Equality Delivery System (EDS) Engagement Report 1. Background The Equality Delivery System (EDS) has been designed by the Department of Health to help NHS organisations measure their equality performance, and understand how driving equality improvements can strengthen the accountability of services to patients and the public. It will support NHS Calderdale, Kirklees & Wakefield District identify local needs and priorities, particularly any unmet needs of populations, and allow them to assist in the commissioning of services to deliver better health outcomes . It will also help NHS organisations to demonstrate compliance with the Equality Act 2010. At the heart of the EDS is a set of 18 outcomes grouped into four goals; 1. Better health outcomes for all 2. Improved patient access and experience 3. Empowered, engaged and well-supported staff 4. Inclusive leadership at all levels (Appendix 1, Goals & Outcomes) 2. Engagement approach Public Engagement One of the features of the EDS is that it relies on organisations working with local interests to assess organisational performance. This engagement will strengthen existing relationships and build new ones, ensuring that patients and the public have a voice in the grading and setting of objectives for the organisation. The engagement focused on the following goals with local interests; 1. Better health outcomes for all 2. Improved patient access and experience A consistent approach to engagement was carried out across NHS Calderdale, Kirklees & Wakefield District. A short questionnaire was developed to use generically across the cluster and six events were organised, two within each cluster area. (Appendix 2, Questionnaire) To ensure effective engagement with local interests the Equality team worked closely with the Engagement team to; recruit representative communities and local people to attend the local events visited community groups and gave out flyers and questionnaires attended events to raise awareness of the EDS and the upcoming events 1
Those who returned the interest forms were sent an invitation to attend the 2 events for their chosen cluster area to be part of an Equality Panel to help grade and set objectives for the organisation. They were also asked what their area of interest was, of the 9 protected characteristics Age Disability Sexual Orientation Religion & Belief Race Pregnancy & Maternity Marriage & Civil Partnership Sex (gender) Transgender Given the short timetable the events were developed to use people’s own knowledge and experience of the NHS and that of the groups they represented. To enable the events to be interactive and inclusive, colour coded voting cards were used to grade each of the 18 outcomes. Votes were recorded alongside any feedback given by the participants to add depth to the voting.
Undeveloped
Developing
Achieving
Excelling
Six events were run over a period of three weeks across NHS Calderdale, Kirklees and Wakefield District. Two events were carried out in each locality. Event 1 Participants were presented with the organisations self-assessment of each of the 18 outcomes and overall assessment for Goals 1 and 2. They were then asked to consider the evidence presented and grade the organisation with the colour coding voting cards, whilst giving feedback on their own or their service users’ experiences of NHS services; in respect of their interest areas around the 9 protected characteristics. (Appendix 3, Grading Template) Their experiences often related to services that are provided, which the PCTs commission. It would not have been possible to engage with the public to discuss how they feel about our commissioning decisions in the accessible format we chose to adopt. Event 2 Participants were presented with the collated grades and their feedback from the previous meeting and were asked to seek agreement. As there were some different people at each event this allowed for people to catch up on what had happened and also feed in their views should they disagree with the grade given. Some grades were adjusted. Those present then looked at the areas of weakness for the PCT concerned. They gave feedback about what would make a difference to those areas and we agreed priority areas for action. 2
Wakefield PCT carried out additional pieces of engagement in partnership with Wakefield Together Public Sector Engagement group. The outcomes of these events were also incorporated into the findings of the final grades for the EDS. Staff Engagement Engagement with staff was also undertaken to ensure their views and experiences also contributed to the final 2 goals of the EDS; 3. Empowered, engaged and well-supported staff 4. Inclusive leadership at all levels To assess our progress against the above two goals a staff survey was developed and shared with all staff via the electronic newsletter as an article and a link to the survey. (Appendix 4, Staff Survey). This was circulated twice with limited success. There were 9 respondents from Calderdale and 2 from Kirklees