via surveys and feedback forms to working with us on procurement panels to evaluate tenders and helping us to select winning bidders in procurement processes. Throughout this year we have invested time in building consensual, clear and visible mechanisms that support engagement throughout the entire commissioning process, from pre-planning to implementation and on-going review. The diagram below shows the key points during which the CCG engages with patients and the public and their key roles in supporting the CCG. Some examples of how we have worked with patients and the public, using the commissioning cycle framework, are highlighted below under the key stage headings. Analysis and Planning The CCG works with a wide range of organisations to ensure that the voices of residents from all of Croydon diverse communities are heard. The table below shows the range of community groups and forums we work with and how it fits into our engagement structure. 17 CCCG Public Sector Equality Duty Report Jan 2018

18 Engaging Croydon s communities in our Big Ideas Generator In July we held a Big Ideas Generator in which we invited Croydon residents to work with us to help find solutions to achieve the best possible services for Croydon, led by the views of local people. A long list of over 700 ideas collected on the night is available here. Ideas were given around what we can stop or start doing and what we can do more or less of. We also divided ideas into what the CCG can do, versus what we need to escalate to a regional level and what is a statutory duty (what the CCG has to do or cannot do e.g. we cannot charge for missed GP appointments). Over 60 Croydon residents and representatives from community and voluntary sector groups joined us and continue to support this work. Developing the CCGs QIPP Assessment Process At an open meeting for patients and members of the public, participants helped us to develop the criteria we use to assess proposals involving changes to the way we deliver services to support the CCG s financial recovery plan. The participants were asked to develop an assessment tool focusing on key considerations the CCG should take into account when developing transformation programmes. As a result of this an assessment framework has been developed which includes local residents around patient access, safety and health inequalities and potential future impacts for Croydon residents and services. 18 CCCG Public Sector Equality Duty Report Jan 2018

19 Buying services Designing services The CCG are working with our partners in the NHS to transform planned care services for Croydon residents. Our aim is to improve patient care and health outcomes. By changing the way we use community and GP facilities we can bring more care closer to home. As well as bringing more services into the community, we are improving the way different parts of the local NHS work together. This will give patients more control over their care, and make sure that they are always seen by the right person, in the right place at the right time. We are also working on new ways to help patients take control of their health, helping them make better, more informed decisions about their health and care. This transformation will require significant on-going engagement with our residents to help support this work, with representatives from across Croydon s being involved at all stages of the transformation. The CCG have held several joint workshops which include providers, staff, patients, the public and commissioners to start this process. The workshops drew people together to begin the process of redesigning services to make them more accessible to patients and improve patient experience. The next stage of this are regular working groups whose role is to shape and design new models of care. The working groups are responsible for looking at things like current number of users of a service, patient experience, where the demand for the service is heaviest. A much wider group of Croydon residents are then engaged in these discussions to refine the models of care to ensure that they meet the needs of all Croydon residents. Procuring services A standard expectation within the CCG is that patient representatives and/or service users will be an integral part of all re procurement processes and panels. This is expectation is met in a number of ways. One of which is targeted groups of patients working with the engagement team to develop service specifications. An example of this is working with BAME groups and older people to develop ideas to increase these populations groups use of IAPT talking therapies service, as they were under represented as service users. By including their recommendations in the service specification e.g. working through faith groups and trusted local voluntary organisations, we are confident that we can make services more equitable and inclusive. 19 CCCG Public Sector Equality Duty Report Jan 2018

20 Monitoring and Assurance By working with local residents we have been able to develop a Key Performance Indicator (KPI) which is included in the new urgent care contract to improve patient outcomes where support from community and voluntary providers will support a patient s wider health and well-being. This indicator was developed by a patient working group supporting the urgent care procurement. Our patient leads and volunteers have supported us by developing and carrying out patient surveys for the CCG across Croydon. Most recently our volunteers have supported feedback work in Muscular-Skeletal services and Anti-coagulation services. The results of this feedback will be fed into the re-procurement process for these two services. Patients and members of the public who have been part of the planned care transformation working groups will continue to meet throughout the transformation process and take on an assurance role during the mobilisation of services. Widening and Diversifying our Volunteer Base This year the CCG has set up a more formalised volunteer recruitment, selection and induction process. A recruitment drive to attract Croydon residents who are reflective of the population of Croydon has been on-going since March The CCG have attracted nine new volunteers who have taken part in first induction programme and continue to work with us as active volunteers. Of these 40% are from BAME backgrounds and a third are of working age. Engaging with Seldom Heard Groups Given that the CCG is limited in the number of people we have to undertake direct engagement we have found that one of the the most successful ways for us to engage with seldom heard groups is through our Voluntary and Community Sector partners. We regularly work in partnership with: The Croydon BME Forum Croydon Asian Resource Centre Croydon Voluntary Action Hear Us (Mental Health Forum) Asian Elders Groups Off the Record (Refugee and Asylum seekers) And many others We recently worked with our patient leads and volunteers to co-design new ways to reach out and engage groups that we have not significantly worked with in the past. The following ideas were suggested as way to increase our reach to all Croydon residents. 20 CCCG Public Sector Equality Duty Report Jan 2018

