Annual Report

Equality and Diversity Steering Group Annual Report 2012-2013 April 2013 1

Contents Page No Introduction 3 Equality Act 2010 3 NHS Lanarkshire s Equality and Diversity Reporting Structure Equality and Diversity Steering Group Over-Arching Equality and Diversity Activities 1. Equality and Diversity Impact Assessment (EDIA) 2. Equality and Diversity Training 3. Interpreting and Translating 4. Internal Audit Report 5. Community Engagement 6. Partnership Working 7. Gender Based Violence 8. Workforce and Workforce Development 9. Spiritual and Religous Care 10. Facilities 11. NHS Lanarkshire Webpages 12. Complaints 13. Areas of Future Work for the Equality and Diversity Steering Group 5 5 6 6 7 10 12 12 12 12 13 13 14 15 16 16 Conclusion 17 2

INTRODUCTION The last year has been significant in regard to equalities in Scotland and in NHS Lanarkshire. Although the Equality Act was passed in 2010, with its three General Duties, the Equality and Human Rights Commission only published the Scottish Specific Duties in May 2013. These duties are in place to support and inform delivery of the General Duties. Once in place, NHS Lanarkshire, like all other public sector authorities, was tasked to deliver and publish how it was going to meet the specific duties, as well as evidence how it has been mainstreaming equalities in its everyday functions since the commitments it made in the 2010 Single Equality Scheme. In this annual report we hope to show how we met our legal requirements, demonstrate our continuous commitment and drive to embed equality and diversity throughout our services, highlight areas where progress has been made in the last year and indicate where further development is required. EQUALITY ACT 2010 The Equality Act became law on 1 st October 2010 and replaced previous anti-discrimination laws with a single Act. It simplified the law into a single source and ensures that everyone who is protected under law from discrimination, harassment, or victimisation is afforded the same level of protection. The Equality Act introduced the concept of nine protected characteristics. These protected characteristics (PCs) are: Age, Disability, Gender Reassignment, Pregnancy, Maternity, Race, Religion and Belief, Sex and Sexual Orientation 3

The Equality Act also applies to marriage and civil partnership, but only in respect of the requirement to have due regard to the need to eliminate discrimination. The Act stipulates that all Health Boards across NHS Scotland (as are all public bodies) are required meet the Public Sector Equality Duty (PSED/also know as General Duty). The PSED requires Scottish public authorities to pay 'due regard' to the need to: Eliminate unlawful discrimination, harassment and victimisation Advance equality of opportunity Foster good relations between people. The General Duty is supported by Specific Duties, set out in regulation, which came into force on 27 th May 2012. The requirements of the Specific Duties are listed below with links and information on how NHS Lanarkshire met them, they are as follows: 1. Duty to report progress on mainstreaming the equality see link: http://www.nhslanarkshire.org.uk/about/equality-anddiversity/documents/mainstreaming-equality-report-march-2013.pdf 2. Duty to publish equality outcomes and report progress see link: http://www.nhslanarkshire.org.uk/about/equality-and-diversity/documents/equality- Outcomes-2013-17.pdf 3. Duty to assess and review policies and practices: achieved through mainstreamed equality & diversity impact assessment 4. Duty to gather and use employment information see link: http://www.nhslanarkshire.org.uk/about/equality-and-diversity/documents/staff- Equality-Monitoring-Report-2013.pdf 5. Duty to publish gender pay gap information see link: http://www.nhslanarkshire.org.uk/about/equality-and-diversity/documents/equal- Pay-Statement-and-Pay-Information-2013.pdf 4

6. Duty to publish statements on equal pay see link: http://www.nhslanarkshire.org.uk/about/equality-and-diversity/documents/equal- Pay-Statement-and-Pay-Information-2013.pdf 7. Duty to consider aware criteria and conditions in relation to public procurement: See Procurement statement in equalities mainstreaming report page: 27 8. Duty to publish in a manner that is accessible: We will make the information available in accessible formats and will meet reasonable request for adapted versions of any work. NHS LANARKSHIRE S EQUALITY AND DIVERSITY REPORTING STRUCTURE: NHS Lanarkshire s commitment to Equality and Diversity stems right from the top of the organisation. The current reporting structure is through the Staff Governance Committee and the Clinical Governance Committee who in turn report to the NHS Lanarkshire Board. EQUALITY AND DIVERSITY STEERING GROUP The Equality and Diversity Steering Group has a cross section of representation from across the organisation and is an officer based group. The purpose of the group is to provide a facilitative forum for the implementation of NHS Lanarkshire s Equality and Diversity agenda. 5