and Wakefield. To address this, feedback was also extracted from the national NHS staff survey, which is undertaken every autumn. The responses are analysed via some protected characteristics, although monitoring is done over more areas than are analysed. The resulting grades are detailed at Appendix 5, 6 and 7. The EDS is a new process and this was the first time it was used. To have undertaken the grading in the manner described in the handbook would have been unworkable within the timescales we were working to. It is recognised that narrow timescales had a negative impact on the process; however this practical and accessible approach was developed to create a baseline of information to be used within the first year and in future years. The process will be evaluated and lessons learnt to influence future implementation. 3. Findings Questionnaire People were able to complete the questionnaire electronically and in paper format, with the paper version providing a free post address to return to NHS Calderdale. The majority of the respondents were from Wakefield or used Wakefield services (15/19) one used Kirklees and 3 skipped the question. Given this response rate the return for Wakefield alone will be detailed here. Question 1, asked which area people lived, where they use NHS Services or which area their organisation covers Where do you live? Response Response Percent Total 1 Calderdale
0.00%
0
2 Kirklees
6.25%
1
3 Wakefield
93.75%
15 3
Where do you live? Response Response Percent Total answered
16
skipped
3
Question 2, asked for views on services asking people to grade how much they agreed or disagreed with certain statements. 1. Better health for everyone 1. Local NHS services meet the needs of local communities
Percent
Total
1
Strongly agree
0.00%
0
2
Agree
33.33%
5
3
Neither agree or disagree
40.00%
6
4
Disagree
26.67%
4
5
Strongly disagree
0.00%
0
answered
15
2. The local NHS promotes well being and healthy lifestyles
Percent
Total
1 Strongly agree
0.00%
0
2 Agree
80.00%
12
13.33%
2
4 Disagree
6.67%
1
5 Strongly disagree
0.00%
0
3
Neither agree or disagree
answered 15 3. The local NHS does enough to reduce health Percent inequalities
Total
1 Strongly agree
0.00%
0
2 Agree
13.33%
2
46.67%
7
3
Neither agree or disagree
4
3. The local NHS does enough to reduce health Percent inequalities
Total
4 Disagree
20.00%
3
5 Strongly disagree
20.00%
3
answered 15 4. Patients health needs are assessed adequately and services provided in effective and appropriate ways
Percent
Total
1
Strongly agree
0.00%
0
2
Agree
33.33%
5
3
Neither agree or disagree
26.67%
4
4
Disagree
40.00%
6
5
Strongly disagree
0.00%
0
answered 15 5. Patients move smoothly from one health service department to another
Percent
Total
1
Strongly agree
0.00%
0
2
Agree
6.67%
1
3
Neither agree or disagree
46.67%
7
4
Disagree
33.33%
5
5
Strongly disagree
13.33%
2
answered 15
6. If a patient has to move to another service by a transfer it is discussed with them
Percent
Total
1
Strongly agree
0.00%
0
2
Agree
26.67%
4
3
Neither agree or disagree
73.33%
11
4
Disagree
0.00%
0
5
Strongly disagree
0.00%
0
answered 15 5
7. The safety of patients is a priority
Percent
Total
1 Strongly agree
6.67%
1
2 Agree
20.00%
3
33.33%
5
4 Disagree
40.00%
6
5 Strongly disagree
0.00%
0
3
Neither agree or disagree
answered 15 8. NHS services are free from abuse, harassment, bullying and violence from other patients and staff
Percent
Total
1
Strongly agree
7.14%
1
2
Agree
28.57%
4
3
Neither agree or disagree
28.57%
4
4
Disagree
21.43%
3
5
Strongly disagree
14.29%
2
answered 15 9. Screening services meet the needs of local communities e.g. breast cancer or cervical screening
Percent
Total
1
Strongly agree
15.38%
2
2
Agree
30.77%
4
3
Neither agree or disagree
38.46%
5
4
Disagree
7.69%
1
5
Strongly disagree
7.69%
1
answered 15 10. Vaccination programmes meet the needs of Percent local communities
Total
1
Strongly agree
13.33%
2
2
Agree
33.33%
5
3
Neither agree or
46.67%
7 6
10. Vaccination programmes meet the needs of Percent local communities
Total
disagree 4
Disagree
0.00%
0
5
Strongly disagree
6.67%
1
answered 15 2. Improved patient access and experience 11. I can easily access the NHS services I need Percent
Total
1 Strongly agree
26.67%
4
2 Agree
40.00%
6
6.67%
1
4 Disagree
20.00%
3
5 Strongly disagree
6.67%
1
3
Neither agree or disagree
answered 15 12. After being diagnosed with a condition, or after having treatment, everything was explained to me in a way that I could understand
Percent
Total
1
Strongly agree
13.33%
2
2
Agree
46.67%
7
3
Neither agree or disagree
20.00%
3
4
Disagree
6.67%
1
5
Strongly disagree
13.33%
2
answered 15 13. I have taken an active part in decisions about my treatment
Percent
Total
1
Strongly agree
13.33%
2
2
Agree
46.67%
7
3
Neither agree or disagree
20.00%
3
4
Disagree
6.67%
1 7
13. I have taken an active part in decisions about my treatment
Percent
Total
5
13.33%
2
Strongly disagree
answered 15 14. I have been able to decide on the best place for me to have my treatment.