21 They are: - Feet on the street outreach across Croydon with key themes to be identified by GP s, PPGs and Patient leads - Outreach programmes targeting seldom heard communities to ensure their voices are heard by decision makers - A representative structure that mirrors the neighbourhood based GP networks to encourage residents to identify and work on issues affecting local neighbourhoods with health and social care organisations. The above ideas are currently being set up and advanced by the Engagement team, working closely with Healthwatch Croydon. Grass Roots Programme The NHS in south west London is in year two of an extensive programme of grassroots engagement, talking to groups the NHS does not usually reach about the issues facing local health services and their views on emerging proposals. The programme was managed locally by Healthwatch Croydon and the CCG worked closely with them to ensure that the groups funded were a priority group for engagement and that the CCG had a visible presence at events as well as a direct line of feedback with commissioners. Members of the CCG engagement team and lead commissioners, where possible, attended all the session to speak people about their experiences of local services. The strength of the Grass Roots project was the benefit that each stakeholder gained from the project. Local Healthwatch organisations were able to strengthen their relationships, build their evidence base and raise awareness of their work. Local grassroots organisations were able to run an activity that was enjoyable to their local community - many of which helped to build community cohesion and reduce social isolation. And CCG representatives were able to have meaningful conversations with local people about their experiences of health services in an environment that was comfortable to that population. 6 Partnerships As a commissioning organisation it is vital for Croydon CCG to work closely with other local commissioners, monitors, evaluators and enforcers. We have spent time developing local relationships to ensure that we do not duplicate work, that the needs of all patients are known and provided for and that there is a good strategic fit to our work. 6.1 Public Health From April 2013, the London Borough of Croydon became responsible for commissioning most public health services. 21 CCCG Public Sector Equality Duty Report Jan 2018

22 Croydon CCG works collaboratively with the public health commissioners in Croydon Council to deliver joint priorities as set out in the health and wellbeing strategy and ensure the best health outcomes for local people. This includes working together to: Reduce the prevalence of smoking through primary prevention focused on schools and youth settings, enforcing tobacco control measures, and providing a range of services to help people quit Tackle overweight and obesity through promoting physical activity and a healthy diet across the life course and ensuring that appropriate weight management and treatment services for obesity are in place Improve sexual and reproductive health by provision of advice, prevention and promotion, testing and treatment (including promotion of opportunistic testing and treatment in healthcare settings), and provision of high quality termination of pregnancy services. Increase healthy life expectancy and reduced differences in life expectancy between communities Local organisations will work together to address the factors that drive health problems amongst the poorest and most disadvantaged. Everyone s health will be protected from outbreaks of disease, injuries and major emergencies and remain resilient to harm. Earlier diagnosis and intervention means that people will be less dependent on intensive services The council is also responsible for commissioning adults and children s social care services. The 2017 Director of Public Health Report focuses on health and wellbeing, the relationship between what makes the person, their community and their environment. 6.2 Croydon Health Protection Forum The Croydon Health Protection Forum (HPF) was established in July 2015 with the purpose to have a strategic overview of health protection matters and with the aim to provide assurance to the Director of Public Health that arrangements in place to protect the health of residents, are robust and implemented appropriately to local health needs. The Health Protection Forum meets quarterly bringing together various agencies including Croydon Council, Croydon Clinical Commissioning Group, Croydon University Hospital, NHS England, Public Health England and other agencies relevant to the particular theme under discussion. In 2017 Croydon HPF has focused on the following areas Viral Hepatitis: Changes in provider of Hepatitis B vaccination and testing and the change in coordination of child health data were discussed. Then in May the Antenatal and Neonatal Hepatitis B Subcommittee was convened and made a number of achievements including: Significant progress towards a comprehensive agreed map of local antenatal and neonatal pathways, roles and responsibilities for Hepatitis B services in the 22 CCCG Public Sector Equality Duty Report Jan 2018

23 London Borough of Croydon, in the context of National Screening Committee Guidelines. Establishing a working network of key contacts in each of the organisations involved with viral hepatitis prevention, testing and treatment in the antenatal setting. This included new members of staff/contacts within the Child Health Information System Air quality and health: An Air Quality Action plan was updated for and was put out for consultation from 26 June to 21 August Seasonal Influenza All partners are working together to minimize the health impact of seasonal flu in Croydon through strategic coordination of effective communication, robust monitoring, and prevention and treatment strategies. BCG vaccination Croydon Council s Public Health Department is working with local partners to establish clear communication that will clarify the local position to parents and professionals alike regarding: Implementation of universal vaccination of neonates Vaccination of children above the age of 1 who are in high risk groups and were not vaccinated during the shortage Pathways for BCG vaccination of looked after children MMR/DTaP vaccination Croydon Council is working with the CCG variations team and GP IT lead to develop support for practices to ensure they can use the EMIS system to automatically search, and explore possibilities for capturing patient addresses to increase the options for communicating call recall messages with parents. HIV late diagnosis A joint meeting between the Health Protection Forum and the Sexual Health and HIV partnership board was held in November to discuss late diagnosis of HIV. It was noted that Croydon University Hospital is working towards implementing HIV testing within the Emergency Department. This will allow for approximately 35-40,000 additional tests each year. Public Health specialists from Croydon Council will be working with partners to understand how other hospitals have implemented HIV testing in ED. 6.3 Health and Wellbeing Board Croydon Health and Wellbeing Board (HWBB), is a partnership of local councillors, officers of the council, CCG clinicians and executive managers, public health consultants, Croydon HealthWatch and representatives from the voluntary sector. The Croydon Health and Wellbeing Strategy will develop a multi-agency health and wellbeing strategy focused on the board priorities of: Progressing integration and de3volution, Reducing Inequalities Increasing focus on prevention 23 CCCG Public Sector Equality Duty Report Jan 2018

