NHS Equality Delivery System for Isle of Wight NHS Trust. Interim baseline assessment against the

Transcription

1 Interim baseline assessment against the NHS Equality Delivery System for Isle of Wight NHS Trust The NHS Isle of Wight has adopted the NHS Equality Delivery System as the framework to achieve compliance with the Public Sector Equality Duty. In order to comply with the Public Sector Equality Duty the Trust must: Demonstrate due regard in the exercise of its functions to nine protected characteristics (age, disability, gender reassignment, marriage and civil partnerships, pregnancy and maternity, race, religion and belief, sex and sexual orientation) Publish equalities information to demonstrate compliance with the duty no later than January 31, 2012, and at least annually thereafter. The information must be published in a manner which is accessible Prepare and publish one or more Equality Objectives by April 6, 2012, and at least every four years after that. The objectives must be specific and measurable. Using the NHS Equality Delivery System (EDS) NHS Isle of Wight has completed a baseline assessment of progress on equality and diversity. The assessment has involved gathering evidence for each of the NHS EDS Goals and Outcomes from across the Trust. On the basis of this evidence an initial judgement has been made about the equalities performance of the Trust for each of the 18 EDS outcomes. Excellent Excellent as well as great performance, organisations must fully engage with local interests, take part in peer reviews and demonstrate innovation. Undeveloped performance is very poor, or assessments lack evidence, or organisations are not engaged with local interests Underdeveloped

2 1.1 Services are commissioned, designed and procured to meet the health needs of local communities, promote well-being, and reduce health inequalities The Isle of Wight Joint Strategic Needs Assessment (JSNA) identifies the health inequalities that are prevalent on the Isle of Wight. The Commissioning Strategy2010 to 2014 set out seeks to address these inequalities. The CCG Strategic Priorities 2012 to 2014 has been published for consultation, seeking the views of patients and carers on its draft proposals. Consultation events are led by the organisation with the support of the Rural Community Council, LINks, the Patients Council and relevant patient user groups. The national contract has been adapted by Commissioners to so that services commissioned address the local health needs. Local tendering templates also require providers to demonstrate how they will address health inequalities. 1. Better health outcomes for all Public Health programme working with older people to improve their diet and promote healthy eating. Equality Impact Assessments have been done for Commissioning Strategies. Care plans are designed to take into account individual patient needs and sensitively address the needs of patients from protected groups. 1.2 Individual patients health needs are assessed, and resulting services provided, in appropriate and effective ways The Island Award Ceremony recognised that a number of services had been reconfigured so they could meet the needs of individuals more effectively. They included: Reforming the Stroke Service, Improving Access to Dementia Services, Implementation of End of Life Strategy, and Improving Access to Diagnostic Services in the Community. 1.3 Changes across services for individual patients are discussed with them, and transitions are made smoothly A series of Clinical Summit have been held to give patients and staff the opportunity to review progress on the re-designed clinical pathways and to set up more detailed next steps for making the next stages a reality Presentations to Patient Council and Patients with a Disability Group provide the opportunity for discussion about proposed service changes and how these proposals might affect individual patient needs. For example, patients have been involved in the planning and design of the new Endoscopy Unit. Page 2 of 8

3 Acute services working group looking at documentation is being updated and will provide the mechanism for health professionals to record all nine protected characteristics as well as other meaningful information that needs to be taken into account when paying due regard to individual patients needs. The Out and About magazine used to promote service changes to the LGBT communities. The newly refurbished sexual clinic has access for those with disabilities. Disability - Hearing loop system throughout the department, DDA compliant. Race - we provide language line for those whose English is not their first language. Religion and Belief - all staff undertake Trust Equality and Diversity Training. Age - 'You're Welcome' is a kite mark around services for young people, we also run 'older and wiser' campaigns. Sexual Orientation, Marriage and Civil Partnership - we have an outreach worker specifically for LGBT. Pregnancy and maternity - all staff provide services to support this (provision of termination service). Results of Staff Surveys in 2008 and 2009 (2010 have not been published yet) show that the organisation proactively addresses bullying, harassment and victimisation concerns. An analysis of these results formed part of the Equality Analysis for the recently revised Dignity at Work Policy. 1.4 The safety of patients is prioritised and assured. In particular, patients are free from abuse, harassment, bullying, violence from other patients and staff, with redress being open and fair to all Accident and incident reporting systems have been aligned to the protected groups. All incidents are managed locally with the support of our Local Security Officer. Patient Safety is taken very seriously by providers and commissioners. The organisation has policies and procedures for dealing with vulnerable people and staff have received the appropriate level of training to enable them to undertake these roles. Patient Safety Priorities were set out in our 2010/11 Quality Accounts. Patient Safety Walkabouts are an integral element of our quality programme. This initiative is being extended into a Secret Shopper pilot in Serious concerns affecting patient safety will be placed on the Risk Register. An action plan will be implemented so that the risk can be reduce or eliminated. The organisation is actively rolling out a wide range of Productive Page 3 of 8