Percent
Total
1
Strongly agree
20.00%
3
2
Agree
33.33%
5
3
Neither agree or disagree
20.00%
3
4
Disagree
13.33%
2
5
Strongly disagree
13.33%
2
answered 15 15. Health professionals who cared for me, listened and respected my views
Percent
Total
1
Strongly agree
0.00%
0
2
Agree
66.67%
10
3
Neither agree or disagree
6.67%
1
4
Disagree
13.33%
2
5
Strongly disagree
13.33%
2
answered 15
16. My dignity and privacy were respected
Percent
Total
1 Strongly agree
13.33%
2
2 Agree
53.33%
8
20.00%
3
4 Disagree
6.67%
1
5 Strongly disagree
6.67%
1
3
Neither agree or disagree
answered 15
8
17. If you made a complaint, it was handled with respect and efficiency.
Percent
Total
1 Strongly agree
0.00%
0
2 Agree
20.00%
3
60.00%
9
4 Disagree
13.33%
2
5 Strongly disagree
6.67%
1
3
Neither agree or disagree
answered 15 Equality Monitoring - Questionnaire
The person that reported they were disabled had a number of impairments.
9
One person skipped this question
Two people skipped this question
Of those that declared they had a religion 80% were Christian and 20% Muslim There is little benefit in analysing the results by equality group as there are too few respondents to identify any genuine trends at this time. Events In total 22 people attended all six events, with 8 people attending in Calderdale, 11 people attending in Kirklees and 4 in Wakefield. Event 1 Participants were presented with the organisations self-assessment of each of the outcomes and overall assessment for Goals 1 and 2. Participants were then asked to grade the organisation in view of their interest areas around the 9 protected characteristics for each of the outcomes. Some people chose more than one interest area Interest area Age Disability Sexual Orientation Religion & Belief Race Pregnancy & Maternity Marriage & Civil Partnership Sex (Gender) Transgender
Calderdale 6 7 1 4 3 1 4 1 1
Kirklees 7 5 3 2 2 1 -
Wakefield 3 4 2 3 2 2 2 2 2
Participants had a choice of four grades; Excelling - working well for all of the protected groups Achieving - working well for most of the protected groups Developing - working well for some of the protected groups Undeveloped is- working well for just a few or none of the protected groups
10
Event 2 Between the events the feedback was collated and analysed alongside the returned questionnaires. This was then presented to the next meeting and an opportunity given to review the grades and make adjustments as required. Having finalised the grades the groups then used this information to determine which areas were priorities for action. Each group then considered what activity could make a difference to the areas concerned and this feedback was developed into the organisations strategic equality objectives. As the objectives were developed after the meeting they were emailed out to the participants for further comment. No comments were received. A low number of people participated in the Wakefield event, with four people who participated at the first event and only one person attending the second event, which meant the second event, had to be cancelled. Despite low attendance at these events we were able to grade the EDS based on the returns from the questionnaire and those present at the first event. Further information was also obtained through the engagement events held by the Wakefield Together Public Sector Engagement Group, this was also used to inform Wakefield Districts final grading’s Calderdale Appendix 5, Final grading - Calderdale Kirklees Appendix 6, Final grading - Kirklees Wakefield Appendix 7, Final grading - Wakefield Staff survey Given the low number of returns from other organisations, only the results from the Calderdale staff questionnaire are detailed below. 1. How we recruit and select staff is inclusive and fair
Percent
Total
1 Strongly agree
22.22%
2
2 Agree
22.22%
2
11.11%
1
4 Disagree
33.33%
3
5 Strongly disagree
11.11%
1
3
Neither agree or disagree
answered 9
11
2. Our staff, including the board and directors are representative of the Calderdale community