24 6.4 Community, Voluntary and Faith Sector Organisations (including Carers support) We believe that by embedding performance and quality improvement in our commissioning processes and communicating and engaging with the public and patients who use our commissioned services, Croydon Clinical Commissioning Group can facilitate an honest dialogue about health, health services and patient needs and views critical to effective and responsive care. In the way that we work, Croydon Clinical Commissioning Group embodies the principles of accountability, putting the patient first in everything we do as championed by the Francis Report Recommendations. Croydon CCG has a programme of listening and acting on patients and public feedback. 6.5 Croydon Healthwatch Croydon Healthwatch was officially launched on 28th November Croydon Healthwatch is the independent champion of local people working to improve health and social care services. Croydon Healthwatch: Find out about people s experiences of health and care in Croydon then suggest ways of improving services so they are the best that they can be for local people. Uses local people s experiences and ideas for changes, to report on what services are doing well and if needed will make recommendations on how they can be improved. Provides Croydon residents with information and signposting on what is available in Croydon and make sure that people can easily find medical help or social care support if needed. Works with all of the health and social care services in Croydon so that local voices are part of decision making. Croydon Healthwatch has the power to enter and view health and social care services across Croydon as well as produce reports and recommendations to influence the way services are designed and delivered. Croydon Healthwatch has consistently represented the views of local people during the year working closely with the CCG, taking part in a range of important engagement including the CCG s urgent care review and anticoagulation re-procurement. Croydon Healthwatch has agreed to work with Croydon partners to bring together a united approach to citizen participation and involvement at all levels of transformation work that is being delivered by the Croydon Transformation Board that was re- launched in July 2017 (see 3.2 above for more details) 6.6 Safeguarding Croydon Safeguarding Adults and Children The Safeguarding Team sits within Croydon CCG and works closely with partners across the health economy and the local authority. This includes the Croydon Safeguarding Children Board, the Croydon Safeguarding Adult Board and the Corporate Parenting Board (in relation to Looked After Children). The Croydon Safeguarding Boards make strategic decisions in response to national and local policy developments, suggestions and any problems or issues that arise. It ratifies 24 CCCG Public Sector Equality Duty Report Jan 2018

25 terms of reference and work plans for its sub groups, endorses work carried out by them, and oversees the implementation of subsequent developments. Croydon CCG has Executive attendance represented at both boards. The safeguarding team completes an annual report which provides detailed information relating to the safeguarding arrangements for adults and children across the health economy. 6.7 Domestic Abuse and Sexual Violence Partnership Action Plan (DASV) The domestic abuse and sexual violence (DASV) strategy was launched in October 2013 and has continued to promote a multi-agency approach to reducing DASV in Croydon. The Partnership is currently working towards the action plan There are twenty five objectives with three for the CCG to facilitate:- DASV screening pads for GP surgeries this work continues and has resulted in an increase in referrals to specialist DASV services from Health. Build up GP Networks by embedding the GP safeguarding leads role as coordinators of DASV issues ensuring that information is cascaded within their practice. Increase the referral rates from health environments and children s social care to DASV specialist services through increased awareness and training. The CCG are fully engaged in this work. The Safeguarding Adults Nurse Practitioner is the lead champion for the CCG and is supported by the CCG Head of Safeguarding. There is also increased focus and oversight of the partnership through the DASV Committee which was established in October 2016 and is attended by the Head of Safeguarding. The health action plan has been completed and updates are reported to the DASV champions group and overseen at the CSCB health sub group and the CSAB via the best practice and procedures group. 25 CCCG Public Sector Equality Duty Report Jan 2018

26 7 Complaints / Patient Advice and Liaison Service (PALS) The CCG purchased these services from the NEL Commissioning Support Unit (NEL CSU). The PALS and the Complaints Service deal with queries, concerns and formal complaints relating either to the commissioning of services or to services commissioned by Croydon CCG. The Complaints and PALS policy sets out the process for accessing Complaints and PALS services to ensure flexibility, access and increase provision of patient information. Information on PALS and Complaints is available on the CCG website Advocacy - independent advocacy is available to all patients. The ICAS (Independent Complaints and Advocacy Service) provider will ensure that any other support e.g. interpreters is also available to our patients. 8 Interpreting service This service enables those with interpreting needs to access and increase knowledge of local health services, improving the health and wellbeing of marginalised communities and supporting community cohesion. The CCG re-procured interpreting services in early 2013 against a new improved service specification, with associated cost efficiencies. 9 Serious Incidents (SI) The CCG has support the NEL Commissioning Support Unit (NEL CSU) s SI management service, which ensures that appropriate management systems are in place across CCG commissioned providers to: Meet nationally identified standards; Report all SIs in a timely fashion and without prejudice; Have systematic measures in place to robustly and effectively manage Sis; Ensure actions are taken to improve quality and safety and to minimise the risk of future reoccurrences; Share the learning. The CCG reviews the performance of all commissioned providers on behalf of Croydon residents and intelligence gained from is used to influence contract monitoring, quality and safety standards for care pathway development and service specifications. 26 CCCG Public Sector Equality Duty Report Jan 2018

