Equality Delivery System South Tyneside NHS Foundation Trust Goals, Outcomes and Grades 1
EQUALITY DELIVERY SYSTEM Introduction South Tyneside NHS Foundation Trust are committed, and as a public sector organisation statutorily required, to ensure that equality, diversity and human rights are embedded into all our functions and activities within our organisation. We provide a full range of acute services for elective (planned) and emergency care including in-patient, out-patient, day case and day care largely for the population of South Tyneside. In addition, we also provide community services for the population of South Tyneside, Sunderland and Gateshead, this includes, district nursing, health visiting, school nursing, urgent care services such minor injuries/walk in centres, palliative care services as well intermediate care services. The Equality Act 2010 The equality duty was created by the Equality Act 2010 and replaces the race, disability and gender equality duties. The duty came into force in April 2011 and covers nine protected characteristics which are: Age Disability Sex Race including nationality & ethnicity Religion or belief Marriage & Civil Partnership Sexual Orientation Gender re-assignment Pregnancy and maternity In undertaking our functions and activities we must have due regard to the need to: Eliminate discrimination, harassment and victimisation and any other conduct that is prohibited by or under the Act. Advance equality of opportunity between people who share a relevant protected characteristic and people who do not share it. 2
Foster good relations between people who share a relevant protected characteristic and those who do not share it. We have recently published equality and diversity information in order to comply with The Equality Act 2010, we need to demonstrate through the information that we are complying with the need to eliminate harassment, advance equal opportunities and foster good relations between different groups. All NHS organisations will need to set specific equality objectives by 6 April 2012 in order to comply with the public sector duties of the Act. The Equality Delivery System (EDS) The Equality Delivery System (EDS) is a tool to help assess how well embedded equality, diversity and human rights are within the Trust s systems and processes. It helps us to understand better how we meet the needs of different people. The EDS is the first time the NHS has tried to introduce a systematic framework relating to equality, diversity and human rights. It tries to capture the essence and spirit of both the Equality Act and the Health and Social Care Bill (currently going through Parliament) by focussing less on process and more on outcomes. It is also designed to help deliver on the NHS Outcomes Framework and the NHS Constitution, as well as supporting the organisation to continue to meet CQCs Essential Standards of Quality & Safety. The framework is dependant upon good engagement with both staff and patients and their active involvement in the rating and grading of the Trust. At the heart of the EDS is a set of 18 outcomes grouped into four goals: Better health outcomes for all Improved patient access and experience Empowered, engaged and well-supported staff Inclusive leadership at all levels The outcomes focus on the issues of most concern to patients, carers, communities, NHS Staff and Trust Boards. It is against these outcomes that our performance is analysed, graded and action is determined. For each EDS outcome, there are four grades to choose from: 3
Excelling (for all protected groups) Purple Achieving (for most protected groups) Green Developing (for some protected groups) Amber Undeveloped (for none of the protected groups) Red The grades are intended to help us clearly identify equality progress and challenges and embed equality into mainstream business. The table in appendix 1 gives a summary of our provisional grades/performance against the 18 outcomes. In assessing the grades for STFT we have looked at a wide range of information for e.g. annual report, joint strategic needs assessment (JSNA), board performance reports, patient surveys, patient stories, staff surveys, board workforce reports, personnel policies. A list of the evidence/information considered as part of the self assessment in detailed in Appendix 2 and Appendix 3. We have also discussed with patient, carers, local interest groups as well as Trade Union representatives and staff. We have also worked in partnership with other NHS Organisations and local stakeholders. We will use the evidence/information and the EDS grading to identify specific measurable equality objectives. Sonia Atkinson Assistant Head of Personnel 28 March 2012 4
Appendix 1 EDS Outcomes and Our Provisional Grades Goal 1 Goal 2 Goal 3 Better health outcomes for all The NHS should achieve improvements in patient health, public health and patient safety for all, based on comprehensive evidence of needs and results 1.1 Services are commissioned, designed and procured to meet the health needs of local communities, promote well-being, and reduce health inequalities 1.2 Patients health needs are assessed, and resulting services provided in appropriate and effective ways 1.3 Changes across services are informed by engagement of patients and local communities, and transitions are made smoothly 1.4 The safety of patients 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 1.5 Public health, vaccination and screening programmes reach and benefit all local communities and groups Improved patient access and experience The NHS should improve accessibility and information, and deliver the right services that are targeted, useful, useable and used in order to improve patient experience 2.1 Patients, carers and communities can access services, and should not be denied access on unreasonable grounds 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 Empowered, engaged and well-supported staff The NHS should increase the diversity and quality of the working lives of the paid and non paid workforce, supporting all staff to better respond to patients and communities needs 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 3.2 Levels of pay 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 5