Percent
Total
1
Strongly agree
11.11%
1
2
Agree
0.00%
0
3
Neither agree or disagree
44.44%
4
4
Disagree
44.44%
4
5
Strongly disagree
0.00%
0
answered 9 3. Staff have effective personal development and performance appraisal
Percent
Total
1
Strongly agree
0.00%
0
2
Agree
66.67%
6
3
Neither agree or disagree
11.11%
1
4
Disagree
22.22%
2
5
Strongly disagree
0.00%
0
answered 9 4. Staff are supported, trained and developed to be competent and confident to plan, procure Percent or deliver services that meet the needs of all communities in Calderdale
Total
1
Strongly agree
0.00%
0
2
Agree
55.56%
5
3
Neither agree or disagree
22.22%
2
4
Disagree
22.22%
2
5
Strongly disagree
0.00%
0
answered 9
12
5. Staff are free from abuse, harassment, bullying and violence from patients, their relatives and colleagues
Percent
Total
1
Strongly agree
11.11%
1
2
Agree
55.56%
5
3
Neither agree or disagree
22.22%
2
4
Disagree
11.11%
1
5
Strongly disagree
0.00%
0
answered 9 6. Staff have access to a full range of flexible working options
Percent
Total
1
Strongly agree
33.33%
3
2
Agree
55.56%
5
3
Neither agree or disagree
0.00%
0
4
Disagree
11.11%
1
5
Strongly disagree
0.00%
0
answered 9 7. Staff are supported to remain healthy and have access to initiatives that promote healthy Percent lifestyles
Total
1
Strongly agree
22.22%
2
2
Agree
77.78%
7
3
Neither agree or disagree
0.00%
0
4
Disagree
0.00%
0
5
Strongly disagree
0.00%
0
answered 9
13
8. Board members and senior leaders, lead the organisation effectively, communicating their vision for equality, actively creating diverse Percent teams and developing diverse talent in the organisation
Total
1
Strongly agree
0.00%
0
2
Agree
44.44%
4
3
Neither agree or disagree
44.44%
4
4
Disagree
11.11%
1
5
Strongly disagree
0.00%
0
answered 9 9. Board members and senior leaders, ensure equality is considered as part of mainstream business and internal assurance processes
Percent
Total
1
Strongly agree
11.11%
1
2
Agree
22.22%
2
3
Neither agree or disagree
55.56%
5
4
Disagree
11.11%
1
5
Strongly disagree
0.00%
0
answered 9 10. Middle and line managers, motivate and support their staff in understanding and responding to the needs of, communities and staff from the protected groups and support culturally competent ways of working?
Percent
Total
1
Strongly agree
0.00%
0
2
Agree
44.44%
4
3
Neither agree or disagree
33.33%
3
4
Disagree
22.22%
2
5
Strongly disagree
0.00%
0
answered 9
14
Equality monitoring Gender – what sex are you? Response Percent
Response Total
1 Female
88.89%
8
2 Male
11.11%
1
3 Prefer not to say
0.00%
0
answered 9 skipped
0
Response Percent
Response Total
1 Under 25
0.00%
0
2 26-35
33.33%
3
3 36-45
33.33%
3
4 46-55
22.22%
2
5 56-65
11.11%
1
6 66 +
0.00%
0
7 Prefer not to say
0.00%
0
How old are you?
answered 9 skipped
0
Response Percent
Response Total
Kashmiri
11.11%
1
British English/Scottish/Welsh/Northern Irish
88.89%
8
What is your ethnic group?
answered 9 skipped
0
15
Do you consider yourself to have a disability? Response Percent
Response Total
1 Yes
0.00%
0
2 No
77.78%
7
3 Prefer not to say
22.22%
2
answered 9 skipped
0
Response Percent
Response Total
11.11%
1
88.89%
8
What is your sexual orientation?
2 Lesbian (same sex) 4
Heterosexual/Straight (opposite sex)
answered 9 skipped
0
Response Percent
Response Total
1 Yes
55.56%
5
2 No
44.44%
4
3 Prefer not to say
0.00%
0
Do you consider yourself to belong to any religion?
answered 9 skipped
0
Response Percent
Response Total
1 Yes
22.22%
2
2 No
66.67%
6
3 Prefer not to say
11.11%
1
Do you provide care for someone
answered 9 16
4. Equality data All participants who completed a questionnaire or attended events were asked to complete an equality monitoring form. (Appendix 8, Equality Monitoring) 5. Recommendations To continue to work with the equality leads to establish future work of the EDS to meet the objectives developed by the Equality Panels. To maintain and develop relationships with interested parties, to develop an Equality Panel in each locality across the cluster.