27 10 Equality Case Studies Case Study: Cardiology Service Catheterisation Laboratory ( Cath Lab ) Cardiovascular disease (CVD) is an umbrella term for all diseases of the heart and circulation, including heart disease, stroke, heart failure, cardiomyopathy, and atrial fibrillation. For Bangladeshis, Indians and Pakistanis, and people with an African Caribbean background, cardiovascular risk can be higher than for the rest of the UK population.* Other risk factors that can significantly increase the risk of developing cardiovascular disease, include age, gender and family history.* *Source: The cath lab is part of Croydon Heart Centre at Croydon University Hospital that was officially opened in October The new Centre gives the people of Croydon the state-of-the-art facilities that are purpose-designed to meet the needs of the 30,000 patients seen each year. The cath lab is where tests and procedures including ablation, angiogram, angioplasty and implantation of pacemakers / ICDs are carried out. staffed by a team of different specialists, usually led by a cardiologist. different to an operating theatre, where surgery such as a heart bypass operation is completed under a general anaesthetic. Cath Lab : Most frequent tests/procedures Angiogram Used to assess the health of blood vessels and how the blood flows through them. It includes inserting a small plastic tube is placed into one of the person s arteries, usually through the wrist or groin. A map of the arteries is created. Depending on the complexity, it can normally take between 30 minutes and two hours. Percutaneous Coronary Intervention (also known as angioplasty) Used to widen blocked or narrowed coronary arteries (the main blood vessels supplying the heart). A very thin wire is guided under x-ray image control. Once in place, a balloon is fed over this wire. Inflating the balloon squashes the blockage out of the way and widens the artery. In most cases a stent is then implanted. The balloon is then withdrawn, leaving the stent in place. In the last few years drug eluting stents have been developed to prevent the development of cell proliferation which could otherwise block the stented artery. 27 CCCG Public Sector Equality Duty Report Jan 2018

28 Cath Lab : Why is a PCI needed? The majority of people who receive a PCI fall into three categories of clinical syndrome that are the reason for the PCI: ST-elevation myocardial infarction (STEMI) - A type of heart attack characterized by a specific abnormal appearance on the electrocardiogram, thought to be indicative of complete occlusion (blockage) of a coronary artery. Non ST-segment elevation myocardial infarction / unstable angina (NSTEMI/UA) - A type of heart attack where urgent admission to hospital is needed but immediate treatment to restore blood flow through blocked arteries may not be required Stable angina - Pain or constricting discomfort that typically occurs in the front of the chest During the year April 2016 March 2017 the service collected data on the age, gender and race of patients. Data also showed that the service is used equally by people aged over 40 across the borough. Feedback has been extremely positive. Case Study: Community Diabetes Service Type 2 diabetes usually appears in middle-aged or older people, although more frequently it is being diagnosed in younger overweight people, and it is known to affect people from BAME backgrounds at a younger age.* Type 2 diabetes is more than six times more common in people of South Asian descent and up to three times more common among people of African and African-Caribbean origin.* *Source: The intention of the Community Diabetes Service is to meet the Community needs of Diabetic patients that are suitable for tier three services and encompasses an integrated care approach with collaboration from all service stakeholders, including patient, carer, healthcare professional, healthcare organisational third and voluntary sector and commissioners. The services are planned in alignment with national standards, local population needs and emerging best practice. One of the main strands of diabetes care is to empower the patient as much as possible in order to take ownership of the care and to enhance self-management; and to work in partnership with health care professionals. Diabetes as a condition affects all aspects of patients life and this wider scope can include individual lifestyles, employment, housing and social care. A further key aspect of the service specification and diabetes care is prevention and education. Bromley Healthcare (BHC) provides a full range of structured patient education programmes that are nationally accredited and also ensures that patients are made aware of the National Diabetes Prevention Programme and works with other 28 CCCG Public Sector Equality Duty Report Jan 2018

29 organisations / HCPs with regard to the prevention agenda. The Community Diabetes Services is staff by a Multi-Disciplinary Team, comprising a consultant, diabetic nurse specialists, dieticians and health care assistants. The service is based at two sites in Croydon: Parchmore Medical Practice, Thornton Heath Network and Selsdon Park Medical Practice, New Addington / Selsdon Network. Diabetes Patient Education A significant element of the service is Diabetes Patient Education. Structured validated education programmes include the following: The DAFNE programme for people with Type 1 Diabetes The DESMOND programme for people with Type 2 Diabetes within 12 months of diagnosis Type 2 education update and conversation mapping One to one educational sessions with specialist healthcare professionals (e.g. DSN & dieticians) The service: Improves levels of quality of care Reduces numbers of diabetes complications and mortality levels Improves patient experience & quality of life All patients have personalised car plan Increases levels of self-care / management Care is closer to home at all times During the year the service collected data on the age, gender and race of service users. Data shows that service users are representative of the three protected characteristics numbers in Croydon. Case Study: Outcomes Based Commissioning (OBC) In April 2017, health and care partners in Croydon signed the Croydon Alliance Agreement to deliver the contract for Outcomes Based Commissioning (OBC) for over 65s. The partners include: Croydon CCG, Croydon Council, The Croydon GP Collaborative, Croydon Health Services, South London and Maudsley Mental Health trust and Age UK Croydon. The alliance will be operating under the name One Croydon, and their vision Working together to help you live the life you want will support the delivery of the strategic visions of all partners. This includes, Croydon CCG s vision of longer, healthier lives for all the people in Croydon and meets the key national overarching aims Everyone Counts: Planning for Patients 2014/15 to 2018/19. NHS England and supports the Council s key strategic priorities with regard to promoting and sustaining independence, well-being and good health outcomes for Croydon residents. The outcomes are aligned to Ambitious for Croydon promises: creating growth in the economy; helping residents be as independent as possible, and; 29 CCCG Public Sector Equality Duty Report Jan 2018