4 programmes. The objective of these programmes includes: The core objectives of the project are to improve efficiency of care, improve patient safety and reliability of care, improve the patient experience and improve staff wellbeing. Historically, the project has been found to give nurses back 10% of time to spend on patient care, it creates calmer wards which results in reduced numbers of patient complaints. It also demonstrates increased safety (as shown in observation reliability scores) and raises staff morale 1.5 Public health, vaccination and screening programmes reach and benefit all local communities and groups A Nursing Dashboard is being developed to highlight progress to improve patient safety and experiences. Island immunisation rates are considerably lower than comparator rates in the South of England and the SHA, but in recent years the gap has narrowed. While in general analysis of reach by sex and age is possible, it is currently difficult to analyse the reach to all the protected groups. This is because many of the protected characteristics are not routinely recorded; and because IT system limitations (e.g. the current Child Health Computer) prevent analysis of reach in general, including by protected characteristics. The School Nursing Team was engaged to undertake the HPV immunisation programme, which was a new and exciting challenge. This programme is now embedded and streamlined in its approach. The key its success is ensuring all girls receive all 3 injections as this increases the benefits of the vaccination overall, and working in tandem with the vaccination timetable to ensure that those girls that have missed vaccinations are offered the opportunity to have them in a timely fashion. The Isle of Wight has consistently achieved the highest take-up rate for all 3 vaccines in the South Central Region. 2. Improved patient access and experience 2.1 Patients, carers and communities can readily access services, and should not be denied access on unreasonable grounds Engagement with the community when changes to Mental Health Services were being planned. A good example of this was the Phoenix Project. It was set up as social enterprise, one of only two created at the time in the South Central area, in response to the news that learning disability day services at Meadowbrook and Medina faced closure. Initiated by a Mental Health & Learning Disability Services project group, but later expanded into a wider project board, the team worked tirelessly to ensure the service had a viable future. Planned Directorate have increased the number of evening clinics in response to the Outpatient Survey where 34% of responds said they would attend Page 4 of 8

5 evening clinics. The Island is in the process of a significant service re-design programme. These are widely publicised in the local press and on the organisations website. In addition each work stream actively involves service users representing some, but not all protected groups. A tool has been developed locally to support service managers and project leads to ensure the service changes support the general principles of the Equality Act. 3. Empowered, engaged and well-supported staff 2.2 Patients are informed and supported to be as involved as they wish to be in their diagnoses and decisions about their care, and to exercise choice about treatments and places of treatment 2.3 Patients and carers report positive experiences of their treatment and care outcomes and of being listened to and respected and of how their privacy and dignity is prioritised 2.4 Patients and carers complaints about services, and subsequent claims for redress, should be handled respectfully and efficiently 3.1 Recruitment and selection processes are fair, inclusive and transparent so that the workforce becomes as diverse as it can be within all occupations and grades CQC Regulation Self Assessment illustrates how services involve and inform patients in decisions about diagnosis and care. All decisions are Our mortuary staff had an excellent comprehension and due regard to people s religions and beliefs at a time of death. Quality Account Report 2010/11 highlighted that in recent patient surveys we received positive feedback from 95% of respondents. All complaints in the same way and they are managed in line with the NHS Complaints Regulations, every complainant is advised of the right to seek support via the Independent Complaints Advocacy Service or via CQC if we have failed to resolve their concern. The Providers Performance against a range of Quality Indicators are published internally on the Performance Dashboard (Quality).The Quality Team also provide monthly reports to directorate forums and Board. These reports highlight that the number of complements from patients outweigh the number of complaints All recruitment activity uses NHS Jobs, with the exception of Volunteer s which has adopted an informal approach. Policies are in place to promote the organisation as an Employer of Choice. The organisation became a MINDFUL Employer A applicant who had informed us that they have a special need during the Page 5 of 8