17
Appendix 1. Goals & Outcomes Goal 1. Better health outcomes for all
Narrative The NHS should achieve improvements in patient health, public health and patient safety for all, based on comprehensive evidence of needs and results
2. 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
3. Empowered, engaged and wellsupported 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
Outcome 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 discussed with patients, and transitions are made smoothly 1.4 The safety of patients is prioritised and assured 1.5 Public health, vaccination and screening programmes reach and benefit all local communities and groups 2.1 Patients, carers and communities can readily access services, and should not be denied access on unreasonable grounds 2.2 Patients are informed and supported so that they can understand their diagnoses, consent to their treatments, and choose their places of treatment 2.3 Patients and carers report positive experiences of the NHS, where they are listened to and respected and 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 3.2 Levels of pay and related terms and conditions are fairly determined for all posts, with staff doing the same work in the same job being remunerated equally 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 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 18
Goal
4. Inclusive leadership at all levels
Narrative
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
Outcome 3.5 Flexible working options are made available to all staff, consistent with the needs of patients, 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 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 NHS Equality & Diversity Competency Framework to recruit, develop and support strategic leaders to advance equality outcomes
19
Appendix 2. Questionnaire
We would like to hear your views on how well we are doing with meeting our Equality goals. What is the survey about? The survey is about our Equality Delivery System (EDS) which has been developed to help the NHS understand how well it is doing on promoting equality and making sure services are suitable for those that need them. What will happen to my views? Your views will support NHS Calderdale, Kirklees and Wakefield District to identify local needs and priorities and allow them to shape services around people’s specific circumstances, and so help to deliver better outcomes. It will also assist organisations to meet their duties under the Equality Act 2010. Your views will help us to understand your needs, so we can provide local services which help to strengthen existing relationships and build new ones. What are the goals for the EDS? The EDS has four goals, divided into 18 outcomes. These focus on areas which mean the most, or are likely to have the greatest impact on patients, carers and staff. Your response Please help us to improve services by completing the questionnaire. You can do this as an individual or organisation. We need to have received all responses by Friday 2nd March 2012. You can send the response by freepost (no stamp needed) to the following address, FREEPOST RLTG-JAYY-ZSRX PPI Team @ Calderdale PCT Dean Clough Office Park, F Mill Halifax, HX3 5AX Please tick the appropriate boxes and add information where requested. If you do not know the answer or do not want to answer please leave the question blank.
20
1. Please state which area you live in, where you use NHS services or which area your organisation covers. Tick all that apply. Calderdale O Kirklees O Wakefield O We commission (buy) a number of NHS services on your behalf. These services include GP practices, pharmacies, dentists and opticians, services you receive in the community and in hospital. We want you to tell us your view about these services using the statements below. Please tell us how much you agree or disagree with the following;
Statement
Neither Strongly agree or Agree Disagree agree disagre e 1. Better health for everyone
Local NHS services meet the needs of local communities The local NHS promotes well being and healthy lifestyles The local NHS does enough to reduce health inequalities (Health inequalities are when some people, due to their location, income or because they belong to different groups have different health outcomes, such as living shorter lives or more health problems) Patients health needs are assessed adequately and services provided in effective and appropriate ways Patients move smoothly from one health service department to another If a patient has to move to another service by a transfer it is discussed with them The safety of patients is a priority (This would include things like being treated with a professional standard of care,
Strongly disagree
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
21
in clean and safe environments) NHS services are free from abuse, harassment, bullying and violence from other patients and staff Screening services meet the needs of local communities e.g. breast cancer or cervical screening. Vaccination programmes meet the needs of local communities
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
We also want you to think about your experience of services by telling us how much you agree or disagree with the following statements. 2. Improved patient access and experience I can easily access the NHS services I need After being diagnosed with a condition, or after having treatment, everything was explained to me in a way that I could understand I have taken an active part in decisions about my treatment I have been able to decide on the best place for me to have my treatment. Health professionals who cared for me, listened and respected my views My dignity and privacy were respected If you made a complaint, it was handled with respect and efficiency.
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
O
22
Appendix 3. Grading Template
EDS Goal 1 „Better health outcomes for all‟ EDS Outcome 1.1 “Services are commissioned, designed and procured to meet the health needs of local communities, promote well-being, and reduce health inequalities” Factor Through the use of best available evidence how many protected groups can the organisation demonstrate that the health needs of patients & carers are being met, and well-being is promoted?
Undeveloped Developing → → No evidence For some at all or, for protected few or none of groups the protected groups
Achieving → For most protected groups
Excelling For all protected groups
EDS Outcome 1.2 “Individual patients‟ health needs are assessed, and resulting services provided, in appropriate and effective ways”
Factor Through the use of best available evidence how many protected groups can the organisation demonstrate that patients from protected groups have their health-needs assessments, and resulting services, provided in appropriate and effective ways?
Undeveloped →
Developing →
No evidence For some at all or for protected few or none of groups the protected groups
Achieving → For most protected groups
Excelling For all protected groups
23
EDS Outcome 1.3 “Changes across services for individual patients are discussed with them, and transitions are made smoothly”
Factor Through the use of best available evidence how do service changes and transitions for patients from protected groups compare with the changes and transitions for patients as a whole?