30 creating a pleasant place in which people want to live. Additionally, the programme aligns with the aims of the Better Care Fund which are that health and social care services must work together to meet individual needs, to improve outcomes for the public, provide better value of money and be more sustainable. The programme builds on a long history of joint work in Croydon, including recent developments in delivering whole person integrated care through the Transforming Adult Community Services work. In June, 2017 the One Croydon alliance agreed the business case to transform Out of Hospital Services this included initiatives developed as part of the OBC transformation programme. One Croydon will integrate health and social care for the over 65s and has a comprehensive outcomes framework that is focussed on improving outcomes for people. Extensive consultation with local people on what outcomes they wanted took place, and they chose the following: Staying healthy and active for as long as possible; Having access to the best quality care available in order to live as I choose and as independent a life as possible; Being helped by a health and social care team that has had the training and has the specialist knowledge to understand how my health and social care needs affect me; Being supported as an individual, with services specific to me; Having improved clinical outcomes. The work of One Croydon draws on a number of recommendations from existing strategies that have been developed, including The Independence strategy and Croydon-wide End of Life Strategy and the emerging Out of Hospital Strategy It aligns with the wider health system changes outlined in the South West London Sustainable Transformation Plan (SWL STP). The contract for delivery of integrated health and social care will go further than before and takes a pro-active and transformational position. The individual and their family will be at the centre of Croydon s health and care system, ranging from the promotion of good health and well-being, through early intervention and support and, when needed, the delivery of treatment and care services. Croydon s older people and their families should expect to experience seamless, joined- up care and health provision of consistent quality and high standard; services will be arranged around them and their needs, rather than their having to fit in with how health and social care professionals structure or organise services. Case Study: Equalities and commissioning services for people with a learning disabilities 2017 The CCG have continued to commission specialist services for people with Learning Disabilities that support mainstream health services in primary and secondary acute care to ensure the delivery of good quality general health care for people with learning disabilities and reduce inequalities in health outcomes. Croydon CCG also commission a specialist MHLD team to support individuals around their Mental Health needs. The CCG commission a specialist Community Learning Disability health team and Acute Hospital Liaison Nurse commissioned with CHS and that includes Learning Disability nurses/allied Health Professionals with the explicit role to liaise with, train and support the primary care and acute sector. There has been consideration of increasing the 30 CCCG Public Sector Equality Duty Report Jan 2018

31 promotion in primary care in the delivery of comprehensive annual health checks for people with Learning Disabilities and Health Action plans. The CCG Learning disabilities joint Commissioner and Safeguarding team are working to implementation of the Learning disability mortality review programme to drive improvement in the quality of health and social care service delivery for people with learning disabilities (LD) by looking at why people with learning disabilities typically die much earlier than average. Building the Right Support and transforming care for people with learning disabilities and complex needs Croydon CCG have had a comprehensive and focussed program related to delivery of Building the Right support and Transforming Care agenda to review and Move on individuals with learning disability who have been in in patient units across the country. The Complex Care Team undertake Care and Treatment reviews which included an external clinical input and experts by experience to review care and to conclude readiness for discharge and Move On destinations. Croydon CCG invested in the Complex Care Team to focus exclusively on supporting this cohort to carry out the recommendations of the Care and Treatment Reviews, follow up the work and Move On of individuals, the team also includes a temporary reviewer with continuing health care background which has increased the ability to Move people on. The reviews include: Ensuring that placements remain safe, clinically effective and suitable Checking that the care and fee level is appropriate to deliver the best outcomes for the individual Ensuring that people are living in the least restrictive environment based on their individual need i.e. doors are not locked or deprivation of liberty orders (DOLS) are in place where this is not appropriate. Improve quality of life outcomes by using Health Equalities Framework Tool The process is very person centred and takes the individual and family views into account The main outcomes have Demonstrable benefits : The team have supported a total of seven discharges from in patient placements Destinations include : 1 has discharged to prison To residential settings outside Croydon and near next of kin 1 to supported living in Croydon With each discharge back to the community lessons are being learned and processes adapted. In a situation where readmission happened a Root Cause Analysis was commissioned to look independently at causes and implement lessons learnt. As more panels and MDTs are convened, fine-tuning has occurred and expectations made clearer. Consulting between providers and Croydon s clinical teams has helped develop guidelines and move plans along. Where clients and family are able to engage the plans are more person-centred and focused. The outcomes for those that have moved have been positive. Their quality of lives has improved immensely. They are engaged in more activities, have more choices & opportunities and, for those with families, regularly local contact is more possible. They are more accessible to clinicians 31 CCCG Public Sector Equality Duty Report Jan 2018