Goal 4 pay 3.3 Through support, training, personal development and performance appraisal, staff are confident and competent to do their work, so that services are commissioned and provided appropriately 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 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 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 Inclusive leadership at all levels NHS Organisations should ensure that equality is everyone s business, and everyone is expected to take an active part, supported by the work of specialist equality leaders and champions 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 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 4.3 The organisation uses the Competency Framework for Equality and Diversity Leadership to recruit, develop and support strategic leaders to advance equality outcomes 6
List of Information/Evidence used in Self Assessment EDS - Goals 1 & 2 Appendix 2 Director of Public Health Annual Report Gateshead 2009/2010 Director of Public Health Annual Report Sunderland 2009/2010 Director of Public Health Annual Report South Tyneside 2008/2009 NHS South of Tyne and Wear Health Protection Annual Report 2007 2010 Joint Strategic Needs Assessment Gateshead 2010 Joint Strategic Needs Assessment Sunderland 2009 Joint Strategic Needs Assessment South Tyneside 2009 NHS South of Tyne and Wear Strategic Plan 2010/2015 Integrated Strategic Operational Plan Gateshead 2011 2015 Integrated Strategic Operational Plan Sunderland 2011 2015 Integrated Strategic Operational Plan South Tyneside 2011 2015 NHS South of Tyne and Wear Duty to Involve Report 2010/2011 Performance Against Vital Signs Report Gateshead 2010/2011 Performance Against Vital Signs Report Sunderland 2010/2011 Performance Against Vital Signs Report South Tyneside 2010/2011 STFT Annual Report & Summary Financial Statements 2010/2011 STFT Complaint Trend Analysis Report 2010/2011 STFT Customer Services Report 2010/2011 STFT Hospital Services Activity Report 2010/2011 STFT Community Services Activity Report 2010/2011 STFT Patient Stories Report 2010/2011 CQC Dignity and Nutrition Report July 2011 & November 2011 NHS Outpatients Survey February 2011 NHS Inpatient Survey May 2010 NHS Maternity Care Survey December 2010 STFT Complaints Policy STFT Listening, Acting & Improving STFT Trust Board Visit Reports The Centre for Enabling Health Improvement (CEHI) weblog for Gateshead, Sunderland and South Tyneside NHS Patient Safety Framework October 2011 NICE Standard for Patient Experience in adult NHS services Learning Disability Self Assessment Framework for the NHS in England 2012/2013 consultation document STFT Quality Governance Assurance Framework 7
STFT Equality Strategy 2011 STFT Single Equality Scheme 2008 2011 EDS Consultation Event Report February 2012 STFT Access to Healthcare for people with a Learning Disability Action Plan March 2011 STFT Agendas, Meetings Council of Governors Use of Direct Enquiries, the Nationwide Access Register STFT Clinical Governance Annual Report 2009/2010 STFT Clinical Audit Policy 2011 Integrated Audit Board Report Sunderland November 2010 Integrated Audit Board Report Gateshead February 2011 Integrated Audit Board Report South Tyneside February 2011 STFT Toolkit for Supporting Patient, Carer, Service User and Public Involvement STFT Annual Plan STFT Food & Nutrition Policy STFT Clinical Record Keeping Policy STFT Privacy & Dignity Policy STFT Your Privacy, Our Responsibility STFT Membership Strategy National Cancer Patient Survey Francis Report review and action plan Healthnet Membership Useful Weblinks NHS South of Tyne and Wear www.sotw.nhs.uk/aboutus/publications South Tyneside NHS Foundation Trust www.sthct.nhs.uk/about-the-trust/reports-publications www.sthct.nhs.uk/about-the-trust/equality-and-diversity www.sthct.nhs.uk/about-the-trust/council-of-governors/meetingagendas-and-papers www.sthct.nhs.uk/for-patients/customer-services www.sthct.nhs.uk/for-patients/how-to-find-us Care Quality Commission www.cqc.org.uk 8
List of Information/Evidence used in Self Assessment EDS - Goals 3 & 4 STFT Annual Report STFT Equality Strategy 2011 STFT Recruitment and Selection Procedure NHS South of Tyne and Wear Recruitment and Selection Policy NHS Employment Check standards STFT Workforce Report December 2011 STFT Workforce Board Reports STFT Staff Survey Results 2010 STFT Staff Survey Results 2011 STFT Analysis of Exit Questionnaires NHS Terms and Conditions of Service NHS Job Evaluation Process STFT Job Evaluation Policy STFT Appraisal Policy STFT Study Leave Policy STFT Equality & Diversity Meeting Minutes STFT Disability Group Meeting Minutes STFT HR Strategy STFT Fairness at Work Matrix Group Minutes STFT Health Safety and Wellbeing Matrix Group Minutes STFT Recruitment and Retention Matrix Group Minutes STFT Workforce Planning Matrix Group Minutes STFT Lifelong Learning Group Minutes STFT Organisational Development Matrix Group Minutes STFT Investors in People Matrix Group NHS North East Inclusive Leadership Project NHS Energising For Excellence STFT Bullying and Harassment Policy STFT Health and Safety Strategy STFT Workplace Health and Wellbeing Strategy STFT Lone Worker Policy STFT Lone Worker Device System STFT Risk Assessment Process Bronze Better Health at Work Award STFT Well Person Screening Service STFT Seasonal Flu Campaign STFT Manual Handling Policy & Training Appendix 2 9
STFT Cardiovascular Disease Initiative STFT Feeling Safe at Work Strategy STFT Staying Healthy Strategy STFT Occupational Heath Service STFT Counselling Services Paradigm Mediation Services STFT Health, Safety & Wellbeing Progress Reports NHS South of Tyne and Wear Flexible Working Policy STFT Workforce Analysis of part time working and flexible options Useful Weblinks NHS South of Tyne and Wear www.sotw.nhs.uk/aboutus/publications South Tyneside NHS Foundation Trust http://www.sthct.nhs.uk/about-the-trust www.sthct.nhs.uk/about-the-trust/reports-publications www.sthct.nhs.uk/about-the-trust/equality-and-diversity www.sthct.nhs.uk/about-the-trust/council-of-governors/meetingagendas-and-papers Care Quality Commission www.cqc.org.uk NHS Employers www.nhsemployers.org 10