Undeveloped →
Developing →
Achieving →
No evidence at all or no difference for few or none of the protected groups
No difference for some protected groups
No difference for most protected groups
Excelling No difference for all protected
EDS Outcome 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” Factor Through the use of best available evidence can the organisation demonstrate that patients from protected groups have their safety prioritised and assured?
Undeveloped →
Developing →
No evidence at all Or For few or none of the protected groups
For some protected groups
Achieving → For most protected groups
Excelling For all protected groups
24
EDS Outcome 1.5 “Public health, vaccination and screening programmes reach and benefit all local communities and groups”
Factor Through the use of best available evidence can the organisation demonstrate that public health, vaccination and screening programmes reach and benefit all protected groups within local communities?
Undeveloped →
Developing →
No evidence at all Or For few or none of the protected groups
For some protected groups
Achieving → For most protected groups
Excelling For all protected groups
EDS Goal 2 „Improved patient access and experience‟ EDS Outcome 2.1 “Patients, carers and communities can readily access services, and should not be denied access on unreasonable grounds” Factor Through the use of best available evidence can the organisation demonstrate that patients, carers & communities from protected groups can readily access services, and are not denied access on unreasonable grounds?
Undeveloped →
Developing →
No evidence at all Or For few or none of the protected groups
For some protected groups
Achieving → For most protected groups
Excelling For all protected groups
25
EDS Outcome 2.2 “Patients are informed and supported to be as involved as they wish to be in their diagnosis and decisions about their care and to exercise choice about treatments and places of treatment” Factor Through the use of best available evidence can the organisation demonstrate that patients from protected groups are informed and supported to be involved in decisions about their care, and to exercise choice about treatments and place of treatment?
Undeveloped →
Developing →
No evidence at all Or For few or none of the protected groups
For some protected groups
Achieving → For most protected groups
Excelling For all protected groups
EDS Outcome 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” Factor Through the use of best available evidence can the organisation demonstrate that patients & carers report and enjoy positive experiences of the organisation, including being listened to and respected, and having their dignity and privacy prioritised?
Undeveloped →
Developing →
No evidence at all Or for few or none of the protected groups
For some protected groups
Achieving → For most protected groups
Excelling For all protected groups
26
EDS Outcome 2.4 “Patients‟ and carers‟ complaints about services, and subsequent claims for redress, should be handled respectfully and efficiently” Factor Through the use of best available evidence can the organisation demonstrate that complaints by patients & carers from protected groups, and any subsequent redress, are handled respectfully and efficiently?
Undeveloped →
Developing →
No evidence at all Or For few or none of the protected groups
For some protected groups
Achieving → For most protected groups
Excelling For all protected groups
EDS Outcome 3 Empowered, engaged and well-supported staff “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” Factor
Undeveloped Developing → →
Achieving →
Excelling
Through the use of best available evidence, can the organisation demonstrate that staff from protected groups experience inclusive and equitable recruitment and selection processes within all occupations and grades?
No evidence at all Or For few or none of the
For most protected groups
For all protected groups
For some protected groups
27
protected groups 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” Factor
Undeveloped Developing → →
Achieving →
Excelling
Through the use of best available evidence, can the organisation demonstrate that staff from protected groups enjoy levels of pay and related terms & conditions no different to the pay and related terms & conditions for staff as a whole doing equal work or work rated as of equal value?
No evidence at all Or For few or none of the protected groups
For most protected groups
For all protected groups
For some protected groups
“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” Factor
Undeveloped →
Developing →
Achieving →
Excelling
Through the use of best available evidence, can the organisation demonstrate that staff from protected groups receive both personal development and performance appraisals no different to that received by staff as a whole?
No evidence at all Or For few or none of the protected groups
For some protected groups
For most protected groups
For all protected groups
28
“Staff are free from abuse, harassment, bullying, violence from both patients and their relatives and colleagues, with redress being open and fair to all” Factor
Undeveloped →
Developing →
Achieving →
Excelling
Through the use of best available evidence, can the organisation demonstrate that staff from protected groups are free from abuse, harassment, bullying and violence from patients, their relatives and colleagues
No evidence at all Or For few or none of the protected groups
For some protected groups
For most protected groups
For all protected groups
“Flexible working options are made available to all staff, consistent with the needs of the service, and the way people lead their lives” Factor Through the use of best available evidence, can the organisation demonstrate that staff from protected groups have access to a full range of flexible working options?