32 and social care and therefore less out of sight and out of mind. The key outcomes also relate to the improved quality of life for the individual and better quality of care in a least restrictive environment. Two case studies: Case study 1 Mr Y is twenty one years old. He was sectioned under the mental health act in January He was placed in an ATU in the North East of England. He is diagnosed with severe learning disabilities and autistic spectrum disorder. Last year Mr Y experienced a series of placement breakdowns, the last of which was very traumatic for him. Upon admission Mr Y presented as very distressed. It has taken a number of months for his team at the ATU to build rapport and rebuild Mr Y s trust. Challenges are now less frequent & less impactful. Mr Y struggles to engage with planning his transition from hospital. His family have been key to sharing insights and ideas in his Move On Plan. They have also been part of the Care & Treatment Review process and Root Cause Analysis which was commissioned in the wake of his last service breakdown. On-going multi-disciplinary meetings at the hospital and at our local Transforming Care group monitors progress and are actively facilitating Mr Y s discharge planning with his family. He is still someway of a discharge date but is moving in the right direction. Case study 2 Miss Z is a fifty seven year old woman who has diagnoses of severe learning disability and autism. Miss Z also has a number of health conditions. She is diagnosed with epilepsy, osteoarthritis and asthma. She is at risk of falls, choking and chest infections. She uses a wheelchair to access her environments. Miss Z went into care at the age of two. Her family are no longer in contact with her. Miss Z has lived in a number of care settings all over the south east of England. More recently she was admitted to a hospital in Essex. In hospital her health and mobility deteriorated after a serious incident in which she was attacked by another patient. A Move On plan was developed with Miss Z and her then team and this was shared with potential providers. Providers assessed and a transition plan was developed for Miss Z to move to by the seaside, something she had wished for her in her plan. Miss Z moved out of hospital in April She seemed to settle well and reviews indicated that she was happy. Unfortunately despite the progress made the home served notice on Miss Z citing issues with compatibility between Miss Z and others. Miss Z was supported to plan her next steps. Her Move On plan was reviewed and updated and she visited a number of potential options. Miss Z favoured a move to a smaller unit near where she had lived for a number of years before. The service specialised in meeting the complex health needs of people with learning disability who also had mobility issues. Miss Z moved in January this year. She is flourishing in her new environment. Previously unidentified health needs are being addressed, her quality of life has improved and she is doing more. A recent follow up assessment using the Health Equalities Framework indicated that there has been a marked improvement in her health presentation. Case Study: Shining a spotlight on lupus during October 2017 NHS Croydon CCG supported residents and families with lupus during October 2017 as part of lupus awareness month. Lupus is a painful, debilitating condition in which a person's immune system malfunctions and attacks healthy tissues, cells and organs. Most common in black and Asian women, lupus (also known as systemic lupus erythematosus (SLE)) causes symptoms such as extreme tiredness, joint pain and 32 CCCG Public Sector Equality Duty Report Jan 2018

33 swelling, and rashes particularly on the face, wrists and hands. Miscarriage, depression, anaemia, feverishness, headaches, hair loss and mouth ulcers, and as well organ damage, may also be part of the pattern of the condition. While genetic factors are implicated in the development of lupus, a number of environmental factors may also be responsible for triggering SLE in vulnerable individuals. These include: exposure to sunlight (ultraviolet light) hormonal changes during puberty or pregnancy certain infections, such as by the Epstein-Barr virus (EBV) which causes glandular fever. Glandular fever is spread through a person's saliva, through coughing, sneezing, shared cutlery and crockery, and kissing And, even though there's currently no cure for SLE, medication and lifestyle changes can make the condition easier to live with. Londoners with a diagnosis of lupus are fortunate to have two Lupus UK centres of excellence in the city at King's College London and at University College London Hospitals offering specialist help and resources including lupus information literature and helplines. The aim of the 2017 Lupus Awareness Month campaign was to make this 'invisible' condition visible. Patients, carers and healthcare professionals with an interest in the condition could share photos, videos and stories relating to Lupus. Case Study: Mental Health Programme: Improving Discharge Processes for patients and reducing Reliance on Inpatient Beds This case study demonstrates how the CCG with its partners have improved outcomes for people accessing/using local mental health services, especially black males. Background A year on year increase in Mental Health Occupied Bed Days (OBDs) was identified from 2015/ /17. A Joint Diagnostic Audit was carried out in November 2016, between South London and Maudsley (SLaM) NHS Foundation Trust and NHS Croydon Clinical Commissioning Group (CCG), in order to understand the drivers behind the increase. The diagnostic reflected that the increase in bed -days were due to an increase in delayed discharges, rather than an increase in patient activity. Key Findings from Diagnostic Housing people losing tenancy whilst admitted or delays in finding suitable housing at discharge Benefits changes to benefits and appeals delaying the ability to discharge people Primary care the ability/capacity for Primary Care to manage patients in the community Voluntary sector not enough joint working with the voluntary sector to support people to avoid admissions 33 CCCG Public Sector Equality Duty Report Jan 2018

34 Top 10 reasons for Delayed Discharge Delay in transfer to different service Delay in getting funding/residential placement Complex needs Long wait for 24 hour supported accommodation No recourse to public funds Delay in finding placement due to risky behaviour/complex needs Accommodation and financial issues Awaiting court outcome Treatment delayed by physical health issues Slow response to treatment The audit led to a review of the Home Treatment Team in 2016 and an improvement in handling of referrals as well as focussed efforts to understand and resolve the barriers to an individual patient s discharge. Changes Implemented Post Diagnostic Audit A review of Home Treatment Teams was carried out in 2016 which led to the following changes being made: Introduction of psychology, discharge practitioners dedicated to assessments on wards and the creation of a new role focusing on the delivery of psycho-educational interventions. Increased shift patterns to provide 24hr gatekeeping. Local borough referral screening process (8am to 5pm) replaced with a 24/7 Acute Referral Centre central triage function hub and spoke model. Developed Inpatient Discharge Task and Finish Group which deals with patients being identified as having barriers to discharge with Local Authority, SLaM and CCG involvement Identified patients at admission with barriers to discharge and escalate to the appropriate stakeholder Allocation of an estimated date of discharge for all patients being admitted Assigned a care co-ordinator within 72 hours of admission Piloted internal Housing Advice to the SLaM Home Treatment Team to facilitate access to housing for individuals with housing needs Worked with Local Authority housing teams to support access to housing and support retaining tenancies during admission Weekly teleconferences take place with community teams and associated senior clinical management to discuss all patients with a LoS over 40 days, looking at the processes in place by those teams to support the discharge of the patient Increased placement capacity in Shared Lives Scheme, as an alternative and step down option from high support for those people not ready for independent housing. This was funded through the Better Care Fund jointly with the Local Authority Since actions were implemented in response to the review, a steady decrease in delayed discharges had been observed as well as reduced use of overspill bed and reduced Croydon acute bed days. Outcomes of the Changes AMH Acute LOS Steady decrease in Delayed discharges in 2017/18 Reduction in people placed in Acute overspill beds out of borough from 28 beds In April 2017 to 3 beds in August 2017 Reduction in Croydon Acute Bed use from 2925 OBDs on March 2017 to CCCG Public Sector Equality Duty Report Jan 2018