The focus of the group is to provide a steer for the implementation of the 2012-2013 Single Equality Scheme Action plan and feed into new strategies and policies which include ensuring that our equality priorities are achieved. At Steering Group meetings members update on equality issues pertinent to their area and present new ideas and developments from local and national levels. The group regularly showcases models of good practice within the organisation as well as inviting external speakers when appropriate to help inform members about national issues and topics. The group has been actively involved in overseeing and supporting the identification and production NHS Lanarkshire s Equality Outcomes and Mainstreaming report 2013 (see below for further details). In 2013 the group will be reviewing NHS Lanarkshire s existing equalities work plan, with the intention of setting the agenda and direction of the equalities work within Lanarkshire for the next 4 years, incorporating existing on-going work and new areas of development. OVER-ARCHING EQUALITY AND DIVERSITY ACTIVITIES The following is an annual report of the work that has been overseen by the group and identifies where progress has been made and where there needs to be continued work or further development. 1. Equality and Diversity Impact Assessment (EDIA) As an organisation we recognise the importance of embedding equality and diversity within all our structures and processes and continue to strengthen the integration of equality and diversity within our services. The revised EDIA guidance was re-published in May 2012 incorporating the additional Protected Characteristics has proved to be successful. 6

To support the mainstreaming of EDIA, it is embedded within NHS Lanarkshire s guidance to policy writing guidance. Completing and submitting EDIAs is still an area of concern for the organisation, as evidenced by the recent internal audit report on equality and diversity. The following areas have been identified as areas for development in 2013/14: Ensure that all Board papers submitted to NHS Lanarkshire s Board have a completed EDIA Review the current recording methods of completed EDIAs, with the proposal to develop a more robust online/virtual data base and develop the current EDIA tool into an online version which can be accessed by staff at source. It is proposed that this method would ensure ease of recording, production of reports, reminders sent to NHS staff responsible for completing EDIAs. Work with project leads to support them to ensure EDIAs are embedded and completed on any areas of work. Continuous promotion on the importance of embedding EDIA within the organisation s decision making process 2. Equality and Diversity Training NHS Lanarkshire recognises the importance of embedding equalities into the learning and development for new and existing staff. As such, we provide all new staff with information on equality and diversity as part of their induction programme when joining the organisation and equality and diversity training is a core development topic for staff. We currently deliver a number of training programmes on equality and diversity including: 7

1 day Equality and Diversity Training Course for all staff 3 courses a month were delivered and between April 2012-2013, 309 participants completed the course. This is highly evaluated with a number of staff showing an interest increasing their knowledge by doing the Equality Champions programme. Half day Equality and Diversity Training Course for consultants and junior medics Two sessions a year are run in partnership for medical education and is a well received course, due to the demand for the course we will be looking to have a discussion with medical education about increasing the number of courses. 3 day Equality and Diversity Champions Programme This is a 3 day training programmed delivered in partnership with North Lanarkshire council and is being delivered quarterly. In order to keep existing champions skills and knowledge updated, an online refresher course will be designed for the champions to complete allowing them to be kept up to date with recent legislative changes and other equality issues pertaining to their role. Equality and Diversity Impact Assessment This is a ½ day requested session requested by project teams, departments, and groups requiring support and advice on EDIA and bespoke programmes are delivered at request. In order to improve the completion rates of EDIAs, in 2013 a number of ½ day training sessions will be delivered across the organisation to ensure that staff are informed and confident on completing EDIA s. 8

Inclusive Customer Care Programme This is a ½ day course is bespoke training delivered to front-line staff that supports staff in taking an inclusive and sensitive, person-centred approach to practice to a diverse community. Gender Based Violence Training Courses Including a Gender-Based Violence introductory Learnpro Module and a range of specific inputs to support a variety of programmes and staff training needs, such as, routine enquiry of abuse or responding to the dual issues of domestic abuse and substance use. 1 day Child Protection The Child protection course is for all registered health professional working in NHS Lanarkshire 1 day Multi-agency Adult Protection This is a multi-agency adult protection course delivered in partnership with North Lanarkshire council 12 week Basic Introduction to Sign Language This is an accredited BSL course delivered by Coatbridge College and is open to all staff, the course is run twice a year, giving front-line staff basic BSL skills to communicate with BSL users within their services. We regularly review our training based on assessments or feedback to allow us know that the training is meeting need, to adjust content or to re-focus. With a view to more integrated and partnership working, we intend to continue to work collaboratively with other agencies and organisations both locally and nationally to promote and embed equalities through joint learning and development. 9