Undeveloped →
Developing →
Achieving →
Excelling
No evidence at all Or For few or none of the protected groups
For some protected groups
For most protected groups
For all protected groups
29
“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” Factor Through the use of best available evidence, can the organisation demonstrate that staff from protected groups are supported to remain healthy and have access to initiatives that promote healthy lifestyles?
Undeveloped →
Developing →
Achieving →
Excelling
No evidence at all Or For few or none of the protected groups
For some protected groups
For most protected groups
For all protected groups
EDS Outcome 4 Inclusive leadership at all levels “Boards and senior leaders conduct and plan their business so that equality is advanced, and good relations fostered, within their organisations and beyond” Factor
Undeveloped →
Developing →
Achieving →
Excelling
Do Board members and senior leaders communicate their vision for services and workplaces that are personal, fair and diverse within the organisation and beyond to the wider health and care system?
No evidence at all Or For few or none of the protected groups
For some protected groups
For most protected groups
For all protected groups
30
“Middle managers and other line managers support and motivate their staff to work in culturally competent ways within a work environment free from discrimination” Factor
Undeveloped →
Developing →
Achieving →
Excelling
Do middle and line managers actively take steps to create high performing diverse teams and develop diverse talent in the organisation?
No evidence at all Or For few or none of the protected groups
For some protected groups
For most protected groups
For all protected groups
“The organisation uses the Competency Framework for Equality and Diversity Leadership to recruit, develop and support strategic leaders to advance equality outcomes” Factor
Undeveloped →
Developing →
Achieving →
Excelling
Does the organisation use the Competency Framework for Equality and Diversity Leadership?
No evidence at all Or For few or none of the protected groups
For some protected groups
For most protected groups
For all protected groups
31
Appendix 4. Staff Survey
Equality Delivery System (EDS) NHS CKW have committed to implement the EDS, this is a performance monitoring framework to assess the progress of equality within the NHS. It relies on the engagement of patients, the public and yourselves to assess and grade itself against four goals, divided into 18 outcomes. These focus on areas which mean the most, or are likely to have the greatest impact on patients, carers and staff. Performance will be analysed, graded and future plans determined. The goals are; 1. Better Health Outcomes for all 2. Improved patient access & experience 3. Empowered, engaged & well supported staff 4. Inclusive leadership at all levels Staff are asked for their feedback against goals 3 & 4 in the questions outlined below. The questions mirror some of the content of the annual staff survey, this is intentional and will capture some of the issues for the organisation before the release of the 2011 survey results. The results of the 2010 staff survey will also be considered as part of the EDS.
32
Please indicate, using the tick box how much you agree with the following statements Strongly agree
Agree
Neither agree Disagree or disagree
Strongly disagree
How we recruit and select staff is inclusive and fair Our staff, including the board and directors are representative of the Calderdale community Staff have effective personal development and performance appraisal Staff are supported, trained and developed to be competent and confident to plan, procure or deliver services that meet the needs of all communities in Calderdale Staff are free from abuse, harassment, bullying and violence from patients, their relatives and colleagues Staff have access to a full range of flexible working options Staff are supported to remain healthy and have access to initiatives that promote healthy lifestyles 33
Board members and senior leaders, lead the organisation effectively, communicating their vision for equality, actively creating diverse teams and developing diverse talent in the organisation Board members and senior leaders, ensure equality is considered as part of mainstream business and internal assurance processes Middle and line managers, motivate and support their staff in understanding and responding to the needs of, communities and staff from the protected groups and support culturally competent ways of working?