35 OBDs as of August 2017 with a forecast to deliver the OBD target of 30,066 OBDs Reduction in Length of Stay in acute Beds Improved partnership working between SLaM, Local Authority and CCG to ensure patients are being stepped down appropriately and to the right care setting from Acute Inpatient Beds with minimal delay There has been improved partnership working between SLaM, Croydon Local Authority and the CCG through the Inpatient Task & Finish Group. This work ensures that patients are being stepped down appropriately and to the right care setting from Acute Inpatient Beds with minimal delay. Case studies of patient experiences were given showing how solutions were found to individual accommodation challenges, including through a commitment to a Community Treatment Order that the patient successfully adhered to. Case Study 1 Adult Male in private rented accommodation supported by housing benefits Became unwell and stopped signing on for benefits Built up arrears prior and during admission Landlord would not accept him back to accommodation until arrears were cleared Identified as having a barrier to discharge and presented to the Inpatient Task and Finish Group Local authority Gateway service identified patient as being eligible for assistance with arrears. Benefits reinstated and arrears cleared by Gateway Patient was discharged back to his own home with a delay of 7 days Case Study 2 Adult Male in supported housing prior to admission Evicted from accommodation due to risky behaviour and referred to Prevent Patient unable to return to previous accommodation Identified as having barrier to discharge and presented to Inpatient Discharge Task and Finish Group Support Needs Assessment Panel Lead suggested alternative housing provided by Local Authority Client accepted on the basis of support in the form of a Community Treatment Order being put in place and client placed on a long lasting slow release medication administered as an injection, with SLaM Housing and Benefits support to ensure no lapse of benefits Patient discharged with no delay The CCG acknowledges that other aspects of Mental Health service provision may offer further opportunities for improvements and outlined next steps to include reviews of: Primary & Community Care pathways; A&E Psychiatric Liaison; and Older Adult Length of Stay. 35 CCCG Public Sector Equality Duty Report Jan 2018

36 11 Main Provider Organisations Croydon CCG has in place mechanisms to meet its duties to ensure that key provider organisations comply with their equality duties, working in partnership with main provider organisations to include equality, diversity and human rights clauses within its contract. This also requires the CCG to monitor workforce and service delivery activity in relation to the Public Sector Equality Duty (PSED). Croydon CCG holds contract review meetings and Clinical Quality Review Group (CQRG) meetings to ensure services are being delivered to agreed service quality and performance specifications, and that providers are seeking the views of patients and carers about service delivery, responding to complaints and redesigning the way services are delivered in response to patient feedback. CQRG meetings are chaired by CCG Clinical Leads, and provide a robust mechanism where commissioners and providers work together to identify opportunities for improvement that will ensure delivery of safe and effective services, and drive up quality, including through reviewing themes raised in patient complaints, surveys and through engagement events. The results and feedback from the national surveys and the Friends and Family Test are reviewed at the CQRGs, and providers are required to produce action plans to address issues of concern. NHS Provider Croydon Health Services NHS Trust South London and Maudsley NHS Foundation Trust Annual Equality Report published on website Equality Objectives published on website Equality Delivery System results published on website Workforce Race Equality Standard results published on website 11.1 Croydon Health Services NHS Trust Croydon Health Services NHS Trust is one of the main providers of acute hospital and community services in Croydon. Croydon CCG is the lead commissioner for this organisation and ensures that it meets its legal duties in relation to equality, diversity and human rights by including clauses within its contract. This also requires the Trust to monitor workforce and service activity in relation to the Public Sector Equality Duty (PSED). The Trust has been implementing its Equality, Diversity & Inclusion Strategy (including Equality Objectives) and report progress as follows: Implementation of EDS2 in 2016 focused on the following services: Homeless Health 36 CCCG Public Sector Equality Duty Report Jan 2018

37 Maternity Services Out Patients Results of the process can be found on the Trust s Equality and Diversity webpage. Workforce Race Equality Standard (WRES) This is the first year that the Trust had a comprehensive set of WRES data of which to compare the previous year. Increasing the number of staff returns for the National Staff Survey has provided the opportunity for a more robust set of outcomes of which to compare the experience of BME staff to White staff within the organisation. The comparison of outcomes from to has revealed areas that need further attention. The Trust be reviewing its WRES action plan to address areas that it was not possible to identify before. There are activities and actions that the Trust plans to discuss with the EDI Committee of senior managers, and Staff Network Group. In addition, the Trust is in the process of organising focus groups with BME and White Staff. This will give a real opportunity to understand the experiences of staff, and support the data, to enable the Trust to make any changes to improve the outcomes for WRES The EDI Committee is also in discussion with the Trust Board to increase their involvement regarding WRES. Integration of the WRES into the Business Planning process together with identifying the actions that need to be taken in HR and across the Directorates was included in the business planning process for each Directorate to identify their plans to progress EDS2 and the WRES, this will know be an annual requirement. Accessible Information Standard (AIS) A working group of managers has been set up to take this forward. The standard requires the Trust to have systems in place to meet peoples needs when they visit our hospital. Staff must be able to; Identify; Record; Flag; Share and Act, on patients communication or support needs. The Trust is currently conducting an audit of key services to identify future actions. Workforce Disability Equality Standard (WDES) The Trust is in the early stage of planning for the DWES and is having discussions in its forums. The Trust recognises that there is work needed in relation to increasing the staff profiles, and circulating information for staff and managers. The EDI Committee of senior managers and Staff Network Group will be working on this agenda. Annual Equality Reports for Croydon Health Services NHS Trust can be accessed by following the link: South London and Maudsley NHS Foundation Trust South London and Maudsley NHS Foundation (SLaM) Trust provides inpatient and Community mental health services for the residents of Croydon. The Trust delivers specialist mental health and substance misuse inpatient services to Croydon s population. They provide services for adults, as well as specialist services for young people. These include daycare, inpatient care and community services. 37 CCCG Public Sector Equality Duty Report Jan 2018