3. Interpreting and Translating Since the NHS Lanarkshire s Interpreting and Translating policy was first developed the demand for interpreting services in particular has grown. Consequently in 2012, it is was agreed to review both the policy and the commissioning arrangements to ensure that the needs of patients are being met and that the financial impact is being managed efficiently. Following the review, NHS Lanarkshire introduced two new policies one on accessing and using Interpreting services and another on the process and procedure in getting information translated. Interpreting Policy In January 2013 NHS Lanarkshire introduced a new way of accessing faceface interpreting services. All face to face and British Sign Language (BSL) interpreters are now being provided by NHS Greater Glasgow and Clyde (NHSGGC) in-house interpreting service. All bookings are made through central administration teams. The new arrangements allow staff to complete an online form and email it through to their allocated central administration team, who will email it through to NHSGGC interpreting service or, in the case of emergencies, requests will be phoned through. Access to the service is now available to all health professionals providing services for NHS Lanarkshire, which now also includes GPs, and dentists but not pharmacists (unless a BSL interpreter is required - see telephone interpreting). Guidance on the new policy and procedure was issued to all staff and can be accessed via Firstport. In addition the protocol and information leaflets for patients on the role of interpreters during appointments is available. See link: http://firstport2/staff-support/interpreting/default.aspx 10

Telephone Interpreting For telephone interpreting NHS Lanarkshire is using Langauge Line interpreting services. This service is available to all health professionals providing services for NHS Lanarkshire and has also been extended to community based pharmacists. Currently there are quarterly review meetings being held with NHSGGC, to look at any issues or trends that are emerging and as of May 2013 both services have seen an increase in requests and general feedback from staff and patients accessing and using the services has been positive. HOW TO BOOK AN INTERPRETER FLOW CHART: Translation Policy The revised Translation Policy was re-issued in March 2013. All requests for translation are submitted to the Patient Information Manager. This enables provision of resources in alternative formats and avoids possible duplication and unnecessary costs. The Policy is available for staff to access on Firstport http://firstport2/resources/policies/pages/default.aspx 11

4. Internal Audit Report An internal audit was carried out in 2012 to review and assess that equality and diversity complied with the Equality Act 2010 and that it was embraced and implemented throughout NHS Lanarkshire. A number of findings and recommendations were submitted which have been actioned and will continue to be reflected in future work plans for the Equaltiy and Diversity Steering Group. 5. Community Engagment NHS Lanarkshire continues to support and fund a number of community based groups that represent and articulate the needs of some of the groups who share protected characteristics. NHS Lanarkshire will continue to support and promote partnership work between community based groups, the third sector and the North and South Lanarkshire Public Partnership Forums (PPFs). The PPFs have sought the active engagement of a number of equality groups, with varying degrees of success. This is an area of work which is on-going and requires further development, both from the PPFs and NHS Lanarkshire. 6. Partnership Working NHS Lanarkshire continues to work in partnership with a range of local and national statutory partners on joint and single equalities agendas. In 2013 NHS Lanarkshire will be looking at identifying and developing joint equality outcomes, with our local statutory partners, especially in the area of joined up services. At national level NHS Lanarkshire continues to contribute and work with national bodies, like NHS Education Scotland (NES) and Health Scotland, in shaping and supporting the equalities agenda. 7. Gender Based Violence An NHS Lanarkshire Forced Marriage and Human Trafficking Action Plan was devised during 2012 In response to new Forced Marriage Statutory Guidance (October 2011) and CEL 19 (June 2012), which provided guidance on detecting 12

and responding to human trafficking. The routine enquiry of abuse programme is on-going and will support this work. EVA Services participated in a national pilot named TREM (Trauma Recovery Empowerment Model). This therapeutic group-work programme is aimed at helping women who have experienced abuse to improve their health outcomes. NHS Lanarkshire were part of a multi-site research study in collaboration with Napier University. 8. Workforce and Workforce Development Workforce information is key to delivering positive improvements in equality and diversity of our employees. We are commited to the continued development of robust systems that enhance the quality of data on our employees from all protected characteristics. It is planned to implement the national HR system (Electronic Employee Support System ) during 2013/2014 to support and focus positive equality improvements. In addition we intend promote participation in the 2013 national staff survey to deliver improved information from our employees and will conduct an analysis of the survey results to direct and focus equality improvements that will reduce discrimination experienced by staff, considering age and ethnic origin as a priority. 9. Spiritual and Religious Care The facilitation and delivery of religious care to patients, carers, staff and volunteers is the responsabilitiy of the Spiritual and Religious Care Department of NHS Lanarkshire. This department has recently moved from Organisational Development and is now placed within the Nursing, Midwifery and Allied Health Proffessions Directorate, with the Head of the Department reporting to the Director of Allied Health Professionals. This reflects the remit of the department to provide spiritual care to people of all faiths and no faith as an integral part of 13