34
Appendix 6. Outcome of grading – Calderdale EDS Goal 1 - „Better health outcomes for all‟ EDS Outcome 1.1 Services are commissioned, designed and procured to meet the health needs of local communities, promote well-being, and reduce health inequalities EDS Outcome 1.2 Individual patients’ health needs are assessed, and resulting services provided, in appropriate and effective ways EDS Outcome 1.3 Changes across services for individual patients are discussed with them, and transitions are made smoothly EDS Outcome 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 EDS Outcome 1.5 Public health, vaccination and screening programmes reach and benefit all local communities and groups Overall - Developing
Developing
Developing
Under developed
Developing
Achieving
EDS Goal 2 – „Improved patient access and experience‟ EDS Outcome 2.1 Patients, carers and communities can readily access services, and should not be denied access on unreasonable grounds EDS Outcome 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 EDS Outcome 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 EDS Outcome 2.4 Patients’ and carers’ complaints about services, and subsequent claims for redress, should be handled respectfully and efficiently Overall - Developing
Developing
Developing
Under developed
Developing
35
EDS Goal 3 - „Empowered, engaged and well-supported staff‟ EDS Outcome 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 EDS Outcome 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 EDS Outcome 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 EDS Outcome 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 EDS Outcome 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) EDS Outcome 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 Overall – Achieving
Developing
Ungraded
Achieving
Achieving
Achieving
Achieving
EDS Goal 4 - „Inclusive leadership at all levels‟ EDS Outcome 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 EDS Outcome 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
Achieving
Achieving
36
EDS Outcome 4.3 The organisation uses the “Competency Framework for Equality and Diversity Leadership� to recruit, develop and support strategic leaders to advance equality outcomes Overall - Achieving
Under developed
37
Appendix 6. Outcome of grading - Kirklees EDS Goal 1 - „Better health outcomes for all‟ EDS Outcome 1.1 Services are commissioned, designed and procured to meet the health needs of local communities, promote well-being, and reduce health inequalities EDS Outcome 1.2 Individual patients’ health needs are assessed, and resulting services provided, in appropriate and effective ways EDS Outcome 1.3 Changes across services for individual patients are discussed with them, and transitions are made smoothly EDS Outcome 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 EDS Outcome 1.5 Public health, vaccination and screening programmes reach and benefit all local communities and groups Overall - Developing
Under developed
Developing
Developing
Achieving
Developing
EDS Goal 2 - „Improved patient access and experience‟ EDS Outcome 2.1 Patients, carers and communities can readily access services, and are not denied access on unreasonable grounds EDS Outcome 2.2 Patients are informed and supported to be as involved as they wish to be in their diagnosis and decisions about their care, and to exercise choice about treatments and places of treatment EDS Outcome 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 EDS Outcome 2.4 Patients’ and carers’ complaints about services, and subsequent claims for redress, should be handled respectfully and efficiently
Achieving
Achieving
Achieving
Developing
38
Overall - Achieving EDS Goal 3 - „Empowered engaged and well supported staff‟ EDS Outcome 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 EDS Outcome 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 EDS Outcome 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 EDS Outcome 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 EDS Outcome 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) EDS Outcome 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 Overall – Achieving
Ungraded
Ungraded
Achieving
Achieving
Achieving
Achieving
EDS Goal 4 - „Inclusive leadership at all levels‟ EDS Outcome 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 EDS Outcome 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
Achieving
Achieving
39
EDS Outcome 4.3 The organisation uses the “Competency Framework for Equality and Diversity Leadership� to recruit, develop and support strategic leaders to advance equality outcomes Overall - Developing
Under developed
40
Appendix 7. Outcome of grading - Wakefield Event 1, Outcome of grading - Wakefield EDS Goal 1 - „Better health outcomes for all‟ EDS Outcome 1.1 Services are commissioned, designed and procured to meet the health needs of local communities, promote well-being, and reduce health inequalities EDS Outcome 1.2 Individual patients’ health needs are assessed, and resulting services provided, in appropriate and effective ways EDS Outcome 1.3 Changes across services for individual patients are discussed with them, and transitions are made smoothly EDS Outcome 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 EDS Outcome 1.5 Public health, vaccination and screening programmes reach and benefit all local communities and groups
Developing
Developing
Developing
Developing
Developing
Overall - Developing EDS Goal 2 - „Improved patient access and experience‟ EDS Outcome 2.1 Patients, carers and communities can readily access services, and are not denied access on unreasonable grounds EDS Outcome 2.2 Patients are informed and supported to be as involved as they wish to be in their diagnosis and decisions about their care, and to exercise choice about treatments and places of treatment EDS Outcome 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 EDS Outcome 2.4 Patients’ and carers’ complaints about services, and subsequent claims for redress, should be handled respectfully and efficiently
Developing
Achieving
Achieving
Developing
41
Overall – Developing EDS Goal 3 - „Empowered engaged and well supported staff‟ EDS Outcome 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 EDS Outcome 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 EDS Outcome 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 EDS Outcome 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 EDS Outcome 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) EDS Outcome 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 Overall – Achieving
Developing
Ungraded
Achieving
Achieving
Achieving
Achieving
EDS Goal 4 - „Inclusive leadership at all levels‟ EDS Outcome 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 EDS Outcome 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
Ungraded
Achieving
42
EDS Outcome 4.3 The organisation uses the “Competency Framework for Equality and Diversity Leadership” to recruit, develop and support strategic leaders to advance equality outcomes Overall – Developing
Ungraded
43
Appendix 8. Equality Monitoring - Events
44
45