38 The Trust is currently delivering seven CAG equality objectives ( ). The Trust is also developing Trust-wide equality objectives for service delivery and workforce as part of a new Trust equalities strategy that will be submitted to its Board in 2018 (date tbc). SLaM has been using the Equality Delivery System as a framework to identify where they need to focus their attention to improve on equality since In 2015 SLaM developed a substantial Workforce Equality Objective that brings together a number of strands and work streams. An integral component to the objective is the implementation of the Workforce Race Equality Standard (WRES) that is now a national contract requirement and expectation of all NHS Provider Organisations. SLaM published a WRES report for 2016 that compares results in The 2017 WRES report is being reported to the CQRG meetings in the Spring On 31 October 2017 the Care Quality Commission published its report of its July 2017 inspection of SLaM s Community-based mental health services for adults of working age. The overall rating of Requires improvement was given. The latest Annual Equality Reports South London and Maudsley NHS Foundation Trust can be accessed by following this link Friends and Family Test Patients have an opportunity to routinely give their feedback after receiving care or treatment through the Friends and Family Test (FFT). This test aims to assess the quality of patient experience from responses to the simple question Would you recommend this service to your friends and family? A snapshot of results for Croydon CCG Providers are as follows: NHS Provider Month/Year Percentage that would recommend service Croydon Health Services September % (of 753 responses) NHS Trust (In Patient) Croydon Health Services September % (of 532 responses) NHS Trust (Community) South London and Maudsley NHS Foundation Trust September % (of 1,652 responses) Source: Croydon CCG also commissions significant number of acute hospital services from St George s NHS Foundation Trust and King s College Hospital NHS Foundation Trust for the local population, as well as a range of other hospital services from other London NHS providers. 38 CCCG Public Sector Equality Duty Report Jan 2018

39 12 Workforce Race Equality Standard The Workforce Race Equality Standard (WRES) is a benchmarking tool introduced by NHS England to assess the progress of race equality within NHS organisations annually, following an initial evidence baseline gathered in The WRES is based on new research on the scale and persistence of such disadvantage and the evidence of the close links between discrimination against staff and patient care. The Standard highlights any differences between the experience and treatment of White staff and BME staff in the NHS with a view to closing those metrics through an action plan. The WRES definition of White and BME staff is as follows: White staff includes White British, Irish and Any Other White. The Black and Minority Ethnic staff category includes all other staff except unknown and not stated. Any Other White contains minority groups including white European Workforce Race Equality Standard in Croydon CCG Croydon CCG has gathered data against the nine WRES metrics for The data does not have to be published due to the small numbers reported and to protect staff identity under the Data Protection Act. However, the CCG has agreed to publish the metric regarding BME staff in bands 8-9 and VSM (Very Senior Management) compared to the workforce overall please see chart below for details Analysis The percentage of BME staff in bands 8-9 and VSM is 24.56% which is four per cent less than the CCG representation of BME employees in its workforce that is 28.57%. The CCG has noted that these BME figures do not reflect the percentage of BME people in the Croydon population which is %. 39 CCCG Public Sector Equality Duty Report Jan 2018

40 12.2 Workforce Race Equality Standard in Croydon CCG s Providers Since , all CCGs need to demonstrate that they are giving due regard to using the WRES indicators, and assurance that their Providers are implementing the WRES. In 2017, the CCG s Clinical Quality Review Group will receive reports from Providers who are expected to: Carry out a comparison of baseline data from April 2015 with April 2017 including steps underway to address key shortcomings in data, or significant gaps between the treatment and experience of white and BME staff. Publish WRES data for August 31st 2017 on Trust web site and share with Board and staff 13 Croydon CCG Workforce Information The Public Sector Equality Duty highlights that information on the make-up of the workforce must be published where public authorities have 150 or more employees; Croydon CCG has a total of 77 employees and also purchases additional commissioning support services from NEL Commissioning Support Unit. The workforce is the major factor in delivery of Croydon CCG business. A quarterly workforce monitoring report is submitted to the senior management team of the CCG including workforce information relating to numbers of staff in post, turnover and sickness absence and an equalities profile relating to six of the nine protected characteristics and highlights key differences and /or issues to the senior management team. Croydon CCG Workforce Equalities profile Although Croydon CCG has no legal duty to publish our workforce data as the CCG employs less than 150 staff, the CCG has chosen to do so as part of our good practice. The following tables are a snapshot profile of the organisation (by percentage), relating to six of the nine protected characteristics as at 30 th November Monitoring will continue to identify any priority areas to address. The data below for Race/Ethnicity shows that the CCG has a representation of BME employees in its workforce (28.57%) compared to the demographics (according to the 2011 National Census), BME people make up of around 45% of Croydon s population. The CCG is working towards reflecting the communities that its serves at all levels of the workforce. 40 CCCG Public Sector Equality Duty Report Jan 2018

41 41 CCCG Public Sector Equality Duty Report Jan 2018