holistic, person centred care. Religious care is a smaller but important aspect of care and is a strand of the equality and diversity agenda. To ensure equity of care and appropriate care the Spiritual and Religious Care Department provides multi faith resources for staff, meets regularly with community faith and belief group representatives through the Spiritual Care Advisory Committee, maintains contact information for faith and belief groups and has developed protocols for staff to help them access faith and belief groups if support is requested by patients or carers. Work has recently been undertaken to ensure that the sanctuary space in the three acute care hospitals is suitable for use by people of all faiths and none, in accordance with government guidelines and the Equality Act. 10. Facilities By understanding the needs of the local population, NHS Lanarkshire can understand how to influence behaviours in relation to health and sustainable development. This is achieved by listening to, understanding and involving the local community in decision-making and scrutiny processes as follows: Involving members of the local community in the planning and delivery of healthcare services through the Public Partnership Forum. Working positively with key stakeholders to ensure local decisions consider and ensure healthier travel options leading to more sustainable outcomes, through NHS Lanarkshire Travel Planning process and actions undertaken by the Srategic Transport and Access Group. Promoting healthy, sustainable food and nutrition choices. Co-shared service provision / delivery with other partners to meet local community needs through NHS Lanarkshire Local Delivery Plan and through the delivery of the 3 new Primary Care Investment Project Health Centres. Empowering the local community to adopt healthier, more sustainable lifestyles. 14

Reducing waiting times and the financial burden on the NHS Scotland resources by helping to move from treatment to prevention. For the last 3 years NHS Lanarkshire has achieved and maintained the Healthy Living Award Plus, which is recognition of our efforts to encourage staff and patients to make healthy and sustainable food and nutrition choices. In NHS Lanarkshire non patient facilities tea and coffee are Fair Trade products. Within NHS Lanarkshire the Fruits and Roots initiative which operate across a number of sites offers staff, patients and visitors the opportunity to purchase fresh fruit and vegetables from a local supplier. NHS Lanarkshire also run a social prescribing programme Gardening for Health which is being run as part of the NHS Well Connected Programme and is based in Lanark. Gardening for Health provides patients with mental health issues a programme of therapeutic horticulture and green activities which can contribute to their recovery programme and improve self management of long-term conditions. NHS Lanarkshire has made good progress in delivering many of the above actions through projects identified in the Strategic Transport and Access Group Action Plan (2008-2011), as well as through a number local initiatives supported by the Healthy Working Lives Teams. 11. NHS Lanarkshire Webpages External: NHS Lanarkshire has developed an equality and diversity external webpage, which is currently being populated with the publications of the recent work completed in meeting our specific duties. In 2013 further work will be done to populate the site with increased information for the public and staff. The webpage is now available and is compliant with current legislation. 15

Service users are also able to choose the text size on the screen to suit their need. See link: www.nhslanarkshire.org.uk Firstport: On Firstport there are a number of WebPages with information and support documents for staff to access, these range from accessing an interpreter to information on the spiritual care services. In 2013 upon the launch of the new Firstport site, a equality and diversity page will be created as a central source that links to all the other internal pages, thus creating an equalities one-stop shop of information for staff. 12. Complaints NHS Lanarkshire continues to be committed to managing all forms of feedback in accordance with the Patient Rights (Scotland) Act 2011 and the related guidance from the Scottish Government called Can I Help You? This includes feedback, comments, concerns, and complaints. The latest version of the booklet and fact sheet information is available electronically on the staff intranet. http://firstport2/staff-support/complaintshandling/documents/can%20i%20help%20you%20guidance.pdf 13. Areas of Future Work for the Equality and Diversity Steering Group 2013/14 In the following year the group will: Review and update Single Equality Scheme and Action Plan Ensure that EDIA is embedded more robustly within NHS Lanarkshire decision making processes Continue to support community engagement structures to attract engagment from a diverse range of the population. Continue promotion of the interpreting services to service users and staff 16

And in terms of workforce will: Continue to develop a robust system to capture data of service users and our employees from all protected characteristics to enable effective monitoring of equality through the Electronic Employee Support System (eess) Analyse the results of the Staff Survey 2013 and reduce any discrimination experienced considering age and ethnic origin as a priority. CONCLUSION In this report we have given an update on our progress across the year and this demonstrates that we have been proactive and have a strong commitment to improving and changing the experiences of our service users and staff in a meaningful and inclusive way. The report also indentifies where we still need to do more work and this will inform our work programme for 2013 2014. Hina.sheikh@lanarkshire.scot.nhs.uk Susan.dunne@lanarkshire.scot.nhs.uk April 2013 17