6 recruitment, every effort is made to meet their specific needs. Our ESR data illustrates that our workforce is as whole very diverse; with variations between occupational groups. All HR Policies have an EQIA. Workforce data, including recruitment can be found on the Trust s internet site. 3.2 Levels of pay and related terms and conditions are fairly determined for all posts, with staff doing equal work and work rated as of equal value being entitled to equal pay Pay Gap has been published in the Workforce Report - December All roles are subject to the NHS Job Evaluation Process, all roles are independently verified in partnership. Agenda for Change Terms of Service are applied to all non-medical roles. A Partnership Working Group has been established to negotiate a local On-Call agreement. The draft proposal has been subjected to an Equality Analysis. The organisation Grievance Procedure supports employees who feel they have been disadvantaged by the pay and related terms and conditions process. No employee has raised concerns through this process. Any concerns raised by an employee may well have been handled by their line manager at a local level. 3.3 Through support, training, personal development and performance appraisal, staff are confident and competent to do their work, so that services are commissioned or provided appropriately The Workforce Report illustrates that staff from minority ethnic backgrounds attend training and are not disadvantaged. Our systems do not enable us to report training attendance for any of the other protected groups. Compliance against all mandatory training requirements across all functions in November 2011 was 51%, with Commissioners achieving 70%. Appraisals undertaken are an integral element of service performance management system. 45% appraisal rate as at 30 Nov 2011 including Commissioners who rate was 42%. 3.4 Staff are free from abuse, harassment, bullying, violence from both patients and their relatives and colleagues, with redress being open and fair to all Results of Staff Surveys in 2008 and 2009 (2010 have not been published yet) show that organisation proactively addresses bullying, harassment and victimisation concerns. The Staff Survey Results are analysed and an action plan is developed by a multi-professional Staff Survey Champions Group. Our Incident Reporting systems has been aligned to protected groups defined in the Equality Act. Staff side are involved in the development of all HR policies, not just those Page 6 of 8

7 that protect staff from bullying and harassment. Dignity at Work Policy and Health Working Road show to promote new policy and e-learning module. The organisations Equality and Diversity and Dignity at Work policies and training describe the protected groups, but aim staff to treat everyone as an individual. Employee Relation cases are reported to the Trust Board (Part 2) each month reports highlight concerns relating to bullying, harassment and discrimination. 3.5 Flexible working options are made available to all staff, consistent with the needs of the service, and the way that people lead their lives. (Flexible working may be a reasonable adjustment for disabled members of staff or carers.) Excelling Flexible Working Policy supports working options for all groups of staff, especially people who want to work full time or part time (as long as organisational needs can be met). Staff are offered permanent or temporary re-deployment. Multi-faith facilities are available for staff to use. Managers are reminded of their responsibly to support staff should they wish to use it. The majority of flexible working requests come from staff returning to work from maternity and paternity leave. Managers endeavour to accommodate requests were practicable and does not compromise the needs of the business. 3.6 The workforce is supported to remain healthy, with a focus on addressing major health and lifestyle issues that affect individual staff and the wider population Excelling Healthy Workforce Road shows are accessible to all, including those who work in community locations and outside normal office hours. Staff are able to have their BMI, weight and cholesterol check with an offer of follow-up health and support if necessary. Weekly Weight Watcher Sessions are open to all staff. Occupation Health, Back Care and HR have regular case conferences to Page 7 of 8

8 support staff with long term health problems so they can come back to work as soon as is practicable. Options will include temporary re-deployment and making adjustments to work patterns and work environment. Such initiatives are supported by the organisations Health and Wellbeing Strategy and Attendance Mgt Policy. The HSE Stress Audit tool is widely used within the organisation. 4.1 Boards and senior leaders conduct and plan their business so that equality is advanced, and good relations fostered, within their organisations and beyond The organisation uses a variety of mechanisms to engage with staff and external organisations. Internal methods of engagement include Team Brief, Briefing Sessions with Executive Directors, Chief Exec and Clinical Redesign Open Days. Transition Newsletters have been produced on a regular basis from 2011 once the direction of travel for the NHS became apparent and that Provider and Commissioning functions would need to be separated. The Chief Executive and other Senior Managers regularly attend Partnership Forum. They also do 'walk about s' to wards and departments, giving them an opportunity to get feedback directly from patients and staff. 4. Inclusive leadership at all levels 4.2 Middle managers and other line managers support and motivate their staff to work in culturally competent ways within a work environment free from discrimination High performing Teams and Individuals are recognised at the Trust s Annual Award Ceremony. Valuing Difference is an integral element of the organisations leadership and management development programmes. Equality and Diversity Training supported by Trust wide policies provide the framework which managers are expected to follow. The appraisal conversation also provides an opportunity for managers to give positive and constructive feedback to staff. 4.3 The organisation uses the Competency Framework for Equality and Diversity Leadership to recruit, develop and support strategic leaders to advance equality outcomes Underdeveloped The Competency Framework will be incorporated in to revised Leadership Strategy (in draft Jan 2012). This will be supported by development activities for leaders. Page 8 of 8